How to Change? The Missing Link

  1. Every year 350,000 trials have been identified by the Cochrane Collaboration and 10,000 of them are included in Medline. (Grol & Grimshaw, 2003).  The example of importance of hand washing that Grol and Grimshaw used as a case  is clear since the mid-1800s but this simple obviously necessary part of any health practice is still overlooked by health care practitioners! Two centuries passed and every year we experiment thousands and thousands trials in addition to probably much more thousands and thousands health related research. We are still struggling with this fact that how we can change behaviour of people based on our 200 years ago research finding.
  2. Prevention and Intervention studies is supposed to be the most practical part of public health research because they are designed “to inform, change attitudes and perceptions, modify social norms, transform social contexts, and alter policies that are facilitators or barriers to healthy behaviours” (Lawrence & Fortenberry, 2007). Also it is widely accepted that change behaviour should employ theories of behaviour in their development (Michie, Hardman, & Eccles, 2008) because interventions based on theoretical models are far more likely to succeed than programs that do not benefit from a theoretical model. (Lawrence & Fortenberry p. 24).
  3. Lawrence & Fortenberry (2007) evaluate seven clusters of theoretical frameworks in the STD and HIV intervention studies. For instance, an important limitation of The Health Belief Model (HBM) that is categorized as one of the Cognitive Theories, is that this model “does not explain how perception of risk originate, nor does the model describe how health beliefs develop or persist over time” (p. 27). Again the authors’ criticism on another very popular framework in the intervention literature, Theory of Reasoned Action (TRA) is almost the same; although this model illustrates where to intervene among all related variables in the research, “it offers no specific guidance regarding how to implement intervention strategies” (ibid). The problem of these theories is not just lacking the “how-to” part, but the foundation of them which is based on the assumption that people make “rational choices” is hugely under question.
  4. However, here I see a controversy: “a theory is a systematic way of describing events and behaviours.” (p. 23). As Michie et al. (2008) conclude even when researchers use theory, “they end to use it to explain behaviour but not to change behaviour” (p. 663). They take an example of a systematic review conducted by Azjen of the application of the Theory of Planned Behaviour and show that the theory was “rarely used to design the intervention and was more frequently used as a background to understand he behaviour and to develop measures”. With the aim of filling the current gap of having no comprehensive list of techniques for behavioral change, Michie et al. (2008) conduct a research by reviewing reviews, brainstorming and extracting techniques in textbook. They generate a list of 53 behavioral change techniques with definitions and more 84 techniques without definitions, so they totally present a list of 137 behavioral change techniques. Then by using four specialists’ rating to the application of each technique for 11 behavior determents, they illustrate visually whether each technique can be applied for changing each determent of the behaviour. The figure shows that there is not much agreement among the specialists on the capability of identified techniques in changing behaviour.
  5. What is wrong with us as researchers and academicians? What are we doing really? Let’s look at the following table:
World Hunger Statistics
Total number of children that die every year from hunger 1.5 million
Percent of world population considered to be starving 33%
Time between deaths of people who die from hunger 3.6 seconds
Total number of people in the world who suffer from hunger and malnutrition 800 million
Total number of people who do not have enough to eat 936 million people
Total percentage who do not have enough to eat who live in developing countries 98%
Total percentage of world’s hungry that live in 7 countries 65%
Number of people who died of hunger today 20,864
Total number of people who will die of hunger this year 7,615,360

6. Sorry. I am too emotional to write #6.


Grol, R. & Grimshaw, J. (2003). “From the best evidence to best practice: effective implementation of change in patients’ care”, The Lancet, Vol 362, Oct. pp. 1255-1230.

Lawrence J. & Fortenberry, D. (2007). Behavioral interventions for STDs: Theoretical models and intervention methods. In S. O. Aral & J. M. Douglas (Eds.), Behavioral interventions for prevention and control of sexually transmitted diseases (pp. 23-59). New York: Springer.

Michie, S. et al. (2008). “From theory to intervention: Mapping theoretically delivered behavioral determinants to behavior change techniques”. Applied Psychology: An International Review, 57 (4). pp. 660-680.

World Hunger Statistics:


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