Theory and Complex Interventions

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Theory and Complex Interventions

• Marie Johnston
• Jill Francis
• IAHS seminar 11th March 2008

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Questions

• Why, when and how is theory important?
• Developing complex interventions
• Evaluating complex interventions

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MRC framework for development and evaluation of
complex interventions
Cumulative knowledge base
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What makes interventions complex?

• Behaviour (change)
• Which behaviour?
• Whose behaviour? (individual, group,
  organisation)
• Intervention
• Number of active ingredients
• Mode of delivery
• Flexibility of delivery
• Reporting
• Outcomes
• Multiple
• Primary

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Why is theory important?

• Suggests interventions based on
• proposed causal relationships
• existing evidence
• Explains results
• Where no effect
• To enhance effects
• Results contribute to a cumulative evidence base

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Intervention without theory OXCHECK trial

• reduced
• Serum cholesterol
• SBP/DBP
• BMI
• but
• Dissatisfied by amount of change
• Unable to explain change achieved
• Unable to describe potentially active ingredients

• Johnston M. (1995). Health Related Behaviour
  Change. In Cardiovascular Prevention in Primary
  Care The Way Forward. National Forum for
  Coronary Disease Prevention. Edited by I Sharpe.
  Kings Fund London pp37-47
• Imperial Cancer Research Fund Oxcheck study.
  Effectiveness of health checks conducted by
  nurses in primary care final results of the
  Oxcheck study. BMJ 19953101099-104.

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Intervention without theory SHIP trial

• did not reduce
• Serum cholesterol
• SBP/DBP
• BMI
• but
• Did increase attendance at the nurse clinic
  delivering the intervention
• Content of intervention unclear (cf little red
  pill)

Mant et al. Randomised controlled trial of
follow up care in general practice of patients
with myocardial infarction and angina final
results of the Southampton heart integrated care
project (SHIP) BMJ 1999318706-711
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Implicit models
ISLAGIATT principle
It Seemed Like A Good Idea At The Time
Martin P Eccles
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Predominant Implicit Theories

• Personality
• mad/sad/bad
• fundamental attributional error
• Evidence that underestimates importance of
  situational factors
• Knowledge/Information
• Conflicts with evidence

information
knowledge
attitudes
behaviour
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Theory

• Defines constructs (variables)
• Essential to measurement of outcomes
• Specifies relationships between constructs
• Therefore offers explanations
• Identifies causal mechanisms
• therefore indicates how to intervene

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Theory in Complex Interventions

• Complex interventions involve behaviour
• of patients, healthcare professionals etc.
• Theories of behaviour and behaviour change
• indicate determinants that might be changed to
  enhance outcomes
• May specify relevant behaviour change techniques
• Specify active ingredients of intervention
• Improve reporting of intervention

Health outcomes
Determinants of behaviour
Behaviour
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Using Theory to develop an intervention
Choosing a Theoretical Approach
Selecting behaviour change techniques active
ingredients
Predictive Modelling
Intervention development Modes of
delivery acceptability
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Choosing a theoretical approach many theories of
behaviour

• 33 theories and 128 constructs generated
• In four overlapping areas
• motivation
• action
• organisation
• behaviour change
• Simplified into 12 domains of theoretical
  constructs
• Interview questions associated with each domain

Michie, S., Johnston, M., Abraham, C., Lawton,
R., Parker, D. and Walker, A. (2005) Making
psychological theory useful for implementing
evidence based practice a consensus approach,
Quality and Safety in Health Care, 14, 26-33.
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Motivation theoriesexplain why people want to do
things

• Theory of Planned Behaviour
• Theory of Reasoned Action
• Protection Motivation Theory
• Health Belief Model)
• Social Cognitive Theory
• Locus of control theories
• Social Learning Theory
• Social Comparison Theory
• Cognitive Adaptation Theory
• Social Identity Theory

• Elaboration Likelihood Model
• Goal Theories
• Intrinsic Motivation Theories
• Self-determination theory
• Attribution Theory
• Decision making theories eg. social judgment
  theory, fast and frugal model, systematic vs.
  heuristic decision making
• Fear arousal theory

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Action theoriesexplain why people do things

• Learning theory
• Operant theory
• Modelling
• Self-regulation theory
• Implementation theory/automotive model
• Goal theory
• Volitional control theory
• Social cognitive theory
• Cognitive Behaviour therapy
• Transtheoretical model
• Social identity theory

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Organisation theoriesexplain how groups and
organisations influence what people feel and do

• Effort-reward imbalance
• Demand-control model
• Diffusion theory
• Group theory eg. group minority theory
• Decision making theory
• Goal theory
• Social influence
• Person situation contingency models

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Consensus list of construct domains

• Knowledge
• Skills
• Professional role and identity
• Beliefs about capabilities
• Beliefs about consequences
• Motivation and goals
• Memory, attention and decision processes
• Environmental context and resources
• Social influences
• Emotion
• Action plans
• Nature of the behaviour

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Example of constructs in one domainBeliefs about
own capabilities

• Self-efficacy
• Control of behaviour, and material and social
  environment
• Perceived competence
• Self-confidence/professional confidence
• Empowerment
• Self-esteem
• Perceived behavioural control
• Optimism/pessimism

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Beliefs about own capabilities Questions

• How difficult or easy is it for them to do x?
  (prompt re. internal and external
  capabilities/constraints)
• What problems have they encountered?
• What would help them?
• How confident are they that they can do x despite
  the difficulties?
• How capable are they of maintaining x?
• How well equipped/comfortable do they feel to do
  x?

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Selecting behaviour change techniques

• Some theories define the techniques
• e.g. Bandura specifies techniques for changing
  self-efficacy
• Mastery
• Vicarious
• Persuasion
• Physiological
• Matching techniques to theoretical constructs
• Developing taxonomy of techniques

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Matching behaviour change techniques to
theoretical constructs
agree use agree dont use disagreement
indefinite
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Number of behaviour change techniques matched to
theoretical constructs
.. .. ..
.. .. ..
Number of techniques
Theoretical constructs
Michie, S., Johnston, M., Francis,J. et al (in
press) From theory to intervention mapping
theoretically derived behavioural determinants to
behaviour change techniques. APIR
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Results

• Agreement about link between 35 techniques and 11
  domains of theoretical constructs (385 judgments)
• 71
• 12.2 agreement that would use (effective)
• 59.5 agreement that would not use (ineffective)

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Modelling the theoretical processes

• Theoretical process modelling
• is the behaviour (or its determinants) predicted
  by the theory?
• By which constructs?
• Intervention modelling experiments (IMEs)
• Does the proposed behaviour change technique
  change
• determinants of behaviour?
• Proxy measures of behaviour?

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Theoretical process modelling

• Predicting 5 evidence-based clinical behaviours
• Doctors and dentists
• Multiple theories
• Operant Learning Theory
• Social Cognitive Theory
• Theory of Planned Behaviour
• others

Walker, A., Grimshaw, J.M., Johnston, M.,
Pitts, N., Steen, N. and Eccles, M.P. (2003)
PRIME PRocess modelling in ImpleMEntation
research selecting a theoretical basis for
interventions to change clinical practice. BMC
Health Services Research 2003, 322
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Predicting intention from theories variance
explained
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Predicting behaviour from theories variance
explained
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Intervention modelling experiments (IMEs)
Example

• GPs prescribing antibiotics for URTIs
• Predictive modelling
• 3 theories - 2 predictors
• Self-efficacy
• Consequences
• Two interventions
• Persuasive communication to change perceived
  consequences
• Graded task to change self-efficacy
• Outcomes for the IME
• Intention
• Behavioural simulation

Hrisos S, Eccles MP, Johnston M, Francis JF,
Kaner EFS, Steen IN, Grimshaw J. (2008). An
intervention modelling experiment to change GPs
intentions to implement evidence-based practice
Using theory-based interventions to promote GP
management of upper respiratory tract infection
without prescribing antibiotics. BMC Health
Services Research, 810
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Persuasive Communication Intervention

• Dr A, in the first row of scenarios, manages
  URTIs by prescribing antibiotics, while Dr B, in
  the second row of scenarios, manages URTIs
• without prescribing antibiotics.
• With respect to managing patients with URTI
• Who do you try to be like?
• 100 like Dr A
  100 like Dr B
• Who are you actually like?
• 100 like Dr A
  100 like Dr B

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Persuasive Communication Intervention Dr A
Not another four extras with sore throats
wanting antibiotics!
Im sorry I gave you my cold, here, have some of
the antibiotics Dr A gave me.
Im worried about our Colin, hes got a dreadful
cough and a sore throat.
Penicillin 3 times daily
You should take him to Dr A for some antibiotics
More sore throats does Dr A have any
appointments left for this week?
Dr A manages patients with URTI by prescribing
antibiotics
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Persuasive Communication Intervention Dr B
No extras today. Ill enjoy this cup of tea
before I start my visits!
Our Martin had that last week a couple of days
on Calpol and he was fine
Im sorry I gave you my cold here let me give
you some Paracetemol
Im worried about our Colin, hes got a dreadful
cough and a sore throat.
Paracetemol, drinks, bed rest
Thats another flu vac clinic booked up
Dr B manages patients with URTI symptomatically
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Graded Task Intervention hierarchy
Graded Task Intervention SECTION ONE Task 1 A).
The following is a list of five situations
relating to the management of sore throat. The
situations have been ranked from easiest to most
difficult based upon the experience of fellow GPs
of the management of URTIs. Starting with number
1, consider each situation in turn. Place a tick
in the box on the right to indicate how confident
you are that you could achieve each situation.

• Could you confidently
• 1. End a consultation for a patient with an URTI
  without prescribing an antibiotic
• 2. Manage patients with URTIs, without an
  antibiotic, who have already tried to self
  medicate for an URTI
• 3. Manage patients with URTIs, without an
  antibiotic, who expect you to prescribe an
  antibiotic
• 4. Manage patients with URTIs, without an
  antibiotic, whose symptoms are distressing them
• 5. Manage patients with URTIs, without an
  antibiotic, who have a past history of chronic
  obstructive airways disease
• If ALL your responses are YES, can you think of a
  situation in which you would find it difficult to
  manage a patient with URTI without an antibiotic?
  Please describe this situation below and then GO
  TO Part C
• ii) If you have responded NO or MAYBE to any or
  all of the five situations above, select FROM
  THEM the situation which you find the LEAST
  difficult.

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Graded Task Intervention planning

• Imagine yourself with a patient in the situation
  you have described or selected above.
• Make a list of all possible alternative
  management strategies for that situation.
• _________________
• ______________________
• Thinking about the strategy or strategies that
  you think would be most clinically appropriate
  and feasible, make a plan of what you will
  actually do to manage your chosen situation in
  the future. Write your plan below
• ______________________
• _________________

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Results Intention
Table 4
Beta
Persuasive Communication
Graded Task
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Results Behavioural Simulation
Table 4
Beta
Persuasive Communication
Graded Task
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Theory specifies techniques Operant Learning
Theory (OLT)

• Behaviour change depends on changing antecedents
  and/or consequences

B behaviour
C Consequences e.g. reward/punishment
A antecedents
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Theory specifies techniquesOperant Learning
Theory

• Consequences
• Reinforcement
• Reward/punishment
• Antecedents
• predict reinforcement
• A ? B ? C

Change behaviour by changing A or C
http//www.bfskinner.org/Operant.asp
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Intervention for Dentists (EBP sealants)Operant
Learning Theory vs Education (atheoretical)
Research Design
Clarkson et al (2006) The effects of remuneration
and education on the implementation of research
evidence to reduce inequalities in oral health.
Report to CSO
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Effects of Contingent Reinforcement on Dental EBP
Mean children with sealant per dentist
Operant increased rate of Evidence-based practice
(fissure sealants) Education had no effect
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Intervention fit for trialling

• Active ingredients
• based on theory
• Techniques can be satisfactorily reported
• Theoretical modelling study
• Control condition
• May contain active ingredients
• Should be equally well specified
• Acceptability
• Intervention
• Mode of delivery

Provider Recipient Administration
(format) Setting Intensity Duration
Davidson et al. 2003 Annals of Behavioral Medicine
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Fidelity of delivery and process

• Delivery
• Were the techniques delivered?
• Pro-Active
• Large of intervention time not using techniques
• Reduced use of techniques with time
• Process
• Did the intervention change the targeted
  constructs?

Hardeman, W., Michie, S., Fanshawe, T. Prevost,
AT., McLoughlin, K. Kinmonth, AL. (in press)
Fidelity of delivery of a physical activity
intervention Predictors and consequences.
Psychology and Health.
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Process Evaluation Example

• Intervention to reduce frequency of extraction of
  3rd molars
• No significant effect
• Intervention increased knowledge (as intended)
• But knowledge did not predict extraction
  behaviour
• Intervention did not affect the variables that
  did predict behaviour

Bahrami M, Deery C, Clarkson JE, Pitts NB,
Johnston M, Ricketts I, MacLennan G, Nugent ZJ,
Tilley C, Bonetti D, Ramsay C (2004)
Effectiveness of strategies to disseminate and
implement clinical guidelines for the management
of impacted and unerupted third molars in primary
dental care a cluster randomised trial.
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Evaluating the outcome

• Interventions target identifiable outcomes
• Outcome measures of convenience may not measure
  the required outcome
• Use of theory in specifying health outcomes
• Atheoretical measures
• not clear what health outcome measures measure
• same measure attributed to different constructs
• e.g. SF36 used to measure
• health status, quality of life, functional
  limitations

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Theoretical approach to Health Outcomes ICF
Model

World Health Organisation 2001
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What are existing measures measuring?
Discriminant Content Validity of items
classified to each construct
Pollard Johnston, Soc. Sci. Med, Pollard,
Johnston Dieppe. J. Rheum,
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Examples of Impairment, Activity Participation
items
I Have you had any sudden, severe painfrom the
affected joint ? How long has your morning
stiffness lasted from the time you wake
up? A What degree of difficulty do you have
walking? What degree of difficulty do have
dressing yourself? P How does your joint
problem stop you getting on with people? How
does your joint problem restrict you affording
things you need?
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Conclusions using theory in complex
interventions how?

• Theory specifies how to change behaviour
• Theory specifies determinants of behaviour which
  can be changed using behaviour change techniques
• Theory can be tested in modelling studies
• Fidelity of delivery of theoretical processes can
  be monitored in evaluation studies
• Theory indicates relevant outcome variables

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Conclusions using theory in complex
interventions why? and when?

• Why?
• Identifies general principles that can be applied
  to many interventions
• Accumulation of evidence
• Difficult in progressing if atheoretical or
  implicit theories
• When?
• Designing intervention
• Reporting intervention and control conditions
• Evaluation
• Outcome measurement
• Fidelity and process evaluation

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Using Theory Advances Science of intervention to
change behaviour
Describe interventions and behaviour
Accumulate evidence within theoretical framework
Develop more effective interventions
Refine theory
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Thank You