Somebody. And Sharon McCann, the director of studies for the NSA evidence based health care.
And I'd like to introduce and welcome to Oxford today.
Susan. Professor Susan, if you sit across from London and I guess I'm not stop to know which of the highlights from Susan's career to talk about.
And I guess we talked about a couple earlier on.
I think probably it's important to say that Susan started her career as a clinical psychologist studying here at Oxford,
both as undergrad and postgraduate. So that's welcome back. Susan has done an amazing amount of work synthesising behavioural theory for
understanding for use of those of us who don't have a strong behavioural background,
which I think is fantastic and we've been talking about that a lot this week.
She's also had a strong and massive international contribution to work around implementation.
So she's done a lot of work with Nice. She's worked with advisory groups in the US, Canada, Australia, which is an amazing piece of work.
And for those of us who've been talking about complex interventions this week,
we have referred to the Medical Research Council guidelines on complex intervention.
Susan was an author, a model. So so without saying anything further,
can I welcome you to the group and invite you to talk to us tonight about a behavioural perspective of translating evidence to policy and practice?
Thank you. Well, thank you very much and very good to be here.
I've been to other talks at Calyx College and I always enjoyed them,
but this is the first one I've given and I'm pleased to ask questions or make comments as I go through the issues I'm going to raise.
And it's a very big subject. So I've just pulled out some, but I hope we'll get the conversation going.
So I'm starting off with, I'm sure, a schematic representation you're all very well familiar with.
What are all the gaps between getting evidence into practice?
We've got the very first one, the first gap often called of Can It Work in terms of efficacy, second gaps?
Does it work in practice? The gap?
Is it routinely delivered as it should be, and the final gap, the uptake by the patient or public.
So if one's looking at the extent to which evidence as produced in the laboratory or the equivalence,
if you're a behavioural social scientist and it actually being taken up and making a difference in the world out there at all these stages,
there's ways in which there's a translational gap.
And what I'm going to mainly address today is just this third one of implementation,
which is what happens between the research trials and clinical practice.
And there's quite a lot that's been written about wastage in research.
And so despite increasingly good evidence about best practice, much is wasted because it's not implemented.
And so good quality health care and best health outcomes may not be achieved.
I'm going to present some ways in which that's the case and also draw your attention to this forthcoming series in The Lancet,
which is called Reducing Waste and Inefficiency in Medical Research.
The papers have been invited and they're basically submitted.
So I don't know what the timeline will be, but some of you will know Ian Chalmers and Paul Glasgow.
So they have to have quite a large group of us have been involved in writing this series.
Okay, so what to do about this situation?
If one looks at the interventions that have been designed to improve implementation,
one comes to the conclusion they've had modest and very valuable success.
And I don't know if you're familiar with implementation science.
It's an open access journal that deals with these issues.
So just go to any sample of papers in there and it'll be a fairly consistent story.
How do we improve implementation? Well,
at the heart of what needs to happen is we need to understand implementation problems in terms of behaviour and also the whole system of behaviour.
So we have health professionals, managers, ancillary staff, commissioners, policy makers to name just the groups that sponsor my mind.
And implementation often depends on many different behaviours within these groups, but also complex system between them.
So the first stage is really understanding behaviour before one jumps into thinking about.
Time to change and improve it.
Although behaviour is at the heart of things and if anything doesn't agree with that, I'm sure you'll pipe up in due course.
And there is a science of behaviour, but behavioural signs is very seldom used to inform either intervention, design or evaluation.
And just to give some examples of just behaviours in terms of professional behaviours, the kinds of things we're talking about.
And I got quite a few of you are medics by background, making referrals,
giving advice, prescribing drugs, keeping hands, clean, whole variety of behaviours.
And there's a range of different studies.
I've chosen a couple here in the Netherlands, estimated 30 to 40% of patients didn't receive health care.
That would be described as evidence based.
And in the US, another study showing up to 25% receive care that was unnecessary or even harmful.
Many different explanations as to why that's the case, but just to illustrate the size and scale of the problem that we're talking about.
So what I want to do is talk about some of the the problems that I think need to be addressed to help this situation.
And one of them is a very basic issue.
But the fact that interventions are not described in sufficient detail to be replicated or to be implemented effectively.
So all the money that goes into the investment of very expensive trials,
which in some cases establishes that interventions that are effective can then not be implemented because the detail is not there.
And I'll show you how that differs when we talk about interventions to change behaviour compared to biomedical interventions.
There's another issue which is that the protocols for interventions that some are used in or the protocols for interventions
are to trialled often when it comes to what's the LibDem practice is very different than what's in the intervention protocols,
and often that's not measured and so we don't know what the difference is.
So that's another problem that's I will illustrate and say something about and
and finally theories of behaviour and behaviour change are rarely applied.
And if one doesn't have some kind of theoretical framework within which to think about one's interventions amongst evaluations,
then you can show that an intervention has the start of the other effect in this situation.
But you're very limited in terms of understanding the mechanisms of action and therefore how
to optimise interventions in the future or how best to generalise across different contexts.
Okay. So and I'm going to finish off by presenting a kind of overarching framework of how to understand behaviour out of behavioural interventions.
So first of all, the issue about describing interventions,
al-Shabaab said earlier all the interventions to improve implementation are complex in that they're
comprised of several potentially interacting techniques and they're often very poorly described.
So here I'm saying it's equivalent in biomedicine if you say it's a big red dry pill.
So anybody who's done systematic reviews of interventions to improve implementation,
I think will kind of understand what I'm saying about the poor descriptions and even where more detailed protocols are available.
The terminology that people use is very variable,
so people will be describing the same thing using different language or use the same words to describe different things.
So really quite fundamental problems. If one is trying to look at this scientifically and these issues impede replication.
So actually accumulating knowledge through replicating studies.
As I said, for MPs implementation and it also impedes evidence synthesis.
How do you put things together if things are poorly described and you don't know if people are meaning the same or different things?
So here's an example. I mean, I've taken behavioural counselling.
We could have taken any, any kind of term to illustrate the issue.
Here's American Journal of Public Health and, and this description of what these authors meant by behavioural counselling.
So I don't know what you think about how good that definition is.
But before I before you answer that and I'll give you another one, this is in JAMA, the Journal of the American Medical Association.
And as you can see, a completely different definition of behavioural counselling.
And I could ask you what you think by that definition.
And in some ways it doesn't really matter which is a better or worse definition.
The issue is that they're different. So people may be thinking they're doing the same thing.
Or if you're trying to make sense of a big literature by synthesising it and you think you're synthesising the same sort of thing,
you're synthesising very different things. And so obviously we need to do better than that.
Just to give another example of pitting biomedicine against behavioural science,
if one takes example of smoking cessation effectiveness, we have very varenicline,
which is the most effective pharmacological intervention for smoking cessation and
behavioural counselling as evaluated by Cochrane Gold Standard systematic review methods.
Okay. So let's look at the biomedical example varenicline.
That's the intervention content. If you get varenicline, you get that.
If you get that, you get varenicline. You know where you are. Mechanism of action.
I won't. Can you read it from the bag? Okay.
I'll read about quickly. Activity is a subtype of the nicotine 8% and where it's binding produces agonistic
activity while simultaneously preventing binding to eight B2 receptors.
The point is that that's quite specific about how that works on the brain.
Now we come to behavioural counselling. Here's the definition.
Review smoking history and motivation to quit.
Help identify high risk situations, generate problem solving strategies, non-specific support and encouragement.
Well, I think if I ask all of you to go out there and replicate that and physiology, you'd all be doing totally different things.
So that's the contents of this intervention. Having seen the content.
Have you got ideas about what the mechanism of action is?
As I said before, if we don't understand mechanism of action, we're not going to be able to improve things in the future.
You're probably struggling. So with the reviewers.
Nothing was mentioned and no whether that's because the primary studies didn't mention it or it's too difficult to make any sense.
But I don't know. But you can see we're really on the back foot and I've taken this is smoking cessation,
but the same is true for interventions in relation to implementation.
Presumably everybody is aware of CONSORT'S guidelines which have made a huge difference in improving the reporting of randomised controlled trials.
And they say. For precise details. The interventions is actually administered.
However, they don't say which precise details particularly.
But a very good paper by Carrie Davidson back in 2003 identified some of the main dimensions we should think of.
So, first of all, various aspects of delivery.
So the modes of delivery, intensity, duration, those delivering, recipients setting, and when you read descriptions of interventions.
And next time you go and read a description of implementation interventions, you get a lot of detail about all of this mode of delivery.
And there's also adherence to delivery protocols.
And then also the content or the elements of the intervention.
These are the active ingredients that actually bring about things, behaviour, change.
And there's usually very little about those and these.
So it's rather like trying to cook a meal with lots of descriptions of all your cooking utensils,
but very little about the actual food ingredients to use.
So I'm just going to take content and talk a bit about that.
But really what I'm saying about that's also true of these these other dimensions.
So how should we describe the content of interventions?
What I'm arguing is we need an agreed standard methods of describing interventions that should
be accessible and supported across disciplines and countries and behaviours and contexts.
And we all work in so many silos, whether it's to do with particular rigour, to studying disciplines that we've come from countries.
And so in Canada it's knowledge translation.
In the UK it's implementation science. In the US there's a lot of talk about quality improvement, improvement science.
And I went to a conference at the end of last year in Canada that Jeremy Grimshaw hosted to try and get I think he got about 16 of us
from different disciplines together to see if we could get a shared terminology and a shared sets of frameworks about implementation,
knowledge, translation, whatever you want to call it. And it was very interesting.
Two days, I don't think we got very far, but it's it is a reflection of the the problem.
I'm going to present a method of describing interventions that I've been developing,
which is to describe interventions in terms of very specific behaviour, change techniques.
And what do I mean by this? I mean the active ingredients designed to change behaviour that are observable,
replicable and that basically the smallest components of an intervention that
on their own in the optimal circumstances could bring about behaviour change.
So really trying to get down to the smallest level. And now just to give you some idea of what I mean.
This was the first what we call a taxonomy.
This is actually a list.
And this was as a result of for many years, I did consultancy work for the Department of Health and they asked us to do a systematic review.
This was about interventions to change physical activity in healthy eating.
And the interventions were very heterogeneous and very difficult to put together.
So I thought, okay, just inductively. Try and look at what's in there in terms of component techniques.
And you can see the last for relapse prevention, stress management.
These are big groups of things, but there's no more detail than that to the articles, which is why they were there.
So at least we could begin to define and specify the interventions using these techniques.
And in order for this to be reliable, that each of them have to have quite detailed definitions as to what's meant by them.
So just to give the example of a couple of them, you can see that there's a lot of detail in there just so that different authors who say coding
the same text or wanting to describe their interventions will be talking about the same thing.
And by doing this, we were able to I'm not presenting this work,
but we were able to use a statistical technique called matter regression to then identify which
individual techniques had an effect over and above all those heterogeneous interventions.
And in this particular review, we find that self-monitoring dates,
and we were then able to use a theoretical approach to think about what other
techniques would you predict would work synergistically in a complex fashion?
And with self-monitoring to bring about even greater effect.
And then compared the interventions that had those techniques with those that didn't and find that they were twice as effective.
So by using this approach, we were able then to make recommendations about particular types of intervention
that could be easily developed that are likely to be effective without this.
All we do is say very high heterogeneity and small to modest effects, which is usually what you get from synthesising literature.
Since then, our own colleagues have gone on to develop taxonomies for different kinds of behavioural domains.
And we've just published this year a 93 item one that's building on all the published ones.
And this has had the inputs of well,
we have an international advisory board of 30 people around the world who are leaders in lots of different domains,
because we wanted this to be something that would be owned internationally and across it,
behavioural medicine or people who are interested in implementation or so, etc.
And then we've had about 50 other behavioural experts across the world doing various kinds of work to produce this.
It's a MRC funded project that's essential this year.
So this is increasingly now being used to define behavioural inspections.
And this as well as helping with evidence synthesis.
This is also very helpful in establishing the extent to which intervention protocols are reported in a faithful way or not,
and also the extent to which protocols is delivered in practice.
So back to thinking about waste and research.
We looked at the percentage of behaviour change techniques that were specified
in intervention protocols compared to those that were reported in publications.
With this kind of approach, one can't look at that in any detail.
So what's your guess of. This was a Cochrane review.
Again, this is interventions in terms of smoking cessation.
So what's your guess is what percentage and 10%?
Okay. What a pessimist it was.
I mean, it was around the average was less than 50%.
Probably some of them were ten. But there's quite a range. So this is a real problem for science.
If we are doing everson's synthesis based on published reports and it's less than half of what was in the protocol is in the published report.
So a real plea, if you're doing evidence synthesis, systematic,
reviewing the follow up and try and get protocols or any information from the authors to supplement what's in the published report.
Most won't respond, but then you publish that because that's an empirical finding.
And the more that the profile of that is raised, the more people will change their behaviour.
It's getting much better now with electronic supplements, but still a real issue.
And then if we think about so these are what's in the protocols,
the finds its way into the published reports not thinking about what's in the protocols that are delivered in practice for those studies where
they actually take recorded consultations and analyse them in terms of behaviour change techniques and looked at the comparison with protocols.
What's your guess there? Well, in some cases, yes, they have.
The average is a 40% or so. But what's interesting is I think that the the the researchers who do the careful work of actually measuring the
extent to which the intervention is delivered in practice tend to be more advanced and more careful scientists.
So I think those who actually publish this material are ahead of the game.
And I reckon probably I would be surprised if your estimates not more realistic.
However, I hope you can see the problem here,
which is that if it's a different 50% that's in the intervention report to the published report, then what's left in practice?
You end up with no correspondence between what was going on in real life and what is published in all those high impact factor peer reviewed journals.
So these are really key issues and I'm amazed that we actually find anything out at all,
but we can really improve if we can tackle some of these issues.
And okay,
so I'm just going to give this tration of using this kind of approach to assessing the extent to which an intervention is delivered in practice.
And also this issue about how do you establish not just does something work, but also how it works.
But before I go on, I've been talking a long time quite quickly.
Any questions or comments on what I've said so far?
Yeah, nothing about the previous slide delivery of of the principles that these are.
Techniques that were meant to be the limits, reasonable degree of flexibility. No, these these were in the in the protocol as meant to be.
But it's a good point to raise is that some protocols say, you know, you must do this,
that and the other and specify exactly almost scripting what people should do.
And other protocols are more evidence based principles that can be adapted and tailored in different situations.
But they're always looking at the extent to which whatever level of specificity is in the protocol is actually reflected in practice.
Yeah. Any other questions?
Yeah, I'm just sort of thinking about how how you perceive sort of problem solution.
Do you think we should try to expand interventions a bit simpler for the practitioners that are trying to deliver them accurately on the sites?
That's an awful lot of stuff that you tend to be reaching out to have have like the trial.
I just thought even on a good day you might not make it.
Maybe part of the problem would be to sort of, you know, try to hone in on some key principles.
And I guess that's what are those really key, very simple things that are very important.
Well,
I think one of the issues is that intervention protocols should be developed with an understanding of behaviour in mind and how people actually work.
So I completely agree with your observation. I think a lot of too complicated.
So we've been looking at a telephone quitline for smoking cessation and where it's absolutely abysmal.
This is the national quitline. But when you look at the protocols and what they're trying to follow is impossible.
So part of the problem, part of the issue is actually making the protocols fit for purpose.
I've got a PhD student looking at that because that's part of the translational problem.
Yeah, that's a really good point. Okay.
And I'm just going to illustrate this in terms of an intervention that was increasing physical activity amongst those who are at
risk of type two diabetes because of family history and a sedentary lifestyle and illustrates an implementation problem there.
And it was designed by an excellent group in Cambridge.
It's includes 14 behaviour change techniques delivered by trained professionals in five sessions over 12 months,
specified in very detailed manuals and protocols, and be asked to use 365 people.
And the result was they increased activity by the companies of 20 minutes a day.
However, that was true in both the control and intervention condition.
So published in The Lancet in terms of trial, no result.
If this has a behavioural science with them, they could have seen that their control was full of behaviour, change techniques.
Their assessment, you know, going in for a day, having lots of questionnaires, were thinking about their own behaviour.
They were getting feedback from lots of different physiological and behavioural tests.
Sure, they're getting lots of support. They knew they're going to be reassessed and six months in a year's time.
You know, it's such a shame because again, a lot of money gets put into this, but without it having a proper control.
And I think that was effective, but you can't say it because of the active control condition.
Anyway, that's another story.
So here are the 14 techniques that were used as part of this, and there were four different theories that underpinned these.
I hadn't really got time to go into theories currently, but just to give you an idea that it was theory based and specified by techniques.
If you think about the implementation process of this particular intervention, those theories of behaviour change underpinning it.
This was then translated into techniques in the manual, then delivered by professionals.
Then the participant responded And then we have the target,
which was to increase physical activity and we tape recorded and transcribe the sessions and
then coded those trance training theories and did this for both professionals and participants.
Okay, so 45%. So ballpark figure in terms of what I showed you, the lecture was delivered and as you can see, see this varies according to technique.
One of the concerns is that if you look at the for at the end habit formation prompts relapse prevention, generalising skills.
These are the kinds of techniques that are really essential for maintenance.
And if things are maintained, obviously they're a very limited use.
So that's a real concern. Also to show you that over the four sessions it deteriorates and it changes between facilitators and when we look at
what are the techniques delivered according to the theories and I haven't really thought too much about theories.
And in fact, this piece of work I did because I was at a conference where.
The people doing this intervention said it's based on these theories and when we get the results of this trial,
it will then show support for these theories. And so I think it's often said, well, unless you're actually measuring what's the limit,
you really can't say that just because the theories were there in the background,
it doesn't mean those theories are good explanation for what is actually happening.
And so empirical question, we got some money and did this bit of work.
So these are the techniques, according to these four theories self theory, plan,
behaviour, self-regulation theory, learning theory, relapse prevention theory.
So that's showing that those that were delivered were kind of mapping on to the what was in the protocol according to theory.
So, so far, so good. You know, they can draw conclusions about the theories in the protocol.
However, when we analysed the participants response and coded them according to the theories, it was a very different pattern.
So the as the participant response because in terms of translation, you have to go all the way down to the end.
If you think about the full gaps. And so this is the picture here.
And so what you can see this one here on the of learning theory is that and the professionals were delivering whatever they were delivering,
but the participants, their behaviour and what they were talking about was showing much more support for opera learning theory.
So the message here is if you want to understand how something is working, you need to track it through all the way to the end.
So if one's looking at which theories best accounted for change, if you just looking at the delivery,
you come to one conclusion, which is self-regulation theory has by far the biggest profile.
But if you are looking at how participants are responding, then operate learning theory, which is basically reward says what that means.
Keys and rewards is a better explanation.
Okay, so just finishing off on models and theories.
Why use these? Is there anybody here who thinks it's a really bad idea to use models and theories in general?
Because sometimes you do get people who think you. No, it's a waste of time.
Airy fairy. You're all signed up to it. Okay, very good.
Well, these are the reasons that I think we need to use them.
First of all, I think theories are a very good way of summarising what we know, bringing it together.
Otherwise, all you've got are bits and pieces of empirical findings.
So it's a framework where you can summarise and aggregate what we know.
Very helpful in terms of structuring, thinking and guiding research.
As I said before,
they identify mechanisms of action so the evidence that can be used to improve interventions and then also importantly facilitating communication,
because a lot of this work, especially implementation science, absolutely needs a multidisciplinary approach.
And that does mean that people need to be able to communicate and share frameworks as well as language and importantly,
frameworks between academics and what I'm calling knowledge users.
So policymakers, intervention designers, practitioners.
And the framework I'm going to present at the end was developed with that in mind.
So I'm a big advocate.
I mean, having said that, this is an issue about, well, which theories to select for which purposes and how best to apply them.
And we're really a very early stage, as I would say, of beginning to address those questions.
Well, and I've got another programme of research in that area.
And one of the key things is we need simple, parsimonious, coherent, coherent and usable models.
Because I'm a health psychologist and guilty,
very guilty discipline of having lots and lots of different models and often very
complex cases and often with very overlapping and redundant constructs in them.
Not helpful. Okay.
So I mentioned earlier the MRC guidance for developing and evaluating complex interventions that people aware of the one,
the earlier one back in 2003 or whatever.
So that was very much about really well where this came.
From us was the MRC I think got got fed up of throwing a lot of money at expensive trials which kept on finding interventions, not being effective.
And one of the reasons was that people weren't putting the investment into really doing the early
formative work to really think about what kind of intervention would be likely to be effective.
And so the first of the frameworks was really helpful.
I should have shown it here. But in terms of putting more emphasis on this early development, feasibility and piloting stage.
But the first framework said, you start here and you do that,
and then you have exploratory trials and definitive trials, and then at the end you think about implementation.
Big problem, because you could get and think about those full gaps in translation.
You can get interventions that work very well in trials and then people say, Ah, well,
now let's roll it out nationally and they are okay, not going to work because of this.
The other hadn't been thought of. So one of the reasons for doing this was to put implementation, put it in a circle,
put implementation case that that you need to think about implementation at the very first stages when you're first designing interventions.
So that was part of what was behind this kind of new, new framework.
And here I've just circled to ways in which theory has been highlighted, highlighted both in terms of developing the intervention to begin with,
having an idea about how the intervention is likely to work, and then making sure that that's followed through in terms of evaluating it.
So you evaluate, well, if it did work, does it work for the reasons that we postulated at the beginning?
Any questions about that? Okay.
So now I'm going to just say a bit about applying theory to systematic review and evidence synthesis.
There was a Cochrane Review in 2006 about autism feedback,
which is a very commonly used intervention to change professional practice and try and improve evidence based practice
in clinical situations defined as any summary of clinical performance of health care over a specified period of time.
That's feedback 118 trials and that the usual, you know, yes, it's affected to some extent massive variation over studies.
And when they try to think, well, what explains variability, they compared intensive moderate and non intensive orders and feedback.
And any of you who used to order the feedback, what is your understanding of intensive audit and feedback?
Don't hazard a guess what you think intensive audio feedback means the Teddy Daily.
Okay, there's this one suggestion so many calling up so far.
Okay. Yeah, right. Daily harassment we got, so.
Yeah. Oh, sorry. Monthly meetings.
Okay, so at meetings. So we've got a kind of idea of frequency, kind of mode of delivery.
I think you're speaking faster. Might be just looking at each and every aspect of this practice protected.
Okay. Okay. Right. So kind of comprehensive type of thing, point of care, protein.
Okay. Okay. These are all good suggestions.
This is what they came up with. So individual that recipients getting the audit feedback and having a verbal format.
I saying in words or a supervisor or senior colleague is a source and moderate or prolonged feedback that you want to come up with that.
Okay, non intensive group feedback not from a supervisor or senior colleague,
all individual feedback advocate format and containing information that costs the
number of tests that that person senses and moderate any other combination of factors.
It was fine sense of a non intensive group. So I read this and I thought okay, they did not have a behavioural scientists involved.
This looks like nonsense to me and no rationale for it.
Yeah. Expensive. Cochrane Review. Those of you who do cop reviews, I don't know how much it costs for a Cochrane review.
I wrote to the authors and said, What was your rationale? They said, We didn't have one.
Okay. And.
Okay, I was I was thinking the same. Sadly, this isn't unique.
It's not unique. It's all so in that I won't go back to it.
But base is a mixture of modes of delivery and content. There's no theoretical rationale for it, so no surprise.
And they couldn't find any pattern effects. And there were a few recommendations for practice.
And Robbie Foy here says all the feedback will continue to be an unreliable approach to quality improvement until we learn how and when it works best,
when we're not going to learn by that sort of approach.
So I thought, okay, let's reanalyse all of this data sets using behaviour change techniques and some theory.
So we generate a theory based hypothesis concerning effectiveness.
We independently code it.
We just did 13 papers and we identified 28 behaviour change techniques from that and we grouped them into three lots of things.
So goal or standard setting feedback can actually imply that that reliably just go with through this.
But this gives you an idea of how we broke it all down, exactly what was happening.
Those were aspects of goals that feedback, lots of different aspects of feedback, but we start with a very basic description and then work upwards.
We would have had a theory of evolution if Don hadn't done his careful, you know,
tiny descriptions of everything and then action plans, various different aspects of action plans.
Okay. And we generated some hypotheses and published in social science medicine.
And this is the theory we use, okay, self-regulation.
So I mentioned earlier this is a very simple representation, but basically a homeostatic mechanism.
And we're doing this all the time. You know, we have goals or standards for our performance.
We compare our current behaviour with that standards.
If we notice the discrepancy, we take certain steps to reduce this.
Now if people don't have a goal where they've got something to compare their behaviour with or they don't have anything they can do about it,
then there are problems.
So one would predict that having an intervention that included a goal or standard would be helpful along with feedback along with the action planning.
So for example, right now I've got a goal to keep you interested for the next 10 minutes and so on, monitoring.
And if you fall asleep I'll probably change my behaviour. So I've got action plans that I can I can do.
So very simply from that theory, feedback should be more effective when there's a goal or target.
Okay, this seems blindingly obvious. Okay. But people don't use this.
And most effective where you've got an action plan for if you see a discrepancy.
Okay. Does that make sense? Yeah.
So you're creating this theory as you just extract the different interventions you have as the results are in a big mistake,
not a mistake from what you've taken out. You coming up with the theory.
Yeah. So to order the feedback, how to think about it.
So it's actually I'm presented in the best order here thought, okay, here's a theory,
here's a theory that would explain how it's working with certain techniques.
And then instead of that funny way of categorising interventions, categorise them in terms of aspects of goals, action plans and feedback.
Okay. And so very simply, we were saying that if you got a goal along with the feedback, it'd be more effective than only feedback.
And if you got a goal feedback and you got an action plan, so you got something you can do about it.
If you see a discrepancy between the goal and your current performance, that would be most effective, right?
Very simple. Okay. So within that review, there were 61 comparisons for feedback only.
This tells the story, just this data.
I'm going to tell you that feedback plus goal eight comparisons, feedback plus goal plus action plan three comparisons.
So we weren't able to do the analysis. There wasn't enough data and less social science and medicine.
They were interested in approach enough to publish a paper that said, Well, we can't think about it.
But this shows that if the primary researchers had an idea about behavioural science,
they'd be doing different research to begin with because obviously systematic reviewing, you can only review what's out there.
So that was all rather sad. But Noah Ivers came along on his white horse in 2012.
Updated the review, got enough data to come forward, board our approach and say have 140 trials the usual thing small effect,
big variation and moderate analysis guided by these theoretical predictions.
And he finds that order and feedbacks more effective when combined with explicit targets on an action plan,
and the reviewer calls for better reporting and explicit use of develop hypotheses.
So so that's that kind of approach could be used with a lot of different systematic reviews.
And I think if we want the maximum out of what we're putting in, then we should be using, first of all,
deconstructing interventions into their component techniques and using theory to guide the analysis.
Three more minutes and then over to you. Yeah.
So I take your point about behavioural psychology and how you have a team pattern.
Everybody will have access to you. Yeah. What was the suggestion in that sense.
Well the well I say behavioural scientists so people it's not just psychologists who've got
an understanding of a behaviour and but that's why we have collaborations across cities and,
and countries. And you know, when I was setting up a program Grant Broad, even Grant who's chair of it, I was on the board and he said,
Well, we need people like you and all the different NIH are funding bodies and all people like you.
And I said, Yes, there are people like you. And I said some 20 names and he put something on all those different boards.
And so they are they're not it's a, you know, at least advise on on the funding.
So, you know, there are people around and yeah yeah I think the way and I was hooked up so it's been working okay.
And so finally I just want to present a framework that was developed as a result of working
with policymakers where often they come with new frameworks to do with behaviour change,
to say, what do you think about this? What do you think about that? And usually they're alright in parts, but a bit muddled or a bit too complicated.
And so I thought, well, it's empirical question,
why does I just look and see what's out there in terms of frameworks and and conducts a systematic review and evaluate them in terms of thinking?
Do they have a clear link to a model of behaviour?
Because if interventions don't start with really understanding behaviour that not that likely to be effective,
are they coherent and do they have comprehensive coverage and importantly of a usable by and useful to policymakers,
service planners and intervention designers? Okay, a thought experiment for you.
This is the model at the heart of this framework. So the question is for behaviour to change what three conditions need to exist
and anybody who's read my paper on the behaviour change will need your answer.
But the rest of you just think about what needs to change for behaviour to change.
Be the model of behaviour.
At the heart of this is called common B, so B stands for behaviour.
So the three factors A, something B and C an m.
Have you read my paper? Yeah. Yeah, we have both.
We probably all read the papers of all. Well, for those of you who happened in US legal system to prove that somebody committed a crime,
you have to prove three things that the person had motivation and motivation.
That's the end. Basically. Maturity, opportunity.
You know, the skills. Yep. Comprehensive skills.
Capability. Exactly. Very good. There we go. And and and I put this in terms of a system with double heads.
It's Ira is because this once wanting to change behaviour, then one can change motivation directly.
But also you can go through capability and opportunity.
And by changing behaviour there's a knock on effect back on capability, motivation, opportunity.
So this is a really simple way of thinking about behaviour but really useful.
So if you're working with anybody thinking about changing behaviour, I'd really recommend helping people think about this.
And government and government, they love it all departments because it, you know, they can understand it and they can apply it.
It makes sense. One can get bit more complicated.
And so capability, oops, wrong direction and the psychological which is basic knowledge and skills or physical ability.
This motivation is reflexive and automatic.
These are kind of psychology terms, but reflexive is the systematic, reflexive, conscious decision making weighing up pros and cons.
Okay, rational approach to to behaviour.
And we all like to think those are the influences on bad behaviour.
The truth is that a lot of our behaviour is influenced by more automatic mechanisms to
do it drives JS emotions habits is that we read the book Blink by Malcolm Gladwell.
Yeah. Okay, so there's all about this.
And David Kahneman has written a very good book, Too Fast and thinking Fast and Slow or something, which is about these two systems.
And we can have a whole talk on that.
But basically really important to think about the two aspects of motivation and opportunity, obviously the physical environment,
but the social environment is absolutely key in terms of influencing behaviour and
chance that some of you have been working with the theoretical domains framework,
which is another framework I've developed and I can sense a shower in office,
a different talk, which shows that basic theoretical domains framework is more complicated.
So those six are basically subdivided and you get to the framework that you've been working with.
Okay, so systematic review identified 19 frameworks and this was health, environment, culture change,
social marketing, etc. None of them met the criteria that with all the criteria that we've identified.
And so what we did was put the this common model of behaviour at the hub of a wheel and then all those
19 frameworks we synthesise them and they were based nine intervention functions that they fitted into.
This is published and implementation science and open access and lots of supplementary files.
So actually if you just Google behaviour change wheel you'll get to it.
But it shows all the different frameworks and all the steps we we went through to synthesise them but basically nine intervention functions
and then we identified that some of them were different to different levels and some of them were what we call policy categories.
So these were categories of things that could enable or support interventions to occur.
And here's the coming model. But I've put it into a hub of a wheel like this, and these are the interventions.
So we've got restrictions education, persuasion, incentivization, coercion, training, enablement,
modelling and environmental restructuring and the behaviour change techniques I showed you before.
Each one of these will have many behaviour change techniques that can be used to to deliver an
intervention and then the policy categories that were there to support to enact these stuff out there.
Guidelines, environmental and social planning, communication, marketing legislation, service provision, regulation and fiscal measures.
Nice currently is updating its behaviour change guidance and so it's been at poor systematic review is who are doing the work for the.
They've had to use the behaviour change technique approach and all of this to try and make sense of the evidence synthesis,
which is kind of an interesting process and I hope we've left enough time for a bit of a discussion.
And so summarising,
I hope I've convinced you that implementing evidence based practice depends on behaviour change and that interventions have been only moderately
effective and this could be improved by improving methods and using paper science and specifically better methods for specifying interventions,
ensuring good fidelity of delivery and theoretical understanding of behaviour and just acknowledgements.
Robert West Murray Johnson Who are the key collaborators in this work and my research team, and that is the behaviour change.
We like that discussion. So thank you.