1 00:00:01,350 --> 00:00:06,000 Somebody. And Sharon McCann, the director of studies for the NSA evidence based health care. 2 00:00:06,300 --> 00:00:09,510 And I'd like to introduce and welcome to Oxford today. 3 00:00:09,750 --> 00:00:19,110 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. 4 00:00:19,440 --> 00:00:22,710 And I guess we talked about a couple earlier on. 5 00:00:23,100 --> 00:00:29,159 I think probably it's important to say that Susan started her career as a clinical psychologist studying here at Oxford, 6 00:00:29,160 --> 00:00:37,770 both as undergrad and postgraduate. So that's welcome back. Susan has done an amazing amount of work synthesising behavioural theory for 7 00:00:37,770 --> 00:00:41,940 understanding for use of those of us who don't have a strong behavioural background, 8 00:00:42,150 --> 00:00:45,960 which I think is fantastic and we've been talking about that a lot this week. 9 00:00:46,650 --> 00:00:53,639 She's also had a strong and massive international contribution to work around implementation. 10 00:00:53,640 --> 00:01:01,860 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. 11 00:01:02,100 --> 00:01:05,760 And for those of us who've been talking about complex interventions this week, 12 00:01:06,210 --> 00:01:11,460 we have referred to the Medical Research Council guidelines on complex intervention. 13 00:01:11,730 --> 00:01:16,260 Susan was an author, a model. So so without saying anything further, 14 00:01:16,260 --> 00:01:24,480 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? 15 00:01:24,780 --> 00:01:27,870 Thank you. Well, thank you very much and very good to be here. 16 00:01:27,900 --> 00:01:31,440 I've been to other talks at Calyx College and I always enjoyed them, 17 00:01:31,440 --> 00:01:39,989 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. 18 00:01:39,990 --> 00:01:46,680 And it's a very big subject. So I've just pulled out some, but I hope we'll get the conversation going. 19 00:01:47,340 --> 00:01:54,840 So I'm starting off with, I'm sure, a schematic representation you're all very well familiar with. 20 00:01:55,110 --> 00:01:59,190 What are all the gaps between getting evidence into practice? 21 00:01:59,820 --> 00:02:08,970 We've got the very first one, the first gap often called of Can It Work in terms of efficacy, second gaps? 22 00:02:09,360 --> 00:02:12,810 Does it work in practice? The gap? 23 00:02:13,500 --> 00:02:21,630 Is it routinely delivered as it should be, and the final gap, the uptake by the patient or public. 24 00:02:22,020 --> 00:02:28,709 So if one's looking at the extent to which evidence as produced in the laboratory or the equivalence, 25 00:02:28,710 --> 00:02:37,620 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, 26 00:02:37,830 --> 00:02:41,310 there's ways in which there's a translational gap. 27 00:02:41,880 --> 00:02:48,540 And what I'm going to mainly address today is just this third one of implementation, 28 00:02:49,590 --> 00:02:54,690 which is what happens between the research trials and clinical practice. 29 00:02:56,580 --> 00:03:02,430 And there's quite a lot that's been written about wastage in research. 30 00:03:02,700 --> 00:03:09,930 And so despite increasingly good evidence about best practice, much is wasted because it's not implemented. 31 00:03:10,200 --> 00:03:14,489 And so good quality health care and best health outcomes may not be achieved. 32 00:03:14,490 --> 00:03:23,129 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, 33 00:03:23,130 --> 00:03:26,670 which is called Reducing Waste and Inefficiency in Medical Research. 34 00:03:27,210 --> 00:03:30,360 The papers have been invited and they're basically submitted. 35 00:03:31,080 --> 00:03:37,140 So I don't know what the timeline will be, but some of you will know Ian Chalmers and Paul Glasgow. 36 00:03:37,380 --> 00:03:42,360 So they have to have quite a large group of us have been involved in writing this series. 37 00:03:44,520 --> 00:03:48,690 Okay, so what to do about this situation? 38 00:03:49,080 --> 00:03:53,910 If one looks at the interventions that have been designed to improve implementation, 39 00:03:54,420 --> 00:03:59,370 one comes to the conclusion they've had modest and very valuable success. 40 00:03:59,760 --> 00:04:04,100 And I don't know if you're familiar with implementation science. 41 00:04:04,110 --> 00:04:07,320 It's an open access journal that deals with these issues. 42 00:04:08,100 --> 00:04:15,600 So just go to any sample of papers in there and it'll be a fairly consistent story. 43 00:04:17,400 --> 00:04:20,790 How do we improve implementation? Well, 44 00:04:20,820 --> 00:04:32,370 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. 45 00:04:32,910 --> 00:04:42,480 So we have health professionals, managers, ancillary staff, commissioners, policy makers to name just the groups that sponsor my mind. 46 00:04:43,620 --> 00:04:54,210 And implementation often depends on many different behaviours within these groups, but also complex system between them. 47 00:04:54,600 --> 00:05:00,870 So the first stage is really understanding behaviour before one jumps into thinking about. 48 00:05:01,310 --> 00:05:03,740 Time to change and improve it. 49 00:05:06,290 --> 00:05:14,060 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. 50 00:05:14,540 --> 00:05:23,930 And there is a science of behaviour, but behavioural signs is very seldom used to inform either intervention, design or evaluation. 51 00:05:25,250 --> 00:05:32,670 And just to give some examples of just behaviours in terms of professional behaviours, the kinds of things we're talking about. 52 00:05:33,230 --> 00:05:38,120 And I got quite a few of you are medics by background, making referrals, 53 00:05:38,120 --> 00:05:44,240 giving advice, prescribing drugs, keeping hands, clean, whole variety of behaviours. 54 00:05:45,010 --> 00:05:48,900 And there's a range of different studies. 55 00:05:49,010 --> 00:05:56,899 I've chosen a couple here in the Netherlands, estimated 30 to 40% of patients didn't receive health care. 56 00:05:56,900 --> 00:06:00,350 That would be described as evidence based. 57 00:06:00,890 --> 00:06:09,290 And in the US, another study showing up to 25% receive care that was unnecessary or even harmful. 58 00:06:09,800 --> 00:06:18,080 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. 59 00:06:19,280 --> 00:06:28,010 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. 60 00:06:28,550 --> 00:06:32,030 And one of them is a very basic issue. 61 00:06:32,840 --> 00:06:42,710 But the fact that interventions are not described in sufficient detail to be replicated or to be implemented effectively. 62 00:06:43,010 --> 00:06:48,590 So all the money that goes into the investment of very expensive trials, 63 00:06:48,770 --> 00:06:57,800 which in some cases establishes that interventions that are effective can then not be implemented because the detail is not there. 64 00:06:58,100 --> 00:07:07,430 And I'll show you how that differs when we talk about interventions to change behaviour compared to biomedical interventions. 65 00:07:08,330 --> 00:07:22,100 There's another issue which is that the protocols for interventions that some are used in or the protocols for interventions 66 00:07:22,100 --> 00:07:29,240 are to trialled often when it comes to what's the LibDem practice is very different than what's in the intervention protocols, 67 00:07:29,570 --> 00:07:33,740 and often that's not measured and so we don't know what the difference is. 68 00:07:34,010 --> 00:07:39,230 So that's another problem that's I will illustrate and say something about and 69 00:07:39,410 --> 00:07:44,500 and finally theories of behaviour and behaviour change are rarely applied. 70 00:07:44,930 --> 00:07:54,080 And if one doesn't have some kind of theoretical framework within which to think about one's interventions amongst evaluations, 71 00:07:54,470 --> 00:08:00,050 then you can show that an intervention has the start of the other effect in this situation. 72 00:08:00,530 --> 00:08:05,629 But you're very limited in terms of understanding the mechanisms of action and therefore how 73 00:08:05,630 --> 00:08:11,540 to optimise interventions in the future or how best to generalise across different contexts. 74 00:08:13,940 --> 00:08:24,470 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. 75 00:08:25,190 --> 00:08:29,660 So first of all, the issue about describing interventions, 76 00:08:30,980 --> 00:08:38,209 al-Shabaab said earlier all the interventions to improve implementation are complex in that they're 77 00:08:38,210 --> 00:08:45,560 comprised of several potentially interacting techniques and they're often very poorly described. 78 00:08:45,830 --> 00:08:51,680 So here I'm saying it's equivalent in biomedicine if you say it's a big red dry pill. 79 00:08:52,130 --> 00:08:58,730 So anybody who's done systematic reviews of interventions to improve implementation, 80 00:08:58,730 --> 00:09:07,100 I think will kind of understand what I'm saying about the poor descriptions and even where more detailed protocols are available. 81 00:09:07,490 --> 00:09:10,309 The terminology that people use is very variable, 82 00:09:10,310 --> 00:09:17,810 so people will be describing the same thing using different language or use the same words to describe different things. 83 00:09:18,230 --> 00:09:29,030 So really quite fundamental problems. If one is trying to look at this scientifically and these issues impede replication. 84 00:09:29,030 --> 00:09:32,960 So actually accumulating knowledge through replicating studies. 85 00:09:33,290 --> 00:09:38,180 As I said, for MPs implementation and it also impedes evidence synthesis. 86 00:09:38,330 --> 00:09:44,570 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? 87 00:09:46,520 --> 00:09:51,160 So here's an example. I mean, I've taken behavioural counselling. 88 00:09:51,170 --> 00:09:56,390 We could have taken any, any kind of term to illustrate the issue. 89 00:09:57,170 --> 00:10:05,660 Here's American Journal of Public Health and, and this description of what these authors meant by behavioural counselling. 90 00:10:06,170 --> 00:10:11,520 So I don't know what you think about how good that definition is. 91 00:10:12,710 --> 00:10:23,060 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. 92 00:10:24,170 --> 00:10:29,120 And as you can see, a completely different definition of behavioural counselling. 93 00:10:29,570 --> 00:10:32,600 And I could ask you what you think by that definition. 94 00:10:33,200 --> 00:10:38,630 And in some ways it doesn't really matter which is a better or worse definition. 95 00:10:39,080 --> 00:10:44,360 The issue is that they're different. So people may be thinking they're doing the same thing. 96 00:10:44,360 --> 00:10:52,549 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, 97 00:10:52,550 --> 00:10:59,600 you're synthesising very different things. And so obviously we need to do better than that. 98 00:11:00,680 --> 00:11:06,350 Just to give another example of pitting biomedicine against behavioural science, 99 00:11:06,350 --> 00:11:11,719 if one takes example of smoking cessation effectiveness, we have very varenicline, 100 00:11:11,720 --> 00:11:17,120 which is the most effective pharmacological intervention for smoking cessation and 101 00:11:17,120 --> 00:11:24,410 behavioural counselling as evaluated by Cochrane Gold Standard systematic review methods. 102 00:11:25,580 --> 00:11:28,730 Okay. So let's look at the biomedical example varenicline. 103 00:11:29,060 --> 00:11:34,700 That's the intervention content. If you get varenicline, you get that. 104 00:11:34,700 --> 00:11:39,920 If you get that, you get varenicline. You know where you are. Mechanism of action. 105 00:11:40,310 --> 00:11:43,940 I won't. Can you read it from the bag? Okay. 106 00:11:45,050 --> 00:11:50,810 I'll read about quickly. Activity is a subtype of the nicotine 8% and where it's binding produces agonistic 107 00:11:50,810 --> 00:11:54,470 activity while simultaneously preventing binding to eight B2 receptors. 108 00:11:54,740 --> 00:11:58,220 The point is that that's quite specific about how that works on the brain. 109 00:11:58,910 --> 00:12:02,360 Now we come to behavioural counselling. Here's the definition. 110 00:12:02,960 --> 00:12:05,420 Review smoking history and motivation to quit. 111 00:12:05,660 --> 00:12:12,770 Help identify high risk situations, generate problem solving strategies, non-specific support and encouragement. 112 00:12:13,340 --> 00:12:20,060 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. 113 00:12:20,870 --> 00:12:25,580 So that's the contents of this intervention. Having seen the content. 114 00:12:25,880 --> 00:12:29,420 Have you got ideas about what the mechanism of action is? 115 00:12:30,290 --> 00:12:36,020 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. 116 00:12:36,920 --> 00:12:40,130 You're probably struggling. So with the reviewers. 117 00:12:40,490 --> 00:12:49,100 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. 118 00:12:49,100 --> 00:12:54,650 But I don't know. But you can see we're really on the back foot and I've taken this is smoking cessation, 119 00:12:54,660 --> 00:12:58,970 but the same is true for interventions in relation to implementation. 120 00:13:01,340 --> 00:13:10,670 Presumably everybody is aware of CONSORT'S guidelines which have made a huge difference in improving the reporting of randomised controlled trials. 121 00:13:11,000 --> 00:13:15,680 And they say. For precise details. The interventions is actually administered. 122 00:13:17,480 --> 00:13:21,440 However, they don't say which precise details particularly. 123 00:13:22,520 --> 00:13:30,890 But a very good paper by Carrie Davidson back in 2003 identified some of the main dimensions we should think of. 124 00:13:30,920 --> 00:13:33,740 So, first of all, various aspects of delivery. 125 00:13:33,920 --> 00:13:42,390 So the modes of delivery, intensity, duration, those delivering, recipients setting, and when you read descriptions of interventions. 126 00:13:42,440 --> 00:13:50,780 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. 127 00:13:51,540 --> 00:13:54,890 And there's also adherence to delivery protocols. 128 00:13:56,210 --> 00:13:59,630 And then also the content or the elements of the intervention. 129 00:14:00,020 --> 00:14:05,390 These are the active ingredients that actually bring about things, behaviour, change. 130 00:14:05,600 --> 00:14:08,450 And there's usually very little about those and these. 131 00:14:08,750 --> 00:14:14,780 So it's rather like trying to cook a meal with lots of descriptions of all your cooking utensils, 132 00:14:14,780 --> 00:14:18,260 but very little about the actual food ingredients to use. 133 00:14:19,610 --> 00:14:23,990 So I'm just going to take content and talk a bit about that. 134 00:14:24,650 --> 00:14:29,510 But really what I'm saying about that's also true of these these other dimensions. 135 00:14:30,890 --> 00:14:34,460 So how should we describe the content of interventions? 136 00:14:35,810 --> 00:14:41,540 What I'm arguing is we need an agreed standard methods of describing interventions that should 137 00:14:41,540 --> 00:14:47,390 be accessible and supported across disciplines and countries and behaviours and contexts. 138 00:14:47,720 --> 00:14:56,870 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. 139 00:14:57,390 --> 00:15:02,390 And so in Canada it's knowledge translation. 140 00:15:02,810 --> 00:15:10,160 In the UK it's implementation science. In the US there's a lot of talk about quality improvement, improvement science. 141 00:15:10,520 --> 00:15:21,140 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 142 00:15:21,320 --> 00:15:30,170 from different disciplines together to see if we could get a shared terminology and a shared sets of frameworks about implementation, 143 00:15:30,170 --> 00:15:35,360 knowledge, translation, whatever you want to call it. And it was very interesting. 144 00:15:35,360 --> 00:15:41,870 Two days, I don't think we got very far, but it's it is a reflection of the the problem. 145 00:15:43,850 --> 00:15:49,700 I'm going to present a method of describing interventions that I've been developing, 146 00:15:49,700 --> 00:15:56,080 which is to describe interventions in terms of very specific behaviour, change techniques. 147 00:15:56,510 --> 00:16:03,860 And what do I mean by this? I mean the active ingredients designed to change behaviour that are observable, 148 00:16:03,860 --> 00:16:08,720 replicable and that basically the smallest components of an intervention that 149 00:16:09,050 --> 00:16:14,270 on their own in the optimal circumstances could bring about behaviour change. 150 00:16:14,420 --> 00:16:22,520 So really trying to get down to the smallest level. And now just to give you some idea of what I mean. 151 00:16:23,360 --> 00:16:26,690 This was the first what we call a taxonomy. 152 00:16:26,700 --> 00:16:28,070 This is actually a list. 153 00:16:29,420 --> 00:16:37,650 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. 154 00:16:37,670 --> 00:16:42,770 This was about interventions to change physical activity in healthy eating. 155 00:16:43,220 --> 00:16:48,980 And the interventions were very heterogeneous and very difficult to put together. 156 00:16:48,980 --> 00:16:54,860 So I thought, okay, just inductively. Try and look at what's in there in terms of component techniques. 157 00:16:55,730 --> 00:16:59,860 And you can see the last for relapse prevention, stress management. 158 00:17:00,110 --> 00:17:06,740 These are big groups of things, but there's no more detail than that to the articles, which is why they were there. 159 00:17:07,760 --> 00:17:15,740 So at least we could begin to define and specify the interventions using these techniques. 160 00:17:16,040 --> 00:17:24,139 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. 161 00:17:24,140 --> 00:17:33,830 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 162 00:17:33,830 --> 00:17:40,640 the same text or wanting to describe their interventions will be talking about the same thing. 163 00:17:41,420 --> 00:17:45,890 And by doing this, we were able to I'm not presenting this work, 164 00:17:46,130 --> 00:17:52,670 but we were able to use a statistical technique called matter regression to then identify which 165 00:17:52,670 --> 00:17:58,850 individual techniques had an effect over and above all those heterogeneous interventions. 166 00:17:59,750 --> 00:18:03,230 And in this particular review, we find that self-monitoring dates, 167 00:18:03,590 --> 00:18:08,030 and we were then able to use a theoretical approach to think about what other 168 00:18:08,030 --> 00:18:12,560 techniques would you predict would work synergistically in a complex fashion? 169 00:18:12,630 --> 00:18:18,270 And with self-monitoring to bring about even greater effect. 170 00:18:18,600 --> 00:18:25,290 And then compared the interventions that had those techniques with those that didn't and find that they were twice as effective. 171 00:18:25,770 --> 00:18:33,509 So by using this approach, we were able then to make recommendations about particular types of intervention 172 00:18:33,510 --> 00:18:38,140 that could be easily developed that are likely to be effective without this. 173 00:18:38,160 --> 00:18:46,170 All we do is say very high heterogeneity and small to modest effects, which is usually what you get from synthesising literature. 174 00:18:47,810 --> 00:18:56,480 Since then, our own colleagues have gone on to develop taxonomies for different kinds of behavioural domains. 175 00:18:56,810 --> 00:19:04,790 And we've just published this year a 93 item one that's building on all the published ones. 176 00:19:05,120 --> 00:19:08,120 And this has had the inputs of well, 177 00:19:08,120 --> 00:19:14,779 we have an international advisory board of 30 people around the world who are leaders in lots of different domains, 178 00:19:14,780 --> 00:19:20,140 because we wanted this to be something that would be owned internationally and across it, 179 00:19:20,410 --> 00:19:26,120 behavioural medicine or people who are interested in implementation or so, etc. 180 00:19:26,450 --> 00:19:35,209 And then we've had about 50 other behavioural experts across the world doing various kinds of work to produce this. 181 00:19:35,210 --> 00:19:40,640 It's a MRC funded project that's essential this year. 182 00:19:41,570 --> 00:19:48,500 So this is increasingly now being used to define behavioural inspections. 183 00:19:50,810 --> 00:19:55,310 And this as well as helping with evidence synthesis. 184 00:19:55,550 --> 00:20:08,690 This is also very helpful in establishing the extent to which intervention protocols are reported in a faithful way or not, 185 00:20:08,690 --> 00:20:11,720 and also the extent to which protocols is delivered in practice. 186 00:20:12,140 --> 00:20:16,730 So back to thinking about waste and research. 187 00:20:18,560 --> 00:20:23,450 We looked at the percentage of behaviour change techniques that were specified 188 00:20:23,450 --> 00:20:28,250 in intervention protocols compared to those that were reported in publications. 189 00:20:29,390 --> 00:20:33,380 With this kind of approach, one can't look at that in any detail. 190 00:20:33,650 --> 00:20:37,550 So what's your guess of. This was a Cochrane review. 191 00:20:37,790 --> 00:20:41,330 Again, this is interventions in terms of smoking cessation. 192 00:20:41,630 --> 00:20:46,020 So what's your guess is what percentage and 10%? 193 00:20:46,040 --> 00:20:49,930 Okay. What a pessimist it was. 194 00:20:49,940 --> 00:20:54,190 I mean, it was around the average was less than 50%. 195 00:20:54,530 --> 00:21:00,350 Probably some of them were ten. But there's quite a range. So this is a real problem for science. 196 00:21:00,650 --> 00:21:09,560 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. 197 00:21:09,890 --> 00:21:12,830 So a real plea, if you're doing evidence synthesis, systematic, 198 00:21:12,830 --> 00:21:21,860 reviewing the follow up and try and get protocols or any information from the authors to supplement what's in the published report. 199 00:21:22,400 --> 00:21:26,690 Most won't respond, but then you publish that because that's an empirical finding. 200 00:21:26,690 --> 00:21:32,480 And the more that the profile of that is raised, the more people will change their behaviour. 201 00:21:33,350 --> 00:21:36,890 It's getting much better now with electronic supplements, but still a real issue. 202 00:21:38,300 --> 00:21:41,990 And then if we think about so these are what's in the protocols, 203 00:21:42,230 --> 00:21:50,690 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 204 00:21:50,690 --> 00:22:01,610 they actually take recorded consultations and analyse them in terms of behaviour change techniques and looked at the comparison with protocols. 205 00:22:01,820 --> 00:22:16,770 What's your guess there? Well, in some cases, yes, they have. 206 00:22:16,920 --> 00:22:28,829 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 207 00:22:28,830 --> 00:22:35,260 extent to which the intervention is delivered in practice tend to be more advanced and more careful scientists. 208 00:22:35,260 --> 00:22:41,190 So I think those who actually publish this material are ahead of the game. 209 00:22:41,190 --> 00:22:48,390 And I reckon probably I would be surprised if your estimates not more realistic. 210 00:22:48,840 --> 00:22:51,000 However, I hope you can see the problem here, 211 00:22:51,300 --> 00:23:00,270 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? 212 00:23:00,690 --> 00:23:09,810 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. 213 00:23:10,320 --> 00:23:16,530 So these are really key issues and I'm amazed that we actually find anything out at all, 214 00:23:17,550 --> 00:23:21,360 but we can really improve if we can tackle some of these issues. 215 00:23:23,750 --> 00:23:24,770 And okay, 216 00:23:24,770 --> 00:23:34,640 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. 217 00:23:34,940 --> 00:23:42,110 And also this issue about how do you establish not just does something work, but also how it works. 218 00:23:42,500 --> 00:23:46,250 But before I go on, I've been talking a long time quite quickly. 219 00:23:46,520 --> 00:23:49,580 Any questions or comments on what I've said so far? 220 00:23:50,450 --> 00:23:57,620 Yeah, nothing about the previous slide delivery of of the principles that these are. 221 00:24:00,220 --> 00:24:07,420 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. 222 00:24:08,260 --> 00:24:15,489 But it's a good point to raise is that some protocols say, you know, you must do this, 223 00:24:15,490 --> 00:24:19,690 that and the other and specify exactly almost scripting what people should do. 224 00:24:20,050 --> 00:24:28,210 And other protocols are more evidence based principles that can be adapted and tailored in different situations. 225 00:24:28,540 --> 00:24:36,580 But they're always looking at the extent to which whatever level of specificity is in the protocol is actually reflected in practice. 226 00:24:37,180 --> 00:24:40,690 Yeah. Any other questions? 227 00:24:42,280 --> 00:24:48,030 Yeah, I'm just sort of thinking about how how you perceive sort of problem solution. 228 00:24:48,430 --> 00:24:58,530 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? 229 00:24:58,540 --> 00:25:03,579 That's an awful lot of stuff that you tend to be reaching out to have have like the trial. 230 00:25:03,580 --> 00:25:06,700 I just thought even on a good day you might not make it. 231 00:25:07,150 --> 00:25:13,270 Maybe part of the problem would be to sort of, you know, try to hone in on some key principles. 232 00:25:13,270 --> 00:25:21,340 And I guess that's what are those really key, very simple things that are very important. 233 00:25:22,120 --> 00:25:22,299 Well, 234 00:25:22,300 --> 00:25:31,210 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. 235 00:25:31,240 --> 00:25:35,590 So I completely agree with your observation. I think a lot of too complicated. 236 00:25:36,010 --> 00:25:44,709 So we've been looking at a telephone quitline for smoking cessation and where it's absolutely abysmal. 237 00:25:44,710 --> 00:25:51,700 This is the national quitline. But when you look at the protocols and what they're trying to follow is impossible. 238 00:25:52,120 --> 00:25:57,580 So part of the problem, part of the issue is actually making the protocols fit for purpose. 239 00:25:58,060 --> 00:26:03,670 I've got a PhD student looking at that because that's part of the translational problem. 240 00:26:04,000 --> 00:26:09,280 Yeah, that's a really good point. Okay. 241 00:26:09,560 --> 00:26:23,530 And I'm just going to illustrate this in terms of an intervention that was increasing physical activity amongst those who are at 242 00:26:23,530 --> 00:26:31,780 risk of type two diabetes because of family history and a sedentary lifestyle and illustrates an implementation problem there. 243 00:26:32,320 --> 00:26:39,610 And it was designed by an excellent group in Cambridge. 244 00:26:40,420 --> 00:26:46,960 It's includes 14 behaviour change techniques delivered by trained professionals in five sessions over 12 months, 245 00:26:47,260 --> 00:26:55,270 specified in very detailed manuals and protocols, and be asked to use 365 people. 246 00:26:55,900 --> 00:27:00,130 And the result was they increased activity by the companies of 20 minutes a day. 247 00:27:01,000 --> 00:27:04,710 However, that was true in both the control and intervention condition. 248 00:27:04,990 --> 00:27:10,000 So published in The Lancet in terms of trial, no result. 249 00:27:10,360 --> 00:27:16,960 If this has a behavioural science with them, they could have seen that their control was full of behaviour, change techniques. 250 00:27:17,440 --> 00:27:23,889 Their assessment, you know, going in for a day, having lots of questionnaires, were thinking about their own behaviour. 251 00:27:23,890 --> 00:27:28,270 They were getting feedback from lots of different physiological and behavioural tests. 252 00:27:28,630 --> 00:27:33,250 Sure, they're getting lots of support. They knew they're going to be reassessed and six months in a year's time. 253 00:27:34,150 --> 00:27:40,840 You know, it's such a shame because again, a lot of money gets put into this, but without it having a proper control. 254 00:27:41,140 --> 00:27:47,140 And I think that was effective, but you can't say it because of the active control condition. 255 00:27:47,290 --> 00:27:48,490 Anyway, that's another story. 256 00:27:49,360 --> 00:27:58,689 So here are the 14 techniques that were used as part of this, and there were four different theories that underpinned these. 257 00:27:58,690 --> 00:28:07,150 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. 258 00:28:08,200 --> 00:28:15,730 If you think about the implementation process of this particular intervention, those theories of behaviour change underpinning it. 259 00:28:16,060 --> 00:28:23,020 This was then translated into techniques in the manual, then delivered by professionals. 260 00:28:23,020 --> 00:28:26,739 Then the participant responded And then we have the target, 261 00:28:26,740 --> 00:28:33,910 which was to increase physical activity and we tape recorded and transcribe the sessions and 262 00:28:33,910 --> 00:28:42,070 then coded those trance training theories and did this for both professionals and participants. 263 00:28:43,300 --> 00:28:58,120 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. 264 00:28:58,330 --> 00:29:06,310 One of the concerns is that if you look at the for at the end habit formation prompts relapse prevention, generalising skills. 265 00:29:06,700 --> 00:29:11,050 These are the kinds of techniques that are really essential for maintenance. 266 00:29:11,350 --> 00:29:15,819 And if things are maintained, obviously they're a very limited use. 267 00:29:15,820 --> 00:29:27,940 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 268 00:29:28,490 --> 00:29:35,320 what are the techniques delivered according to the theories and I haven't really thought too much about theories. 269 00:29:35,440 --> 00:29:39,010 And in fact, this piece of work I did because I was at a conference where. 270 00:29:39,260 --> 00:29:50,150 The people doing this intervention said it's based on these theories and when we get the results of this trial, 271 00:29:50,360 --> 00:29:58,159 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, 272 00:29:58,160 --> 00:30:02,990 you really can't say that just because the theories were there in the background, 273 00:30:03,170 --> 00:30:07,340 it doesn't mean those theories are good explanation for what is actually happening. 274 00:30:07,670 --> 00:30:11,930 And so empirical question, we got some money and did this bit of work. 275 00:30:12,470 --> 00:30:18,290 So these are the techniques, according to these four theories self theory, plan, 276 00:30:18,290 --> 00:30:21,890 behaviour, self-regulation theory, learning theory, relapse prevention theory. 277 00:30:22,310 --> 00:30:31,370 So that's showing that those that were delivered were kind of mapping on to the what was in the protocol according to theory. 278 00:30:31,550 --> 00:30:36,770 So, so far, so good. You know, they can draw conclusions about the theories in the protocol. 279 00:30:37,340 --> 00:30:45,830 However, when we analysed the participants response and coded them according to the theories, it was a very different pattern. 280 00:30:46,220 --> 00:30:52,530 So the as the participant response because in terms of translation, you have to go all the way down to the end. 281 00:30:52,550 --> 00:30:56,990 If you think about the full gaps. And so this is the picture here. 282 00:30:57,320 --> 00:31:07,850 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, 283 00:31:08,180 --> 00:31:15,950 but the participants, their behaviour and what they were talking about was showing much more support for opera learning theory. 284 00:31:16,370 --> 00:31:24,170 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. 285 00:31:26,300 --> 00:31:32,570 So if one's looking at which theories best accounted for change, if you just looking at the delivery, 286 00:31:32,720 --> 00:31:39,170 you come to one conclusion, which is self-regulation theory has by far the biggest profile. 287 00:31:39,440 --> 00:31:45,890 But if you are looking at how participants are responding, then operate learning theory, which is basically reward says what that means. 288 00:31:46,070 --> 00:31:49,520 Keys and rewards is a better explanation. 289 00:31:51,980 --> 00:31:57,080 Okay, so just finishing off on models and theories. 290 00:31:58,490 --> 00:32:07,850 Why use these? Is there anybody here who thinks it's a really bad idea to use models and theories in general? 291 00:32:08,930 --> 00:32:13,550 Because sometimes you do get people who think you. No, it's a waste of time. 292 00:32:14,300 --> 00:32:18,500 Airy fairy. You're all signed up to it. Okay, very good. 293 00:32:18,770 --> 00:32:22,700 Well, these are the reasons that I think we need to use them. 294 00:32:23,630 --> 00:32:30,950 First of all, I think theories are a very good way of summarising what we know, bringing it together. 295 00:32:30,980 --> 00:32:36,080 Otherwise, all you've got are bits and pieces of empirical findings. 296 00:32:36,440 --> 00:32:40,820 So it's a framework where you can summarise and aggregate what we know. 297 00:32:42,260 --> 00:32:46,060 Very helpful in terms of structuring, thinking and guiding research. 298 00:32:46,800 --> 00:32:47,870 As I said before, 299 00:32:47,870 --> 00:32:58,999 they identify mechanisms of action so the evidence that can be used to improve interventions and then also importantly facilitating communication, 300 00:32:59,000 --> 00:33:05,840 because a lot of this work, especially implementation science, absolutely needs a multidisciplinary approach. 301 00:33:06,170 --> 00:33:14,780 And that does mean that people need to be able to communicate and share frameworks as well as language and importantly, 302 00:33:15,980 --> 00:33:20,450 frameworks between academics and what I'm calling knowledge users. 303 00:33:20,450 --> 00:33:23,810 So policymakers, intervention designers, practitioners. 304 00:33:24,050 --> 00:33:29,240 And the framework I'm going to present at the end was developed with that in mind. 305 00:33:29,840 --> 00:33:34,130 So I'm a big advocate. 306 00:33:34,460 --> 00:33:41,600 I mean, having said that, this is an issue about, well, which theories to select for which purposes and how best to apply them. 307 00:33:41,870 --> 00:33:47,149 And we're really a very early stage, as I would say, of beginning to address those questions. 308 00:33:47,150 --> 00:33:52,040 Well, and I've got another programme of research in that area. 309 00:33:53,630 --> 00:34:00,080 And one of the key things is we need simple, parsimonious, coherent, coherent and usable models. 310 00:34:00,350 --> 00:34:04,440 Because I'm a health psychologist and guilty, 311 00:34:04,490 --> 00:34:11,930 very guilty discipline of having lots and lots of different models and often very 312 00:34:11,930 --> 00:34:16,190 complex cases and often with very overlapping and redundant constructs in them. 313 00:34:16,580 --> 00:34:19,819 Not helpful. Okay. 314 00:34:19,820 --> 00:34:29,000 So I mentioned earlier the MRC guidance for developing and evaluating complex interventions that people aware of the one, 315 00:34:29,450 --> 00:34:32,900 the earlier one back in 2003 or whatever. 316 00:34:33,830 --> 00:34:39,070 So that was very much about really well where this came. 317 00:34:39,180 --> 00:34:50,100 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. 318 00:34:50,610 --> 00:34:55,349 And one of the reasons was that people weren't putting the investment into really doing the early 319 00:34:55,350 --> 00:35:01,020 formative work to really think about what kind of intervention would be likely to be effective. 320 00:35:01,320 --> 00:35:07,560 And so the first of the frameworks was really helpful. 321 00:35:08,520 --> 00:35:17,100 I should have shown it here. But in terms of putting more emphasis on this early development, feasibility and piloting stage. 322 00:35:17,790 --> 00:35:22,140 But the first framework said, you start here and you do that, 323 00:35:22,200 --> 00:35:28,380 and then you have exploratory trials and definitive trials, and then at the end you think about implementation. 324 00:35:28,890 --> 00:35:33,480 Big problem, because you could get and think about those full gaps in translation. 325 00:35:33,480 --> 00:35:38,190 You can get interventions that work very well in trials and then people say, Ah, well, 326 00:35:38,190 --> 00:35:44,460 now let's roll it out nationally and they are okay, not going to work because of this. 327 00:35:44,700 --> 00:35:52,320 The other hadn't been thought of. So one of the reasons for doing this was to put implementation, put it in a circle, 328 00:35:52,530 --> 00:36:00,750 put implementation case that that you need to think about implementation at the very first stages when you're first designing interventions. 329 00:36:01,200 --> 00:36:08,880 So that was part of what was behind this kind of new, new framework. 330 00:36:09,180 --> 00:36:19,770 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, 331 00:36:20,070 --> 00:36:27,930 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. 332 00:36:28,170 --> 00:36:34,980 So you evaluate, well, if it did work, does it work for the reasons that we postulated at the beginning? 333 00:36:37,410 --> 00:36:42,450 Any questions about that? Okay. 334 00:36:43,470 --> 00:36:53,080 So now I'm going to just say a bit about applying theory to systematic review and evidence synthesis. 335 00:36:54,630 --> 00:36:59,490 There was a Cochrane Review in 2006 about autism feedback, 336 00:36:59,760 --> 00:37:08,190 which is a very commonly used intervention to change professional practice and try and improve evidence based practice 337 00:37:08,190 --> 00:37:14,370 in clinical situations defined as any summary of clinical performance of health care over a specified period of time. 338 00:37:14,610 --> 00:37:28,110 That's feedback 118 trials and that the usual, you know, yes, it's affected to some extent massive variation over studies. 339 00:37:28,560 --> 00:37:39,000 And when they try to think, well, what explains variability, they compared intensive moderate and non intensive orders and feedback. 340 00:37:40,740 --> 00:37:46,380 And any of you who used to order the feedback, what is your understanding of intensive audit and feedback? 341 00:37:49,290 --> 00:37:55,130 Don't hazard a guess what you think intensive audio feedback means the Teddy Daily. 342 00:37:55,140 --> 00:38:00,150 Okay, there's this one suggestion so many calling up so far. 343 00:38:01,780 --> 00:38:05,460 Okay. Yeah, right. Daily harassment we got, so. 344 00:38:05,520 --> 00:38:10,170 Yeah. Oh, sorry. Monthly meetings. 345 00:38:10,530 --> 00:38:16,830 Okay, so at meetings. So we've got a kind of idea of frequency, kind of mode of delivery. 346 00:38:17,100 --> 00:38:22,660 I think you're speaking faster. Might be just looking at each and every aspect of this practice protected. 347 00:38:23,130 --> 00:38:31,680 Okay. Okay. Right. So kind of comprehensive type of thing, point of care, protein. 348 00:38:32,040 --> 00:38:35,880 Okay. Okay. These are all good suggestions. 349 00:38:36,690 --> 00:38:46,200 This is what they came up with. So individual that recipients getting the audit feedback and having a verbal format. 350 00:38:46,200 --> 00:38:56,460 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. 351 00:38:57,510 --> 00:39:03,899 Okay, non intensive group feedback not from a supervisor or senior colleague, 352 00:39:03,900 --> 00:39:07,530 all individual feedback advocate format and containing information that costs the 353 00:39:07,530 --> 00:39:14,300 number of tests that that person senses and moderate any other combination of factors. 354 00:39:14,310 --> 00:39:20,820 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. 355 00:39:21,090 --> 00:39:25,380 This looks like nonsense to me and no rationale for it. 356 00:39:25,590 --> 00:39:31,350 Yeah. Expensive. Cochrane Review. Those of you who do cop reviews, I don't know how much it costs for a Cochrane review. 357 00:39:31,950 --> 00:39:35,760 I wrote to the authors and said, What was your rationale? They said, We didn't have one. 358 00:39:36,210 --> 00:39:41,160 Okay. And. 359 00:39:41,340 --> 00:39:45,300 Okay, I was I was thinking the same. Sadly, this isn't unique. 360 00:39:45,780 --> 00:39:50,969 It's not unique. It's all so in that I won't go back to it. 361 00:39:50,970 --> 00:39:58,260 But base is a mixture of modes of delivery and content. There's no theoretical rationale for it, so no surprise. 362 00:39:58,260 --> 00:40:03,209 And they couldn't find any pattern effects. And there were a few recommendations for practice. 363 00:40:03,210 --> 00:40:11,190 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, 364 00:40:11,430 --> 00:40:14,310 when we're not going to learn by that sort of approach. 365 00:40:15,030 --> 00:40:24,990 So I thought, okay, let's reanalyse all of this data sets using behaviour change techniques and some theory. 366 00:40:25,620 --> 00:40:29,430 So we generate a theory based hypothesis concerning effectiveness. 367 00:40:29,910 --> 00:40:31,920 We independently code it. 368 00:40:31,920 --> 00:40:42,899 We just did 13 papers and we identified 28 behaviour change techniques from that and we grouped them into three lots of things. 369 00:40:42,900 --> 00:40:49,920 So goal or standard setting feedback can actually imply that that reliably just go with through this. 370 00:40:49,920 --> 00:40:55,110 But this gives you an idea of how we broke it all down, exactly what was happening. 371 00:40:55,110 --> 00:41:07,260 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. 372 00:41:07,860 --> 00:41:11,399 We would have had a theory of evolution if Don hadn't done his careful, you know, 373 00:41:11,400 --> 00:41:18,660 tiny descriptions of everything and then action plans, various different aspects of action plans. 374 00:41:20,400 --> 00:41:27,030 Okay. And we generated some hypotheses and published in social science medicine. 375 00:41:27,390 --> 00:41:30,719 And this is the theory we use, okay, self-regulation. 376 00:41:30,720 --> 00:41:37,140 So I mentioned earlier this is a very simple representation, but basically a homeostatic mechanism. 377 00:41:37,500 --> 00:41:41,820 And we're doing this all the time. You know, we have goals or standards for our performance. 378 00:41:42,180 --> 00:41:45,300 We compare our current behaviour with that standards. 379 00:41:46,890 --> 00:41:53,370 If we notice the discrepancy, we take certain steps to reduce this. 380 00:41:53,640 --> 00:42:02,910 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, 381 00:42:03,270 --> 00:42:04,380 then there are problems. 382 00:42:05,520 --> 00:42:15,630 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. 383 00:42:15,870 --> 00:42:24,709 So for example, right now I've got a goal to keep you interested for the next 10 minutes and so on, monitoring. 384 00:42:24,710 --> 00:42:30,180 And if you fall asleep I'll probably change my behaviour. So I've got action plans that I can I can do. 385 00:42:31,500 --> 00:42:36,990 So very simply from that theory, feedback should be more effective when there's a goal or target. 386 00:42:37,050 --> 00:42:42,060 Okay, this seems blindingly obvious. Okay. But people don't use this. 387 00:42:42,330 --> 00:42:46,620 And most effective where you've got an action plan for if you see a discrepancy. 388 00:42:47,160 --> 00:42:49,410 Okay. Does that make sense? Yeah. 389 00:42:50,260 --> 00:42:58,900 So you're creating this theory as you just extract the different interventions you have as the results are in a big mistake, 390 00:42:59,020 --> 00:43:02,220 not a mistake from what you've taken out. You coming up with the theory. 391 00:43:02,340 --> 00:43:05,549 Yeah. So to order the feedback, how to think about it. 392 00:43:05,550 --> 00:43:10,560 So it's actually I'm presented in the best order here thought, okay, here's a theory, 393 00:43:10,770 --> 00:43:16,740 here's a theory that would explain how it's working with certain techniques. 394 00:43:17,160 --> 00:43:26,190 And then instead of that funny way of categorising interventions, categorise them in terms of aspects of goals, action plans and feedback. 395 00:43:27,090 --> 00:43:38,880 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. 396 00:43:39,240 --> 00:43:44,440 And if you got a goal feedback and you got an action plan, so you got something you can do about it. 397 00:43:44,460 --> 00:43:52,260 If you see a discrepancy between the goal and your current performance, that would be most effective, right? 398 00:43:52,260 --> 00:43:59,640 Very simple. Okay. So within that review, there were 61 comparisons for feedback only. 399 00:44:00,900 --> 00:44:02,940 This tells the story, just this data. 400 00:44:02,940 --> 00:44:11,250 I'm going to tell you that feedback plus goal eight comparisons, feedback plus goal plus action plan three comparisons. 401 00:44:11,820 --> 00:44:18,600 So we weren't able to do the analysis. There wasn't enough data and less social science and medicine. 402 00:44:18,600 --> 00:44:24,870 They were interested in approach enough to publish a paper that said, Well, we can't think about it. 403 00:44:25,350 --> 00:44:30,239 But this shows that if the primary researchers had an idea about behavioural science, 404 00:44:30,240 --> 00:44:36,390 they'd be doing different research to begin with because obviously systematic reviewing, you can only review what's out there. 405 00:44:36,990 --> 00:44:43,150 So that was all rather sad. But Noah Ivers came along on his white horse in 2012. 406 00:44:43,360 --> 00:44:54,550 Updated the review, got enough data to come forward, board our approach and say have 140 trials the usual thing small effect, 407 00:44:54,760 --> 00:45:00,920 big variation and moderate analysis guided by these theoretical predictions. 408 00:45:00,940 --> 00:45:07,270 And he finds that order and feedbacks more effective when combined with explicit targets on an action plan, 409 00:45:07,660 --> 00:45:12,790 and the reviewer calls for better reporting and explicit use of develop hypotheses. 410 00:45:14,840 --> 00:45:22,870 So so that's that kind of approach could be used with a lot of different systematic reviews. 411 00:45:22,870 --> 00:45:29,770 And I think if we want the maximum out of what we're putting in, then we should be using, first of all, 412 00:45:30,550 --> 00:45:35,770 deconstructing interventions into their component techniques and using theory to guide the analysis. 413 00:45:37,030 --> 00:45:40,810 Three more minutes and then over to you. Yeah. 414 00:45:40,870 --> 00:45:45,910 So I take your point about behavioural psychology and how you have a team pattern. 415 00:45:45,970 --> 00:45:51,190 Everybody will have access to you. Yeah. What was the suggestion in that sense. 416 00:45:52,090 --> 00:45:58,419 Well the well I say behavioural scientists so people it's not just psychologists who've got 417 00:45:58,420 --> 00:46:07,690 an understanding of a behaviour and but that's why we have collaborations across cities and, 418 00:46:07,690 --> 00:46:19,660 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, 419 00:46:19,810 --> 00:46:25,690 Well, we need people like you and all the different NIH are funding bodies and all people like you. 420 00:46:25,690 --> 00:46:31,479 And I said, Yes, there are people like you. And I said some 20 names and he put something on all those different boards. 421 00:46:31,480 --> 00:46:36,850 And so they are they're not it's a, you know, at least advise on on the funding. 422 00:46:37,690 --> 00:46:48,310 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. 423 00:46:48,520 --> 00:46:57,370 And so finally I just want to present a framework that was developed as a result of working 424 00:46:57,370 --> 00:47:04,529 with policymakers where often they come with new frameworks to do with behaviour change, 425 00:47:04,530 --> 00:47:13,810 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. 426 00:47:14,140 --> 00:47:17,830 And so I thought, well, it's empirical question, 427 00:47:17,830 --> 00:47:31,360 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? 428 00:47:32,050 --> 00:47:34,660 Do they have a clear link to a model of behaviour? 429 00:47:34,660 --> 00:47:40,690 Because if interventions don't start with really understanding behaviour that not that likely to be effective, 430 00:47:40,840 --> 00:47:47,530 are they coherent and do they have comprehensive coverage and importantly of a usable by and useful to policymakers, 431 00:47:47,530 --> 00:47:53,740 service planners and intervention designers? Okay, a thought experiment for you. 432 00:47:56,380 --> 00:48:04,600 This is the model at the heart of this framework. So the question is for behaviour to change what three conditions need to exist 433 00:48:04,600 --> 00:48:09,670 and anybody who's read my paper on the behaviour change will need your answer. 434 00:48:11,470 --> 00:48:15,790 But the rest of you just think about what needs to change for behaviour to change. 435 00:48:19,790 --> 00:48:24,169 Be the model of behaviour. 436 00:48:24,170 --> 00:48:28,910 At the heart of this is called common B, so B stands for behaviour. 437 00:48:29,090 --> 00:48:32,900 So the three factors A, something B and C an m. 438 00:48:35,820 --> 00:48:41,410 Have you read my paper? Yeah. Yeah, we have both. 439 00:48:41,550 --> 00:48:53,860 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, 440 00:48:53,860 --> 00:48:59,379 you have to prove three things that the person had motivation and motivation. 441 00:48:59,380 --> 00:49:02,610 That's the end. Basically. Maturity, opportunity. 442 00:49:02,640 --> 00:49:06,130 You know, the skills. Yep. Comprehensive skills. 443 00:49:06,970 --> 00:49:16,879 Capability. Exactly. Very good. There we go. And and and I put this in terms of a system with double heads. 444 00:49:16,880 --> 00:49:23,560 It's Ira is because this once wanting to change behaviour, then one can change motivation directly. 445 00:49:23,560 --> 00:49:26,770 But also you can go through capability and opportunity. 446 00:49:26,950 --> 00:49:33,340 And by changing behaviour there's a knock on effect back on capability, motivation, opportunity. 447 00:49:33,670 --> 00:49:37,900 So this is a really simple way of thinking about behaviour but really useful. 448 00:49:38,080 --> 00:49:46,600 So if you're working with anybody thinking about changing behaviour, I'd really recommend helping people think about this. 449 00:49:46,600 --> 00:49:54,309 And government and government, they love it all departments because it, you know, they can understand it and they can apply it. 450 00:49:54,310 --> 00:49:57,940 It makes sense. One can get bit more complicated. 451 00:49:58,360 --> 00:50:08,320 And so capability, oops, wrong direction and the psychological which is basic knowledge and skills or physical ability. 452 00:50:09,490 --> 00:50:13,360 This motivation is reflexive and automatic. 453 00:50:13,360 --> 00:50:25,210 These are kind of psychology terms, but reflexive is the systematic, reflexive, conscious decision making weighing up pros and cons. 454 00:50:25,570 --> 00:50:30,370 Okay, rational approach to to behaviour. 455 00:50:30,910 --> 00:50:34,330 And we all like to think those are the influences on bad behaviour. 456 00:50:34,840 --> 00:50:39,999 The truth is that a lot of our behaviour is influenced by more automatic mechanisms to 457 00:50:40,000 --> 00:50:48,520 do it drives JS emotions habits is that we read the book Blink by Malcolm Gladwell. 458 00:50:49,240 --> 00:50:51,549 Yeah. Okay, so there's all about this. 459 00:50:51,550 --> 00:51:00,340 And David Kahneman has written a very good book, Too Fast and thinking Fast and Slow or something, which is about these two systems. 460 00:51:00,340 --> 00:51:02,229 And we can have a whole talk on that. 461 00:51:02,230 --> 00:51:09,580 But basically really important to think about the two aspects of motivation and opportunity, obviously the physical environment, 462 00:51:09,580 --> 00:51:14,200 but the social environment is absolutely key in terms of influencing behaviour and 463 00:51:14,200 --> 00:51:17,649 chance that some of you have been working with the theoretical domains framework, 464 00:51:17,650 --> 00:51:23,799 which is another framework I've developed and I can sense a shower in office, 465 00:51:23,800 --> 00:51:28,300 a different talk, which shows that basic theoretical domains framework is more complicated. 466 00:51:28,310 --> 00:51:34,240 So those six are basically subdivided and you get to the framework that you've been working with. 467 00:51:35,980 --> 00:51:42,070 Okay, so systematic review identified 19 frameworks and this was health, environment, culture change, 468 00:51:42,070 --> 00:51:52,180 social marketing, etc. None of them met the criteria that with all the criteria that we've identified. 469 00:51:52,690 --> 00:52:00,579 And so what we did was put the this common model of behaviour at the hub of a wheel and then all those 470 00:52:00,580 --> 00:52:09,430 19 frameworks we synthesise them and they were based nine intervention functions that they fitted into. 471 00:52:09,940 --> 00:52:16,479 This is published and implementation science and open access and lots of supplementary files. 472 00:52:16,480 --> 00:52:20,530 So actually if you just Google behaviour change wheel you'll get to it. 473 00:52:20,920 --> 00:52:29,530 But it shows all the different frameworks and all the steps we we went through to synthesise them but basically nine intervention functions 474 00:52:29,830 --> 00:52:37,060 and then we identified that some of them were different to different levels and some of them were what we call policy categories. 475 00:52:37,960 --> 00:52:44,050 So these were categories of things that could enable or support interventions to occur. 476 00:52:45,550 --> 00:52:53,530 And here's the coming model. But I've put it into a hub of a wheel like this, and these are the interventions. 477 00:52:53,530 --> 00:53:01,780 So we've got restrictions education, persuasion, incentivization, coercion, training, enablement, 478 00:53:02,260 --> 00:53:09,340 modelling and environmental restructuring and the behaviour change techniques I showed you before. 479 00:53:09,460 --> 00:53:16,900 Each one of these will have many behaviour change techniques that can be used to to deliver an 480 00:53:16,900 --> 00:53:25,180 intervention and then the policy categories that were there to support to enact these stuff out there. 481 00:53:25,180 --> 00:53:33,760 Guidelines, environmental and social planning, communication, marketing legislation, service provision, regulation and fiscal measures. 482 00:53:35,770 --> 00:53:45,100 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. 483 00:53:45,160 --> 00:53:52,510 They've had to use the behaviour change technique approach and all of this to try and make sense of the evidence synthesis, 484 00:53:52,510 --> 00:53:59,710 which is kind of an interesting process and I hope we've left enough time for a bit of a discussion. 485 00:53:59,950 --> 00:54:02,920 And so summarising, 486 00:54:03,760 --> 00:54:15,100 I hope I've convinced you that implementing evidence based practice depends on behaviour change and that interventions have been only moderately 487 00:54:15,100 --> 00:54:27,190 effective and this could be improved by improving methods and using paper science and specifically better methods for specifying interventions, 488 00:54:27,580 --> 00:54:34,840 ensuring good fidelity of delivery and theoretical understanding of behaviour and just acknowledgements. 489 00:54:35,710 --> 00:54:42,310 Robert West Murray Johnson Who are the key collaborators in this work and my research team, and that is the behaviour change. 490 00:54:42,310 --> 00:54:45,190 We like that discussion. So thank you.