Predicting recovery after hip replacement: the role of pre

Transcript Predicting recovery after hip replacement: the role of pre

Health Psychology and the future of Public Health

www.fuse.ac.uk

Falko Sniehotta, PhD Newcastle University

Why is health psychology relevant for Public Health?

Actual Causes of Death

Leading Causes of Death* Actual Causes of Death † Heart Disease Cancer Stroke Chronic lower respiratory disease Unintentional Injuries Diabetes Pneumonia/influenza Alzheimer’s disease Kidney Disease 0 5 10 15 20 25 30 Percentage (of all deaths) 35 Tobacco Poor diet/lack of exercise Alcohol Infectious agents Pollutants/toxins Firearms Sexual behaviour Motor vehicles Illicit drug use 0 5 10 15 Percentage (of all deaths) 20

*Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-20.

† Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291 (10): 1238-1246.

Foci of behaviour change interventions

general population – –

primary prevention

“Lifestyle” behaviours: major cause of illness and premature death 48% avoidable deaths in US in 2000 from •

smoking

• •

alcohol use poor diet

•

physical activity

• •

unsafe sex driving habits

•

violence

Mokdad et al, 2004

patients – – – secondary prevention reduce delay in seeking help adherence to treatment health professionals – implementation of evidence based practice – Knowledge Translation Gap – Influence population behaviour

Structure of the evidence base for behaviour

Interventions

change interventions

Behavioural determinants

e.g. cognitive, social, motivational & environmental

Behaviour

e.g., exercise; physical activity

Physiological & biochemical variables

e.g. neurological & muscular processes

Health outcomes

health, mobility and quality of life Hardeman, et al. (2005) A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20(6):676-687

Determinants of health

Where and how to intervene

Individual interventions • • • • reduce motivation to engage in unhealthy behaviours increase motivation to engage in healthy behaviours motivation into action and sustain healthy behaviours (behavioural skills) enhance self-regulation Societal interventions • • • • attitudes and culture Choice architecture (nudging) incentive structures restrict or enhance opportunities Dynamic process of interaction level. E.g. walking/cycling: between societal and individual motivation + opportunities ‘Behaviour change at population, community and individual levels’: NICE review 2007

Structure of the evidence base for behaviour

Interventions

change interventions

Behavioural determinants

e.g. cognitive, social, motivational & environmental

Behaviour

e.g., exercise; physical activity

Physiological & biochemical variables

e.g. neurological & muscular processes

Health outcomes

Effects of behavioural interventions on health

Interventions

Good evidence from systematic reviews of RCTs for effectiveness of behavioural interventions on all outcome levels Key challenges: • Considerable heterogeneity of effect sizes • Small to medium effects • Lack of sustainability

Behavioural determinants

e.g. cognitive, social, motivational & environmental

Behaviour

e.g., exercise; physical activity

Physiological & biochemical variables

e.g. neurological & muscular processes

Health outcomes

RE-AIM: A model of sustainable implementation of effective, generalisable, evidence-based interventions

Reach - How do we reach the targeted population with the intervention?

Efficacy - How do we know our intervention is effective?

Adoption - How do we develop organizational support to deliver our intervention?

Implementation - How do we ensure the intervention is delivered properly?

Maintenance - How do we incorporate the intervention so that it is delivered over the long term?

Glasgow et al. (2001) The RE-AIM Framework for Evaluating Interventions: What Can It Tell Us about Approaches to Chronic Illness Management? Pt Educ Couns 2001;44:119-127.

•

Public Health interventions are often complex

Number of interacting components • Number and difficulty of behaviours involved • Number of groups or organisational levels targeted • Number and variability of outcomes • Degree of flexibility or tailoring permitted

Features of Behaviour Change interventions

1. Behaviour change techniques (BCTs), e.g., prompt goal setting or self-monitoring of behaviour 2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc 3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention 4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training.

Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)

MRC framework for development and evaluation of complex interventions

Phase IV Phase III Phase II Phase I Pre-clinical Theory Modelling Exploratory trial Definitive RCT Long term implementation Cumulative knowledge base

Development & evaluation of complex interventions

Craig P et al. (2008) BMJ 337, a1655

Warning

The next slide shows upsetting public health campaign posters. You might wish to close your eyes for a moment

The problem with behaviour change

• Attempts to change people’s behaviour are often geared towards: – • Raising Knowledge (lecturing) “Did you know that…” – • Providing Advice (instructing) “Why don’t you…” – • Motivating (scaring) “If you don’t … then …”

Why are many public health campaigns not informed by behaviour change evidence?

• • • • • Behaviour change evidence is not good enough?

Behaviour change evidence is not relevant for public health?

Behaviour change evidence is not effectively disseminated?

Commissioners don’t listen to psychologists?

A lack of sustainable infrastructure to co produce relevant evidence?

Why theory?

• • • Enables cumulative science • • Provides a shared language Summarises known evidence Explains observations • Allows prediction • Enables intervention Problem of ‘implicit’ theory ‘a

theory

is a set of statements that organizes, predicts and explains observations; it tells you how phenomena relate to each other, and what you can expect under still unknown conditions’

Bem, S and Looren de Jong, H (1997) Theoretical issues in Psychology, Sage publications: London. p. 15

How does Theory help in developing and delivering interventions?

• • • • • Identify targets (e.g., cognitive or social determinants of behaviour) Suggest behaviour change techniques Suggest sequences or combinations of techniques and determinants Allows for tailoring of interventions (e.g., stage theories such as the ‘TTM’ /’stages of change model’  Evidence very weak!

Provides a ‘cover story’ for intervention content

Choosing a theoretical approach

(too) many theories of behaviour

• • • • 33 theories and 128 constructs generated In four overlapping areas: – motivation – action – organisation – behaviour change Simplified into 11 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.

Simplifying theory: domains of behavioural determinants

Knowledge Skills 3.

Role and identity Beliefs about capabilities •

Self-efficacy

•

Control – of behaviour,

Beliefs about consequences

environment

Motivation and goals Memory, attention and decision processes •

Self-confidence

Environmental context and resources •

Perceived competence

•

Empowerment

•

Self-esteem

Social influences

and material and social

•

Perceived behavioural

10. Emotion

control

11. Plans •

Optimism/pessimism

Michie, S., Johnston, M., Abraham, C, Parker, Lawton, R, Walker, A (2005) Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality in Health Care, 14, 26-33.

Progress in theorising:

the decline of landmark theories

• • • Popular landmark theories such as the Transtheoretical Model and the Theory of Planned Behaviour have passed their prime.

They conflict with experimental evidence and showed limited utility for research and practice Development of more comprehensive theories with better evidence fit is ongoing West, R. (2005). Time for a change: Putting the Transtheoretical (Stages of Change) Model to rest.

Addiction

100 (8), 1036-1039. Sniehotta, FF, Presseau, J & Araujo-Soares, V (2014-March). Time to retire the Theory of Planned Behaviour.

Health Psychology Review

Identifying the evidence base:

My involvement in Systematic Reviews

Identifying the evidence base:

Problems with systematic reviews of behaviour change interventions • • • • Interventions are often poorly reported in terms of content, delivery, theory and fidelity.

Often considerable risk of bias within and across trials Limited evidence about sustainability of effects It is surprising how little we know about how best to change people’s health behaviour.

Are theory based interventions more effective?

• In depth analysis of studies included in two systematic reviews of physical activity and healthy eating interventions (k 190). • Interventions based on Social Cognitive Theory or the ‘Transtheoretical’ Model were no more effective than interventions not explicitly based on theory • Implementation of theory variable and overall poor Prestwich, A., Sniehotta, F. F., Whittington, C., Dombrowski, S. U., Rogers, L., & Michie, S. (2013, June 3). Does Theory Influence the Effectiveness of Health Behavior Interventions? Meta-Analysis.

Health Psychology.

Biomedicine vs behavioural science … Example of smoking cessation effectiveness

• • Varenicline JAMA, 2006 Behavioural counselling Cochrane, 2005

Intervention content

• Intervention content – Review smoking history & motivation to quit – Help identify high risk situations – Generate problem-solving strategies

Mechanism of action

– Activity at a subtype of the nicotinic receptor where its binding produces agonistic activity, while simultaneously preventing binding to a4b2 receptors – Non-specific support & encouragement • Mechanism of action – None mentioned

Behaviour change techniques:

reliable taxonomy

to change physical activity and healthy eating behaviours Involves detailed planning of what the person will do 1. General information including, at least, a very specific definition of the 2. Information on consequences 15. General encouragement day/week), intensity (e.g., speed) or duration (e.g., for how 16. Contingent rewards i.e., where, when, how or with whom must be specified. 3. Information about approval 18. Follow up prompts 5. Specific goal setting will be performed.

19. Social comparison 6. Graded tasks 20. Social support/ change 7. Barrier identification 21. Role model 8. Behavioral contract 22. Prompt self talk 9. Review goals 23. Relapse prevention 10. Provide instruction 11. Model/ demonstrate 12. Prompt practice 24. Stress management The person is asked to keep a 25. Motivational interviewing 26. Time management 13. Prompt monitoring diary or completing a questionnaire about their 14. Provide feedback behaviour.

Identifying Effective Change Techniques in Interventions Designed to Promote Physical Activity and Healthy Eating

• Systematic review and meta-analysis • 84 interventions • average of 6 techniques • small effect d = 0.37 (95% CI 0.29 to 0.54, N = 28,838) • self-monitoring – associated with effectiveness (14.6% variance explained). – Interventions including this technique had a medium effect size of d = 0.57. – Interventions combining self-monitoring with at least one other technique derived from control theory were more than twice as effective as the other interventions with d = 0.60 d = 0.26 respectively Michie S, et al (2009) Identifying Effective Techniques in Interventions: A meta-analysis and meta-regression Health Psychology

The Behaviour Change Wheel

Behaviour source Intervention type Policy type Modelling

Reflec tive Physical Psychol ogical Non reflect ive Social Physical Michie, van Straalen & West 2010

Evaluating Public Health Interventions

– – – Newly introduced interventions often not evaluated Ask Fuse – a feature for commissioners and practitioners to collaborate with Fuse, the UK CRC Centre for Translational Research in Public Health Current work commissioned by the NIHR School of Public Health Research to develop guidelines for the evaluation of local public health interventions

Example 1: A&E admission after Stroke

• • People often delay seeking medical help, typically 3-6h Pre-hospital delay prevents access to best treatment

Teuschl et al., 2011

• Various reasons for delay including clinical, contextual and cognitive

Act FAST Campaign

• • • UK national awareness raising campaign Rolled out in multiple waves: – Feb 2009, Nov 2009, Feb 2010, May 2011, March 2012 Targeted : – Population: television, press and radio – Health professionals: emails, newsletters, posters and leaflets

Act FAST Campaign

• • • • FAST = Face, Arms, Speech, Time to call 999 Developed for rapid ambulance protocol to increase diagnostic accuracy of stroke in paramedical staff (Face, Arms, Speech,

est) High levels of diagnostic accuracy and good agreement between professionals Since been adapted as a public awareness instrument in English speaking countries

Act FAST Campaign

Recognition (Face, Arm, Speech) Response (Time) Call 999

Act FAST Campaign

Recognition (Face, Arm, Speech) Response (Time) Call 999

Research Question

Can people apply the FAST acronym to recognise and respond to stroke?

Study Design

5000 people randomly selected from Electoral Roll from Newcastle upon Tyne and randomised to two groups n=2500 Questionnaire + FAST leaflet n=2500 Questionnaire only Reminder and 2 nd pack sent after 2 and 8 weeks

Hypotheses

Leaflet group will have:

1.Better

knowledge

what FAST stands for 2.Better

recognition

of stroke 3.Better

response

to stroke

Results

• 100 Familiar with Act FAST 90 30 20 10 0 80 70 60 50 40 Leaflet No leaflet Leaflet No leaflet The difference in proportions is significant, χ²(1, 1525) = 9.20, p=.001

Results

• •

Knowledge

of FAST elements FAST right: 66.1% vs. 45.3%, t(1613)=9.30, p<.001, d=0.46

100 30 20 10 0 90 80 70 60 50 40 Leaflet No leaflet F correct A correct S correct T correct

Results

•

Response

to stroke scenario 100 90 30 20 10 0 80 70 60 50 40 All 12 stroke scenarios t(1601)=-1.0, p=.32, d=0.05

Leaflet No leaflet FAST scenarios only t(1609)=-1. 05, p=.30, d=0.05

Non-FAST scenarios only t(1608)=-0.63, p=.53, d=0.03

All 12 FAST only Non-FAST

What helps and hinders midwives in engaging with pregnant women about stopping smoking?

30%

Smoking at time of delivery, by region from 2004/05 to 2011/12

25% 20% 15% 10% 5% 0% England North East North West Yorkshire & Humber East Midlands West Midlands East of England London South East Coast South Central South West

Year

Why?



Service concerns



Good evidence base

NICE guidance – behaviours described for health professionals

   

How to ask a pregnant woman about her smoking behaviour How to refer a pregnant woman to the stop smoking service How to give advice to a pregnant woman about her smoking behaviour How to use a carbon monoxide monitor

What & How?



Survey based on theoretical domains of behavioural determinants and NICE guidance



Participants – all midwives employed by eight acute NHS trusts in North East region



Audit of NICE guidance in north east midwifery units



Advisory group



Workshop

Workshop

Strongly agree

5 4 3 2 1

Strongly disagree

Domain

Trust Group Work

Trust name: What are we doing well 1.

– and should keep doing?

How will we do this?

What are we going to do?

And by when?

babyClear systematic approach

•Systematic approach to CO monitoring and referral by all midwives at first booking appointment •Standardised referral pathways •“Risk Perception” intervention by midwives at time of scan clinic •Skills training for midwives and NHS SSS staff (advisors and admin teams) •Supply of all key resources •Systematic monitoring and evaluation • Stepped Wedged Design Evaluation ongoing funded by the NIHR School of Public Health Research

Concluding remarks

• • • • • • Let’s work together to improve public health by changing behaviour We need sustainable collaboration between Public Health and academic partners Joint agenda setting Co-production of knowledge fit for implementation Funding Creating pathways to impact  Healthy People

Acknowledgements

[email protected]

The work was undertaken by Fuse, a UKCRC Public Health Research: Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research council, Medical Research Council, and the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is greatly acknowledged.

Opinions expressed in this presentation do not necessarily represent those of the funders.

Spare slides

Buildings blocks of behaviour change

Self-regulation

• Self-monitoring • Awareness of standards • Means and skills

Planning

• Action Planning • Coping Planning

Motivation

•Attitudes •Perceived Norms • Self-efficacy •Emotion Knowledge & Skills Environment & Social influence

Buildings blocks of behaviour change

Self-regulation

• Self-monitoring • Awareness of standards • Means and skills

Planning

• Action Planning • Coping Planning

Motivation

•Attitudes •Perceived Norms • Self-efficacy •Emotion Knowledge & Skills Environment & Social influence

Buildings blocks of behaviour change

Implemental phase Decisional phase

Self-regulation

• Self-monitoring • Awareness of standards • Means and skills

Planning

• Action Planning • Coping Planning

Motivation

•Attitudes •Perceived Norms • Self-efficacy •Emotion Knowledge & Skills Environment & Social influence

Buildings blocks of behaviour change

Implemental phase Decisional phase

Self-regulation

• Self-monitoring • Awareness of standards • Having means and skills

Planning

• Action Planning • Coping Planning

Motivation

•Attitudes •Perceived Norms • Self-efficacy •Emotion Knowledge & Skills Environment & Social influence How can I change?

Would I like to change?

Intervention types Education Imparting knowledge e.g. on health risks Persuasion Incentivisation Coercion Training Restriction Using communication to induce belief or knowledge Creating expectation of reward Creating expectation of punishment or cost Imparting skills Reducing availability Environmental restructuring Modelling Changing the physical context Providing an example for people to aspire to Enablement/ resources Increasing means/reducing barriers

Policy types Communication/ marketing Guidelines Fiscal Regulation Legislation Environmental/ social planning Service provision Using print, electronic, telephonic or broadcast media Creating documents that recommend or mandate practice Using the tax system Establishing rules or principles of behaviour or practice Making or changing laws Designing and/or controlling the physical or social environment Delivering a service

Persuasive communications and targeted cognitions:

UK safer sex leaflets

1 2 3 4 5 6 7 1. disease severity 2. knowledge/info 3. susceptibility 4. self-efficacy 5.

others’ attitudes 6. attitudes to behaviour 7. intention to change Impact on behaviour (correlation) Average number of messages in UK health leaflets

Abraham, C., Krahé, B., Dominic, R., & Fritsche, I. (2002). Does research into the social cognitive antecedents of action contribute to health promotion? A content analysis of safer-sex promotion leaflets. British Journal of Health Psychology, 7, 227-246.

Motivation theories explain 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

• • • • • • • • • • •

Action theories

explain 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

Organisation theories explain 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