KT ICEBeRG - Workshop 3 Cognitive and Behavioural Change What to

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					Cognitive and Behavioural Change
   What to change and how to do it


• Marie Johnston, University of Aberdeen
• Susan Michie, University College London
  Cognitive and Behavioural Change
   What to change and how to do it


What are you hoping to get from the workshop?
              your KT issues?
                              Plan
WHAT TO CHANGE                   HOW TO CHANGE

• Aims of KT                     • Targets for change
   – groups                          – Report back from groups
• Determinants of KT             • Techniques to change
   – Groups                        behaviour
   – Theoretical approaches          – Introduction to theoretically
• What may impede KT                   linked behaviour change
                                       techniques
   – Theoretical approaches
                                 • Designing an intervention
• How to assess problems
                                   for ‘your’ KT problems
   – Groups select and assess
                                     – groups
     ‘your’ KT problem

              WORKSHOP OUTCOME
        What is the aim of
       Knowledge Transfer?

• KT problems experienced by members
• Select one problem for group to work on
• How would you know that you had
  successful KT?

  Discussion in groups
REPORT BACK
Knowledge Transfer
1. Export from research
  •   Research community
2. Import into practice
  •   Health services: professionals,
      managers etc.
3. Impact
  •   Society …
1. Export from Research

   • Research evidence
   • Synthesis
   • ‘Transferability’
     – Products
     – Techniques
     – Practices
     – Guidelines
2. Import into Practice

• ‘implementability’
  – Resources
  – Environmental support
  – Motivation
  – Mechanisms of change
     • Cognitive
     • Behavioural
• Implement = behaviour change
        3. Impact

•   Uptake/Reach
•   Health outcomes
•   Cost outcomes
•   Organisational change
2. Import into Practice

• ‘implementability’
  – Resources
  – Environmental support
  – Motivation
  –Mechanisms of change
   • Cognitive
   • Behavioural
• Implement = behaviour change
Mechanisms of Behaviour Change

   •   Skills
   •   Behaviour
   •   Evidence-based practice
   •   Health outcomes
             Basic model




cognitions            behaviour
                Basic model




cognitions               behaviour


e.g.                          e.g.
Knowledge                     Skills
Attitudes                     Habits
Self-efficacy
Theory of Planned Behaviour
          Icek Aizen




         http://www.people.umass.edu/aizen/tpb.diag.html#null-link
Theory of Planned Behaviour (Ajzen, 1991)

         would
         like to


         should     Intention   Behaviour




          could
 Using theories of behaviour
 to understand KT problems

• Successful KT requires behaviour change
• Potential value of theories of behaviour
  – Increasingly used in KT research
• Many psychological theories of behaviour
  – Too many?
  – Too much overlap in constructs?
• How to choose and use theory?
   Making theory more useable
Consensus approach

• Health psychologists agreed a set of key
  theoretical areas for use in
    – multidisciplinary KT research
    – designing interventions to improve KT
• Interview questions to assess these areas
• Health service researchers (inc. Grimshaw,
  Eccles) gave feedback and helped refine the
  framework
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
 Identify theories and theoretical
             constructs

• In four overlapping areas:
  – motivation
  – action
  – organisation
  – behaviour change
• 33 theories and 128 theoretical constructs
  generated
Final list of construct domains

1.    Knowledge
2.    Skills
3.    Professional role and identity
4.    Beliefs about capabilities
5.    Beliefs about consequences
6.    Motivation and goals
7.    Memory, attention and decision processes
8.    Environmental context and resources
9.    Social influences
10.   Emotion
11.   Action plans
    Questions for each domain
e.g. beliefs about own capabilities

•   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?
                Group task
• Understanding your KT problem
• Using questions for full set of domains
• One person interviews the individual who
  described the KT problem
• Others take notes
  – Theoretical domain(s) relevant to problem
• Group discussion
  – Formulation of problem in terms of theoretical
    domains
Report back
    Selecting behaviour change
            techniques
• Which techniques can be applied to
  change which theoretical domains?
• Consensus process
    Which behaviour change
techniques would you use as part
of an intervention to change each
        construct domain ?
    4 raters
               Agreement to do
               Dissent
               Agreement not to do
               Indefinite
  Technique for
behaviour
change
                     Social/        Knowled   Skills   Beliefs      Beliefs      Motivati   Memor      Environmen    Social     Emoti   Action
                     Professional   ge                 about        about        on and     y,         tal context   influenc   on      planning
                     role &                            capabiliti   consequenc   goals      attentio   and           es
                     identity                          es           es                      n,         resources
                                                                                            decision
                                                                                            process
                                                                                            es
Goal/target          1              2 1       3 2 3    1            3 1          3 3 3 3    1 1            1         1          1 1     3 2 3 3
specified:
behaviour or
outcome
Monitoring           1              2         3 3 3    1 2 2        1 2 2        1 2 2      1 2 2      2             1 2        2       1 1 2


Self-monitoring                               2 3 3    3 3 2 3      3 2 2 2      1 3 2 1    2 23                                2           1 3



Contract             2 1                      1        1            1 1          2 3 1 2    2                        3 2                2 2 2



Rewards;             1 2 1          1         3 3 3    2 1          2 1 2        2 3 3 3    1 1 2      1             1 2        1 2 1   2 1 1
incentives (inc
Self-evaluation)
Graded task,         1              1         3 3 2    2 2 3        2            2 3 2 2    1 2        1             1          1 1     2 1*
starting with easy
tasks
Increasing skills:   1 2                      3 3 3    2 2 3 2      1            2 3 2      1 2                      1          2       3 1
problem solving,                              3
decision making,
goal setting
Stress               1                        1 2      1 1 1        1            1 2 1      1 2 1                    1          3 3 2   1
management                                                                                                                      1

Coping skills        1                        2/3 3    2 2 2        1            1          1 1                      1 1        3 2 2   1/2
                                              1

Rehearsal of         1                        3 3 3    2 3 2                     2 1        2 1                                 3 2     3 1 1
 l    t kill                                  3
Role-play               1 2 1              1 3   1 3 2 1   3 1                 1                  1 1 1     1      1 1
                                           1

Planning,                                  2 2                       3 2 1     32 3 2   1                   2 1    2 3 3 3
implementation

Prompts, triggers,                         1                                   3 3 3    3         1         2      2 3 3 3
cues

Environmental           1 1 2 1            1/2                       1         2 3 1    3 3 3 3                    1 1
changes (eg, objects
to facilitate behavr)
Social processes of     2 3 3 2            2     3 2 2               2/3 3 2   1                  3 3 3 3   11 2   1 1 1
encouragement,
pressure, support
Persuasive              1 1 1? 1   2 2     1     2 3 1 1   2 3 2 3   2 2 2                        2 2 1            1
communication

Information             3 1?       3 3 3         1 2       3 3 3 3   3 3 2 2   1                                   3 1
regarding
behaviour, outcome
Personalised            1 2 2? 1   2 3     2     1 2 1     2 2       2 2 1     2 2                2         1      2 1
message

Modelling               1 3 3 1            2 3   1 3 2     1         1 1       1                  1 3 3 2
/demonstration of                          3
behaviour by others
Homework                           3 1     3 2   3         3         2 2       1 1      1         1 2       1      2 2
                                           2

Personal                           1 1     1 1   1 2 3 1   1 2 2     1 2       1 2      1         1         1 1    2
experimnts, data
collection (other
than self-monitoring
of behr)
Experiential: tasks                        2     1 1? 2    1         1 3 2     2
to gain experiences
to change
motivation
Feedback                2 1?       3     3 2 3     3 3 2   2 2     1 2     2           1 2



Self talk               1 1    1   1 1   2 1 2 2   1 1     1 2 2   2 2     1   1       1 1 2



Use of imagery          1          1 1   1 1 2 1   1 1     1 2 2   2 1 2       1 2     2 1 2 2



Perform behaviour                  3 3   2 2               1       2 2     1           1 1 2
in different settings              2

Shaping of              1          1 3   1 2               1       1           1       2 1
behaviour                          3

Motivational            1                2 3 2     2 3     3 3 2   2       2   1 1
interviewing

Relapse prevention                 1     2 2               2 2     2           1       2 2



Cognitive               3      1         3 1 2     3 1     2 2     1           2 1     1
restructuring

Relaxation                         1 1                             1           1 1 2



Desensitisation                          1                                     1 1 1



Problem solving                    2 2   2                 1 2 1   1           1 1     1



Time management                          1                 1       1 2         1 1     1



Identify/ prepare for              1     2 2               2 1     2           2       2 3
difficult situation/
problems
      Which behaviour change
 techniques would you use as part
  of an intervention to change your
             KT problem ?

• Group task
• Select relevant techniques
• Design an intervention incorporating these
  techniques and appropriate for the context
Report back
                  Example
• Poor KT: management of acute low back
  pain by GPs
• Problem behaviours
  – too frequent referrals for X-rays of lumbar spine
  – too infrequent advice to keep active




Sally Green, Simon French, Denise O’Connor,
Jeremy Grimshaw, Jill Francis, Susan Michie et al.
    Designing the intervention
• Techniques identified using matrix
• Multidisciplinary discussions to
  consider
  – Other techniques suggested by theoretical
    domain
  – Refinement of techniques, using theory and
    evidence
  – Adaptation according to possibilities and
    constraints of intervention targets and setting
       Intervention design

  The KT problem           GP skills in diagnosis

                         Skill, knowledge, beliefs
 Construct Domains
                            about capabilities

                              Persuasive
                            communication;
Techniques selected
                         modelling; behavioural
                          rehearsal; role play;
                            action planning

Intervention designed
                         small group workshops;
  (mode of delivery,
                        opinion leader; discussion
 context, resources)
                              and reflection
Conclusions