Theories and Techniques of Behaviour
Change and their Application to Speech and
Language Therapy Interventions
Dr. Caroline Wood
UCL Centre for Behaviour Change
The UCL Centre for Behaviour Change
CBC Team
CBC Associates
CBC Volunteers
Key aims:
•
To increase the quality and quantity of research in behaviour change at UCL
•
Build communities to facilitate the engagement of policymakers, practitioners and
researchers with expertise in behaviour change (e.g. project input and collaborative
work)
•
Host cross-disciplinary events addressing social, practical and methodological issues
•
Provide teaching and training in principles and practice of behaviour change
But first:
Some important
definitions…
What do we mean by ‘behaviour’?
Agreed across disciplines of psychology, sociology, anthropology and economics
– “Anything a person does in response to internal or external events
– Actions may be
• overt (motor or verbal) and directly measurable, or
• covert (activities not viewable but involving voluntary muscles) and indirectly
measurable;
– behaviours are physical events that occur in the body and are
controlled by the brain”
Hobbs, Campbell, Hildon, & Michie, 2011
What is a ‘behaviour intervention’?
“An action or set of activities to get individuals to behave
differently from how they would act without such an action”
It can change …
how people behave
how often they perform a behaviour
how long they act for
over what time period
• Considerable recent interest and investment into developing and evaluating health
behaviour change interventions (HBCIs)
• Increasing evidence for the effectiveness of HBCIs
• Rise in wide use and implementation of these interventions in areas beyond research:
Health services, public health practices and areas of social policy (Craig et al. 2008)
Intervening at different levels…
smoking cessation, increasing
physical activity, medication adherence
service delivery (medical
procedures and techniques)
adherence to
guidelines, complying with policy
“Can language therapy strategies and resources
developed for spoken language bring observable
change to Deaf adults’ therapeutic skills?”
Joanna Hoskin, Bencie Woll & Ros Herman
“Investigating the impact of a structured online
environment (‘Better Conversations with Aphasia’)
for Speech and Language Therapists (SLTs) to
develop their skills in delivering conversation
therapy”
Suzanne Beeke, Firle Beckley, Wendy Best et al.
“Improving transitions across SLT services in
Greater Glasgow and Clyde for adults with longterm speech, language, swallowing or
communication (SLSC) needs: a qualitative study
of SLTs’ and service users’ views”
Elspeth McCartney & Margaret Muir
Intervention design: Where to start?
MRC Guidance1 for developing and evaluating
complex interventions:
Tendency to use the ISLAGIATT2 principle of
intervention design…
1.
2.
Craig et al, 2009 BMJ
Martin Eccles, Emeritus Professor of Clinical Effectiveness
So how can we do better?
 Use an integrative theoretical framework
• i.e. a framework that integrates a wide range of theories
 Take a systematic approach to intervention design
• Start by understanding your target behaviour in context
• Make a behavioural diagnosis
• Design an intervention based on the behavioural diagnosis
Understand the problem
Make a diagnosis
Prescribe treatment
The key questions:
1. What exactly do we want the person to do?
2. What will it take to get them to do it?
3. How do we get them to do it?
4. How do we roll out the intervention?
The key questions:
1. What exactly do we want the person to do?
2. What will it take to get them to do it?
3. How do we get them to do it?
4. How do we roll out the intervention?
Specifying the target behaviour:
When do they need to do it?
Who needs to do what
differently to achieve the
desired change?
Where do they need to do it?
How often do they need to do it?
With whom do
they need to do it?
In what context do
they need to do it?
Target behaviour should be specific:
e.g. ‘Eat xxx fewer calories per day for xx days’ is more specific than ‘eat less’
A worked example…
Proposed intervention:
Target behaviour = Increasing participation in
parent-toddler language promotion programme
Target population = Parents
The key questions:
1. What exactly do we want the person to do?
2. What will it take to get them to do it?
3. How do we get them to do it?
4. How do we roll out the intervention?
The COM-B: A simple model to understand behaviour…
Psychological or physical ability to enact
the behaviour
Reflective and automatic mechanisms
that activate or inhibit behaviour
Physical and social environment that
enables the behaviour
Michie et al (2011) Implementation Science, 6, 42
The Behaviour Change Wheel
…result of synthesising 19 frameworks to classify interventions (health,
environment, culture change and social marketing)
Michie et al (2011) Implementation Science, 6, 42
Proposed intervention:
Target behaviour = Increasing
participation in parent-toddler
language promotion
programme
Target population = Parents
Behavioural diagnosis:
“I don’t have time”
“We don’t have a car to get to
the sessions”
Results of behavioural
diagnosis:
Physical opportunity
…needs to shift in order for the
behaviour to occur
The key questions:
1. What exactly do we want the person to do?
2. What will it take to get them to do it?
3. How do we get them to do it?
4. How do we roll out the intervention?
Select
intervention functions…
Inner ring:
•
9 intervention functions (what
purpose does the intervention serve?)
Refer to Michie et al. (2011) or to BCW guide
(Michie et al. 2014)
Appropriate intervention
functions include:
Restrictions
Environmental restructuring
Enablement
Training
Changing the physical or
social context
E.g. “Sending a text-message
several days before the next
session to remind parents to
book travel arrangements”
We selected:
Environmental restructuring
Changing the physical or
social context
• How could we operationalise
‘environmental
restructuring?’
• Likely to consist of more than
one behaviour change
technique
Without knowing the ‘active
ingredients’ in an intervention:
X We can’t easily replicate
X We can’t assess effectiveness
Behaviour Change Technique Taxonomy v1
(BCTTv1):
Points to consider…
•
• Shared language for specifying the ‘active
ingredients’ of behaviour change interventions
Why choose BCT X over BCT Y? – look at the evidence for the effectiveness in
• situations
93 distinct
BCTs with labels, definitions and examples
similar populations and
to yours
Michie et al (2013) Annals of Behavioral Med, 46(1)
•
Is this BCT appropriate for the population and setting of my intervention?
Environmental restructuring
•
Can I afford to use this BCT? Is it going to be acceptable to my population? Can it be
- Refer to Michie et al. (2011) or BCW guide (Michie et al. 2014)
delivered in my intervention?
This intervention function translates into the following BCTs:
E.g.
• Prompts / cues
• Adding objects to the environment
• Remove access to the reward
The key questions:
1. What exactly do we want the person to do?
2. What will it take to get them to do it?
3. How do we get them to do it?
4. How do we roll out the intervention?
Outer ring:
•
7 policy categories
Select appropriate policy categories:
• Refer to Michie et al. (2011)
• Or to BCW guide
Michie et al (2011) Implementation Science, 6, 42
Appropriate policy
categories include:
Environmental / social planning
Guidelines
Fiscal measures
Regulation
Legislation
Creating documents that
recommend or mandate
practice.
E.g. “The programme
handbook was amended to
include advice for practitioners
on how to conduct sessions at
parent/toddler’s home”
Our intervention:
Target behaviour = Increasing participation in parent-toddler
language promotion programme
Target population = Parents
Behavioural diagnosis:
“Parents unlikely attend
programme sessions
due to transport not
being available”:
Physical opportunity
Select intervention functions and
BCTs:
Physical opportunity maps onto
Environmental restructuring.
“Parents were sent a text message
2 days (BCT = Prompts/cues)
before the session to remind them
to book travel arrangements”
Select policy categories:
ER maps onto Guidelines.
“Advice for practitioners on how to
conduct home sessions added to
programme handbook”
Your toolbox:
• Start by understanding the behaviour
– Behavioural analysis and diagnosis using COM-B
• Systematically select appropriate intervention
functions and policy categories to bring about
change
– Design the intervention (‘prescribed treatment’) using
BCW based on the behavioural diagnosis
• Specify active ingredients in the intervention
– Using BCT Taxonomy
@UCLBehaveChange
behaviourchange@ucl.ac.uk
Dr Caroline Wood caroline.wood@ucl.ac.uk
Do you work in behaviour change? We want to
hear from you!
Go to our website:
www.ucl.ac.uk/behaviour-change
•Answer a short questionnaire
•You will be added to our database of expertise
•Linked in with other academics and opportunities
to be contacted for your expert input/collaboration
Theories & Techniques of
Behaviour Change:
Applications to Conversation Therapy for Aphasia
Fiona Johnson
UCL Division of Psychology & Language Sciences
Guys & St Thomas’s Community Services
Supervised by: Dr Suzanne Beeke, Professor Wendy Best
Aims for today
• Discuss role of behaviour change theory in SLT
intervention research
• Describe applications of behaviour change theory
& techniques in my own research
• Highlight benefits and challenges to using a
behaviour change approach in SLT
Background to research
Better
Conversations
with Aphasia
project
Own interests in
implementation
MRC guidelines for
developing &
evaluating complex
interventions (2008)
Behaviour change
research
Why look at theories of behaviour change?
• Need for theory to explain:
– What works?
– Why hasn’t it worked?
– How can I adapt it without compromising effectiveness?
• Expanding remit of SLTs e.g. Social & community participation
focus to intervention
Better Conversations with Aphasia
Raising
Awareness of
Conversation
• Session 1: Conversation & Agrammatism
• Session 2: Turn-taking & Conversational Sequences
• Session 3: Repair
Barriers &
Facilitators in
Conversation
• Session 4: Strategies for PWA
• Session 5: Strategies for CP
• Session 6: Topic
Consolidating
Strategy Use
• Session 7: Practicing strategies in conversation
• Session 8: Reviewing & Moving forward
Key features of therapy
• PWA & CP present for all sessions
• Therapy targets Barrier & Facilitator behaviours in conversation
• Materials include handouts and couples own videoed conversations
• Strategies practiced via coached conversation, and homework activities
Gaps in current knowledge...
BCA outcome measurement is focussed on:
• Decrease in barrier behaviours
• Increase in facilitative behaviours
Assumed theory of change appears to be:
• Raised awareness about ones own conversational behaviours will lead to
changes in behaviour
But...
• Knowing what to do ≠ Doing it (Barnes, Dunning & Rehfeldt 2011; Berkhof, van Rijssen, Schellart, Anema &
Van der Beek 2011; Kennedy, Regehr Rosenfield, Roberts, Lingard 2004; Webb & Sheeran 2006)
So...
• Existing accounts of how conversation therapy works do not adequately
explain how intended outcomes are produced
What works in conversation therapy for
aphasia & how?
My research aims:
• Describe factors that promote or constrain the
use of targeted behaviour (i.e. the aspects of Capability,
Opportunity & Motivation that determine conversational behaviour)
• Identify mechanisms that support conversational
behaviour change (i.e. Changes to Capability, Opportunity &
Motivation that enable change to conversational behaviour)
• Identify potentially active ingredients within
Better Conversations with Aphasia (i.e. Therapy’s BCTs)
Identifying behaviour change techniques
present in the BCA therapy programme
• Taxonomy of Behaviour Change Techniques v1
(Michie et al 2013)
• Coding of BCA’s 8 session plans + all therapy
handouts used with participants
• Coding of two raters compared to establish:
– Behaviour change techniques agreed to be present
– Overall reliability of applying taxonomy
Coding Better Conversations with Aphasia
Extract from BCA
A practice conversation with SLT:
Video the task.
• PWA to put their chosen strategies into
practice as needed
• SLT to coach as necessary
After the task - discuss ease of strategy
use
(SLT to facilitate this discussion by
replaying parts of the task if it has been
video recorded).
BCT 23 Behavioural
practice/ rehearsal
BCT 15 Prompts/cues
BCT 8 Feedback on
behaviour
Findings:
• 16 reliably identified Behaviour Change
Techniques
• Identification of potential new techniques
• Mapping techniques to mechanisms of change =
emerging theory of change for BCA
Findings: Overall Reliability of Using BCT Taxonomy
with Better Conversations with Aphasia
• Two different measures of IRR carried out
– Cohen’s Kappa (adjusts for chance agreement)
– Percentage Agreement (better reflection of range of decision making)
Cohen’s kappa
0.477
= ‘moderate’ agreement
Percentage
Agreement
79.8%
80% is threshold for
satisfactory agreement
What issues compromised IRR?
• Different judgements re:
– Intended meaning of therapy descriptions
– Whether activities had a clear target behaviour
• Differing levels of confidence in coding:
– More subjective concepts e.g. BCT 85 Salience of Consequences
– ‘Unfamiliar’ concepts e.g. BCT 68 Action Planning
Some Reflections
Challenges
• Establishing consistency/ confidence with new terminology & concepts
• Conversation Therapy – jointly produced action vs. individual behaviour
Limitations
• Behaviour change does not account for other intended outcomes of
therapy e.g. Increased acceptance of aphasia, well being, QoL
Questions
• Communicative Behaviour Change = minute adjustments in fast flowing
context
• ?transferability of health behaviour research
• Behaviour change for people with neurological impairments
• ?transferability of research into non-impaired populations
Conclusions
Behaviour change theory & tools
• Offer a framework for investigating and describing SLT interventions
directed at activity & participation
• Enable a systematic analysis of:
– The influences on communicative behaviour
– Possible mechanisms for changing behaviour
– Techniques involved in changing behaviour
• Provide a basis for building theories of change in some SLT
interventions
• Generate new insights with direct applications to clinical practice
Thank you!
Any Comments?
Questions?
fiona.johnson1@nhs.net
fiona.johnson.09@ucl.ac.uk
@msfionajohnson