Changing individuals: from empiricism to theory or Lost In knowledge Translation

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Changing individuals from empiricism to
theoryorLost In (knowledge) Translation?

• Martin EcclesProfessor of Clinical
  EffectivenessUniversity of Newcastle upon Tyne

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Credits content

• Credits
• Jeremy Grimshaw, Marie Johnston, Jill Francis,
  Susan Hrisos, Eileen Kaner, Heather Dickinson,
  Fiona Beyer, Nigel Pitts, Debbie Bonetti, Liz
  Glidewell, Graeme McLennan, Ruth Thomas, Anne
  Walker, Ian Graham, Jo Logan
• Content
• What we know (about the effectiveness of
  interventions) from empirical data
• If not empiricism then what?
• Theory
• Two studies
• Using theory to explore causal determinants
• Using theory to build behaviour change
  interventions

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Researching changing clinical behaviour

• Context
• The scientific study of methods to promote the
  systematic uptake of clinical research findings
  and other evidence-based practices into routine
  healthcare
• To improve the quality and effectiveness of
  health care
• The study of influences on healthcare
  professional and organisational behaviour
• What do we know?
• Systematic reviews
• What do we want to know?
• Predictable change

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What do we know - EPOC

• EPOC epoc_at_uottawa.ca
• 41 Protocols
• 44 Reviews of specific type of interventions

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What do we know?

• Grimshaw JM, Thomas RE, MacLennan G, Fraser C,
  Ramsay C, Vale L et al.
• Effectiveness and efficiency of guideline
  dissemination and implementation strategies.
  Health Technol Assess 2004.
• http//www.hta.nhsweb.nhs.uk/

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Methods

• 285 reports of 235 studies, yielding 309 separate
  comparisons
• Single effect size for each type of endpoint
  identified for each study either primary
  measure (as stated by author) or median measure

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Guidelines review conclusions

• Imperfect evidence base for decision makers
• Many current rigorous evaluations have
  methodological weaknesses (e.g. unit of analysis
  errors)
• Poor reporting of study settings, barriers to
  change, content and rationale of intervention
• Generalisability of study findings is frequently
  uncertain
• Only 27 of studies used theories and/or
  psychological constructs in any way
• Improvements in direction of effect in 86 of
  comparisons
• Reminders most consistently observed to be
  effective
• Educational outreach only led to modest effects
• Dissemination of educational materials may lead
  to modest but potentially important effects
  (similar effects to more intensive interventions)
• Multifaceted interventions not necessarily more
  effective than single interventions

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Its all organisational

• A broad overview of research evidence on
  organizational strategies
• Planned re-arrangements of one or more aspects
  of the organization of patient care
• 36 reviews 684 studies
• Wensing, Wollersheim, Grol.
• Implementation Science 2006.

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Results

• Revision of professional roles 9 reviews
• Can improve professional performance preventive
  care
• Multidisciplinary teams 5 reviews
• Can improve patient outcomes chronic diseases
• Integrated care services 8 reviews
• Can improve patient outcomes and save costs
  chronic conditions
• Knowledge management 6 reviews
• Professional performance and patient outcomes can
  be improved across conditions
• Quality management 2 reviews
• Effects remain uncertain
• Mixed interventions 7 reviews
• 6 showed positive effects

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Conclusions

• Authors
• There is a growing evidence base of rigorous
  evaluations of organizational strategies
• The evidence underlying some strategies is
  limited
• Poorly contextualised studies
• None of the strategies produced consistent
  effects
• For no strategy can the effects be predicted with
  high certainty

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So what do we know?

• Most things work some of the time 9 absolute
  improvement
• There are limitations
• Methodological quality variable and often poor
• Little economics (29) or theory (27)
• Results likely to be confounded
• Researchers didnt randomly choose interventions
• Differences in context etc.
• Direct application of reviews problematic
• Foy, Eccles et al. What do we know about how to
  do audit and feedback? Pitfalls in applying
  evidence from a systematic review. BMC Health
  Services Research 2005, 550.

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And what do we need to know?

• What is the efficiency of interventions?
• What do they do?
• How do they do it?
• What mediates or modifies the effect?
• How generalisable are effects?
• How do you get to a trialable intervention?
• Which means what, exactly?

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Which means what, exactly?

• Generalisable frameworks
• Empirical
• Theoretical
• Design better studies
• Ask and answer smarter questions
• Levels of engagement
• Improved designs
• Process evaluations

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Theories and/or models?

• Classical theories/models of change can be
  informative and helpful for identifying the
  determinants of change
• Provide organization for thinking, for
  observation, and for interpreting what is seen
• They provide a systematic structure and a
  rationale for activities
• Interventions are more likely to be effective if
  they target causal determinants these are
  theoretical constructs
• Models reflect the philosophical stance,
  cognitive orientation, research tradition, and
  practice modalities of a particular group of
  scholars
• Researchers, policy makers, and change agents
  tend to be more interested in planned change
  theories/models that are specifically intended to
  be used to guide or cause change

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Ottawa Model of Research Use
Assess Monitor
Evaluate barriers supports
strategy application
outcomes
degree of use

• Practice Environment
• structural
• social
• patients
• economic

• Outcomes
• patient
• practitioner
• system

• Strategies
• barrier
• management
• transfer
• uptake

• Adoption
• intention
• use

• Potential Adopters
• attitudes
• knowledge
• skill

• Evidence - Based Recommendations
• development process
• innovation attributes

Logan Graham, 2002
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Theory of Planned Behaviour
Attitudes
Subjective Norms
Behavioural Intention
Behaviour
Perceived Behavioural Control
Ajzen Madden, (1986), Journal of Experimental
Social Psychology, 22, 453
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Do theories of human behaviour (TPB) apply to
clinicians?

• Non-clinicians
• Meta-analysis of 10 meta-analyses (Sheeran)
• Intention accounted for 28 of the variance in
  behaviour
• 185 independent studies (Armitage and Connor)
• TPB (intention and perceived behavioural control)
  accounted for 27 of the variance in behaviour
• 31 if behaviour measures were self-reports
• 20 if behaviour measures were objective or
  observed
• Meta-analysis of 47 experimental tests of the
  intention-behaviour relationship (Webb
  Sheeran)
• A medium-to-large change in intention leads to
  a small-to-medium change in behaviour

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Do theories of human behaviour (TPB) apply to
clinicians?

• Clinicians
• Is healthcare different?
• Systematic review of 10 studies included a total
  of 1623 subjects
• Eccles et al, Implementation Science, 2006
• Heterogeneous group of studies
• proportion of variance in behaviour explained by
  intention was of a similar magnitude to that
  found in non-health professionals
• More consistently the case for studies in which
  intention-behaviour correspondence was good and
  behaviour was self-reported

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Levels

• Four levels at which interventions to improve the
  quality of health care might operate
• Individual health professional
• Health care groups or teams
• Organisations providing health care (e.g., Acute
  hospitals)
• The larger health care system or environment in
  which individual organizations are embedded
• Ferlie EB, Shortell SM. Improving the quality of
  health care in the United Kingdom and the United
  States a framework for change. The Milbank
  Quarterly 2001 79(2)281-315.

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Levels

• Different theories will be relevant to
  interventions at different levels
• Psychological theories will be more relevant to
  interventions directed at individuals and teams
• Theories from of organisational change may be
  more relevant to interventions directed at
  hospitals or trusts

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Choosing theories

• Theories of behaviour or of behaviour change?
• Focus on theories that
• Have been empirically tested
• Explain behavior in terms of factors that are
  amenable to change
• Include non volitional factors
• Michie et al. Making psychological theory useful
  for implementing evidence based practice a
  consensus approach. QSHC 2005 14 26-33.
• Francis et al. TPB Manual. www.rebeqi.org

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Study 1 Beyond TPB What are the theoretical
predictors of clinical behaviours?

• To explore the usefulness of a range of
  psychological frameworks to predict health
  professional behaviour relating to the management
  of
• upper respiratory tract infections without
  antibiotics
• Psychological measures were collected by postal
  questionnaire survey from a random sample of
  general practitioners (GPs) in Scotland
• Eccles MP, Grimshaw JM, Johnston M, Steen N,
  Pitts NB, Thomas R, Glidewell E, Maclennan G,
  Bonetti D, Walker A. Applying psychological
  theories to evidence-based clinical practice
  Identifying factors predictive of managing upper
  respiratory tract infections without antibiotics.
  Implementation Science, 2007, 226.

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Outcome measures

• Outcome measures were
• clinical behaviour (proxied by antibiotic
  prescription rates)
• behavioural simulation (scenario-based decisions
  to managing URTI with or without antibiotics)
• behavioural intention (general intention to
  managing URTI without antibiotics)

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Explanatory variables

• Explanatory variables were the constructs within
• Theory of Planned Behaviour (TPB)
• Social Cognitive Theory (SCT)
• Common Sense Self-regulation Model (CS-SRM)
• Operant Learning Theory (OLT)
• Implementation Intention (II)
• Stage Model
• Knowledge

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Analyses

• For each of the outcome measures
• Multiple regression analysis was used to examine
  the predictive value of each theoretical model
  individually
• Stage analysis Already decided v the rest
• A cross theory analysis of constructs was
  conducted to investigate the combined predictive
  value of all significant individual constructs
  across theories

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Results

• Intention
• Theory level
• TPB 30 SCT 29 CS-SRM 27 OLT 43
• GPs who reported that they had already decided to
  change their management to try to avoid the use
  of antibiotics had a significantly higher
  intention to manage URTIs without prescribing
  antibiotics
• Constructs across theories 49 of the variance
  in intention
• OLT evidence of habitual behaviour, TPB
  attitudes, risk perception, CS-SRM control by
  doctor, TPB perceived behavioural control and
  CS-SRM control by treatment

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Results

• Behavioural simulation
• Theory level
• TPB 31 SCT 26 II 6 OLT 24
• GPs who reported having already decided to change
  their management to try to avoid the use of
  antibiotics made significantly fewer
  scenario-based decisions to prescribe
• Constructs across theories 36 of the variance
• perceived behavioural control (TPB), evidence of
  habitual behaviour (OLT), CS-SRM cause
  (chance/bad luck) and intention
• Behaviour
• Theory level
• OLT explained 6 of the variance
• Constructs across theories 6 of variance in
  behaviour
• OLT evidence of habitual behaviour

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Conclusions

• The management of URTI is a frequent behaviour
  and the measure of self-reported habitual
  behaviour consistently predicted the outcome
  measures
• Looking across the three outcome measures there
  are also suggestions that issues of perceived
  control, risk perception and attitudes may also
  be important
• Results suggest that GPs have considered this
  frequently performed behaviour and operate in a
  predominantly habitual manner backed up by
  beliefs that support their habit

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Conclusions

• The theories individually each explained a
  significant proportion of the variance in our
  dependent variables
• Aggregated analysis suggested that they were
  measuring similar phenomena within their own
  individual structures
• What would be an optimum core set of measures if
  the aim was to cover most behaviours and clinical
  groups?
• Given our current limited understanding this
  would have to be the subject of both studies
  replicating this one and further work examining
  different combinations of theories and models.
• Operationalising the constructs with theoretical
  purity was a challenge
• Problems with measuring behaviour
• Response rates

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Study 2 Intervention building

• Evaluate the impact of two theory-based
  interventions on behavioural intention and
  simulated behaviour of GPs in relation to the
  management of uncomplicated URTI
• A randomised 2x2 factorial design with baseline
  and post-intervention assessment
• Measures were delivered in two postal
  questionnaire surveys, with the study
  interventions embedded within the second
  questionnaire
• Participants responding to the first survey were
  included in the second and were randomised twice
  to receive, or not, each of the two study
  interventions.

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Causal determinants

• Baseline survey identified causal determinants
• self-efficacy (from SCT)
• anticipated consequences and risk perception
  (also from SCT)
• How do you change them?

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BPS construct domains

• Six phases (1) identifying theoretical
  constructs (2) simplifying into construct
  domains (3) evaluating the importance of the
  construct domains (4) interdisciplinary
  evaluation (5) validating the domain list and
  (6) piloting interview questions
• The contributors were a psychological theory
  group (n 18), a health services research
  group (n 13), and a health psychology group
  (n 30)
• Twelve domains were identified to explain
  behaviour change (1) knowledge, (2) skills, (3)
  social/professional role and identity, (4)
  beliefs about capabilities, (5) beliefs about
  consequences, (6) motivation and goals, (7)
  memory, attention and decision processes, (8)
  environmental context and resources, (9) social
  influences, (10) emotion regulation, (11)
  behavioural regulation, and (12) nature of the
  behaviour

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How do behaviour change techniques map on to
psychological constructs? Results of a consensus
process Jill Francis1, Susan Michie2, Marie
Johnston1, Wendy Hardeman3, Martin Eccles4
1University of Aberdeen, Scotland, UK
2University College, London 3University of
Cambridge 4University of Newcastle on Tyne

• BACKGROUND
• Theories of behaviour provide a basis for the
  choice of interventions to change health related
  behaviours.
• However, theory can inform interventions only if
  there are clear links between the theoretical
  constructs (determinants of behaviour change)
  and techniques to change the constructs. (Figure
  1)
• This study explored a systematic way to select
  behaviour change techniques in order to design
  interventions.

Persuasive communication

• Figure 1. Representation of the links between
  theories, determinants and techniques relating
  to behaviour change

AIM To pilot a method for achieving consensus to
identify behaviour change techniques for use in
altering a range of theoretical constructs
(determinants of behaviour change).
METHOD Eleven theoretical construct domains were
identified by Michie et al. (20051) as factors
that explain behaviour. Behaviour change
techniques (n35) were identified by independent
reviews of different literatures (Hardeman et al,
20002 Michie et al., 20033). Four experienced
psychologists judged which techniques they would
use as part of an intervention to change each
construct domain. Judgements were aggregated to
represent four outcome categories agreement
(would use technique to change construct)
agreement (would not use technique to change
construct) indefinite and disagreement.
Figure 2. Which techniques would you use as
part of an intervention to change each construct
domain? Matrix representing levels of consensus
 

• CONCLUSIONS
• The consensus task illustrated that
• It is possible to identify techniques for use in
  altering determinants of behaviour change.
• This approach may facilitate the design of
  theory-based interventions and testing hypotheses
  about the effectiveness of techniques.
• This study highlights the need for further work
  to develop a replicable, comprehensive taxonomy
  of techniques and to map the techniques onto
  theory.
• The evidence base for development of behaviour
  change interventions may be strengthened using
  this method a further step would be to conduct
  systematic reviews on the effects of techniques
  specified in the green cells (Figure 2).

RESULTS Out of the 385 cells in the 35 x 11
matrix, judges agreed in 71 of cells (12
agreement would use technique to change
construct 59 agreement would not use technique)
and disagreed in only 8 of cells (Figure 2). 20
of cells were classified as indefinite. Each
construct had at least one technique identified
with it. Three out of the 11 constructs (skills
beliefs about capabilities motivation and goals)
were judged to be changeable by 8 to 10
techniques. Five constructs (bolded in Figure 2),
had only 1 or 2 techniques identified with them.

• REFERENCES
• Michie S, Johnston M, Abraham C, Lawton R, Parker
  D, Walker A. (2005) Making psychological theory
  useful for implementing evidence based practice
  a consensus approach. Quality Safety in Health
  Care, 14, 26-33.
• Hardeman W, Griffin S, Johnston M, Kinmonth AL,
  Wareham NJ. (2000) Interventions to prevent
  weight gain A systematic review of
  psychological models and behaviour change
  methods. International Journal of Obesity, 24,
  131-143.
• Michie S, Abraham C, Jones C. (2003) Achieving
  the "Fully Engaged Scenario" what works and why.
  Unpublished review, Department of Health.

J. Francis, Health Services Research Unit,
University of Aberdeen, Polwarth Building,
Foresterhill, Aberdeen. Scotland AB25 2ZD Tel
44 1224 559672 Fax [phone] Email
j.francis_at_abdn.ac.uk
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Intervention 1

• Intervention 1 targeted the construct of
  self-efficacy (from SCT).
• Mapped on to the theoretical construct domain,
  beliefs about capabilities.
• The main behaviour change technique selected was
  graded task
• to increase GPs beliefs in their capabilities of
  managing URTI without prescribing antibiotics
• does this by promoting incrementally greater
  levels of mastery by building on existing
  abilities.
• Two further behaviour change techniques,
  rehearsal and action planning were additional
  components of this intervention.

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Intervention 2

• Intervention 2 targeted anticipated consequences
  and risk perception (also from SCT)
• Mapped on to the theoretical construct domain,
  beliefs about consequences
• The main behaviour change technique selected was
  persuasive communication
• The aim of this intervention was to encourage GPs
  to consider some potential consequences for
  themselves, their patients and society of
  managing URTI with and without prescribing
  antibiotics.
• This intervention also incorporated the behaviour
  change technique, provide information regarding
  behaviour, outcome and connection between the
  two

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Results

• 1225 GPs at 289 practices were sent the
  pre-intervention survey booklet and 397 (32.4)
  from 191/289 (66) practices, returned a
  completed questionnaire
• Overall, GPs responding to the first mailing had
  been qualified for a mean (SD) of 19.9 (8.0)
  years, 21 were GP trainers, 94 were from
  multi-practitioner surgeries and 57 were male
• 397 respondents were randomised to receive the
  study interventions and were mailed the
  post-intervention survey booklet
• Three hundred and forty (86) GPs returned the
  post-intervention survey booklet, from 178/191
  (93) practices

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Results

• Intervention 1 Graded Task
• Significant effect on the constructs targeted
  (PBC Power and Self-efficacy)
• No effect of this intervention on intention or
  simulated behaviour
• Intervention 2 Persuasive Communication
• Significant effect on the constructs targeted
  (Anticipated consequences and risk perception)
• Significant effect of this intervention on
  intention and behavioural simulation
• Significant effect was also observed on a number
  of constructs not specifically targeted by this
  intervention

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Issues

• Matching constructs to techniques
• No measure of behaviour
• Response rates

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Conclusions/Issues

• Theory has the potential to lead to greater
  understanding
• Theory potentially addresses generalisability
• Which theory/theories to choose?
• Theories of what?
• Behaviour or Behaviour change?
• Many unresolved methodological challenges in
  operationalising theory

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Knowledge
?
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References

• Armitage CJ, Conner M. Efficacy of the theory of
  planned behaviour a meta-analytic review.
  British Journal of Social Psychology
  200140471-99.
• Eccles MP, Hrisos S, Francis J, Kaner E,
  Dickinson HO, Beyer F, Johnston M. Do self-
  reported intentions predict clinicians
  behaviour a systematic review. Implementation
  Science, 2006 1 28.
• Eccles MP, Grimshaw JM, Johnston M, Steen N,
  Pitts NB, Thomas R, Glidewell E, Maclennan G,
  Bonetti D, Walker A. Applying psychological
  theories to evidence-based clinical practice
  Identifying factors predictive of managing upper
  respiratory tract infections without antibiotics.
  Implementation Science, 2007, 226.
• Ferlie EB, Shortell SM. Improving the quality of
  health care in the United Kingdom and the United
  States a framework for change. The Milbank
  Quarterly 2001 79(2)281-315.
• Foy R, Eccles MP et al. What do we know about
  how to do audit and feedback? Pitfalls in
  applying evidence from a systematic review. BMC
  Health Services Research 2005, 550.

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References

• Grimshaw JM, Thomas RE, MacLennan G, Fraser C,
  Ramsay C, Vale L, Whitty P, Eccles M, Matowe L,
  Shirren L, Wensing M, Dijkstra R, Donaldson C.
  Effectiveness and efficiency of guideline
  dissemination and implementation strategies.
  Health Technol Assess 2004 8(6).
• Michie S, M Johnston, C Abraham, R Lawton, D
  Parker, A Walker, on behalf of the
  Psychological Theory Group. Making
  psychological theory useful for implementing
  evidence based practice a consensus approach.
  Qual Saf Health Care 2005142633.
• Sheeran P. Intention-behavior relations A
  conceptual and empirical review. In Stroebe W,
  Hewstone M, editors. European Review of Social
  Psychology. John Wiley Sons Ltd. 2002. p.
  1-36.
• Webb TL, Sheeran P. Does Changing Behavioural
  Intention Engender Behaviour Change? A
  Meta-analysis of the Experimental Evidence.
  Psychol Bull 2006132(2)249-68.
• Wensing, Wollersheim, Grol. Organizational
  interventions to implement improvements in
  patient care a structured review of reviews.
  Implementation Science 2006, 12.