ArticlePDF AvailableLiterature Review

Abstract and Figures

Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations. A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity. Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity. Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.
Content may be subject to copyright.
The behaviour change wheel: A new method for
characterising and designing behaviour change
Michie et al.
Michie et al.Implementation Science 2011, 6:42 (23 April 2011)
RESEARCH Open Access
The behaviour change wheel: A new method for
characterising and designing behaviour change
Susan Michie
, Maartje M van Stralen
and Robert West
Background: Improving the design and implementation of evidence-based practice depends on successful
behaviour change interventions. This requires an appropriate method for characterising interventions and linking
them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change
interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and
develops and evaluates a new framework aimed at overcoming their limitations.
Methods: A systematic search of electronic databases and consultation with behaviour change experts were used
to identify frameworks of behaviour change interventions. These were evaluated according to three criteria:
comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was
developed to meet these criteria. The reliability with which it could be applied was examined in two domains of
behaviour change: tobacco control and obesity.
Results: Nineteen frameworks were identified covering nine intervention functions and seven policy categories
that could enable those interventions. None of the frameworks reviewed covered the full range of intervention
functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the
centre of a proposed new framework is a behaviour systeminvolving three essential conditions: capability,
opportunity, and motivation (what we term the COM-B system). This forms the hub of a behaviour change wheel
(BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of
these conditions; around this are placed seven categories of policy that could enable those interventions to occur.
The BCW was used reliably to characterise interventions within the English Department of Healths 2010 tobacco
control strategy and the National Institute of Health and Clinical Excellences guidance on reducing obesity.
Conclusions: Interventions and policies to change behaviour can be usefully characterised by means of a BCW
comprising: a behaviour systemat the hub, encircled by intervention functions and then by policy categories.
Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.
Improving the implementation of evidence-based prac-
tice and public health depends on behaviour change.
Thus, behaviour change interventions are fundamental
to the effective practice of clinical medicine and public
health, as indeed they are to many pressing issues facing
society. Behaviour change interventionscan be defined
as coordinated sets of activities designed to change
specified behaviour patterns. In general, these behaviour
patterns are measured in terms of the prevalence or
incidence of particular behaviours in specified popula-
tions (e.g., delivery of smoking cessation advice by gen-
eral practitioners). Interventions are used to promote
uptake and optimal use of effective clinical services, and
to promote healthy lifestyles. Evidence of intervention
effectiveness serves to guide health providers to imple-
ment what is considered to be best practice (for exam-
ple, Cochrane reviews, NICE guidance). While there are
many examples of successful interventions, there are
also countless examples of ones that it was hoped would
* Correspondence:
Research Dept of Clinical, Educational, and Health Psychology, University
College London, 1-19 Torrington Place, London WC1E 7HB, UK
Full list of author information is available at the end of the article
Michie et al.Implementation Science 2011, 6:42
© 2011 Michie et al ; licensee BioMed Central Ltd. This is an Open Access art icle distributed under t he terms of the Creative Commons
Attribution License (http://creative, which permits unrestricted use, distribution, and reproduction in
any medium, pro vided the original work is properly cited.
be effective but were not [[1], e.g. [2,3]]. To improve this
situation, and to improve the translation of research into
practice, we need to develop the science and technology
of behaviour change and make this useful to those
designing interventions and planning policy.
The process of designing behaviour change interven-
tions usually involves first of all determining the broad
approach that will be adopted and then working on the
specifics of the intervention design. For example, when
attempting to reduce excessive antibiotic prescribing
one may decide that an educational intervention is the
appropriate approach. Alternatively, one may seek to
incentivise appropriate prescribing or in some way pena-
lise inappropriate prescribing. Once one has done this,
one would decide on the specific intervention compo-
nents. This paper examines this first part of this process.
We and others are also working on how one identifies
specific component behaviour change techniques[4,5].
In order to identify the type or types of intervention
that are likely to be effective, it is important to canvass
the full range of options available and use a rational sys-
tem for selecting from among them. This requires a sys-
tem for characterising interventions that covers all
possible intervention types together with a system for
matching these features to the behavioural target, the tar-
get population, and the context in which the intervention
will be delivered. This should be underpinned by a model
of behaviour and the factors that influence it.
Interventions are commonly designed without evidence
of having gone through this kind of process, with no for-
mal analysis of either the target behaviour or the theore-
tically predicted mechanisms of action. They are based
on implicit commonsense models of behaviour [6]. Even
when one or more models or theories are chosen to
guide the intervention, they do not cover the full range of
possible influences so exclude potentially important vari-
ables. For example, the often used Theory of Planned
Behaviour and Health Belief Model do not address the
important roles of impulsivity, habit, self-control, associa-
tive learning, and emotional processing [7].
In addition, often no analysis is undertaken to guide
the choice of theories [8]. Useful guidance from the UK
Medical Research Council for developing and evaluating
complex interventions advocates drawing on theory in
intervention design but does not specify how to select
and apply theory [9]. It should also be noted that even
when interventions are said to be guided by theory, in
practice they are often not or are only minimally [10].
Thus, in order to improve intervention design, we
need a systematic method that incorporates an under-
standing of the nature of the behaviour to be changed,
and an appropriate system for characterising interven-
tions and their components that can make use of this
understanding. These constitute a starting point for
assessing in what circumstances different types of inter-
vention are likely to be effective which can then form
the basis for intervention design.
There exists a plethora of frameworks for classifying
behaviour change interventions but an informal analysis
suggests that none are comprehensive and conceptually
coherent. For example, MINDSPACEan influential
report from the UKs Institute of Government, is
intended as a checklist for policymakers of the most
important influences on behaviour [11]. These influ-
ences provide initial letters for the acronym MIND-
SPACE: messenger, incentives, norms, defaults, salience,
priming, affect, commitment, and ego. The framework
does not appear to encompass all the important inter-
vention types. Moreover, the list is a mixture of modes
of delivery (e.g., messenger), stimulus attributes (e.g., sal-
ience), characteristics of the recipient (e.g., ego), policy
strategies (e.g., defaults), mechanisms of action (e.g.,
priming), and related psychological constructs (e.g.,
affect). In that sense it lacks coherence. The report
recognises two systems by which human behaviour can
be influenced the reflective and the automatic but it
focuses on the latter and does not attempt to link influ-
ences on behaviour with these two systems.
A second example comes from the Cochrane Effective
Practice and Organisation of Care Review Group
(EPOC)s 2010 taxonomy [12]. This categorises interven-
tions to change health professional behaviour into pro-
fessional, financial, organisational, or regulatory,
covering many of the key intervention types. However,
the categories are very broad and within each is a mix-
ture of different types of interventions at different con-
ceptual levels. For example, professionalincludes
individual behaviour (distributing educational materials)
and organisational interventions (local consensus pro-
cesses); financialincludes individual and organisational
incentives and environmental restructuring (changing
the available products); organisationalincludes input
(changing skill mix), processes (communication) and
effects (satisfaction of providers); and regulatory
includes legal (changes in patient liability) and social
influence (peer review). Professional, financial, and orga-
nisational interventions are found across all categories.
Aside from specific frameworks, there are some broad
distinctions that have been widely adopted. One such
distinction is between population-level and individual-
level interventions [13]. While superficially appealing,
there are many interventions that this distinction cannot
readily classify and it has not been possible to arrive at
a satisfactory definition of the distinction that does not
contain inconsistencies. For example, if wide reach is a
feature of population level interventions, routine general
practitioner (GP) smoking assessment and advice (given
to all patients) should fall into that category; yet it is
Michie et al.Implementation Science 2011, 6:42
Page 2 of 11
delivered specifically to individuals and can be tailored
to those individuals. Indeed, the NHS Stop Smoking
Services might be considered a typical case of indivi-
dual-level interventions, but they reach more than
600,000 smokers each year [14]. We do not consider
these broad distinctions further in this paper.
It appears that most intervention designers do not use
existing frameworks as a basis for developing new inter-
ventions or for analysing why some interventions have
failed while others have succeeded. One reason for this
may be that these frameworks do not meet their needs.
In order to choose the interventions likely to be most
effective, it makes sense to start with a model of beha-
viour. This model should capture the range of mechan-
isms that may be involved in change, including those
that are internal (psychological and physical) and those
that involve changes to the external environment. In
general, insufficient attention appears to be given to
analysing the nature of behaviour as the starting point
of behaviour change interventions [15], a notable excep-
tion being intervention mapping [16]. Nature of the
behaviourwas identified as one of 12 theoretical
domains of influence on implementation-relevant beha-
viours [9]. Whilst this framework of 12 theoretical
domains has proved useful in assessing and intervening
with implementation problems [9], the domain of beha-
viour has remained under-theorised and therefore
underused in its application.
There are a number of possible objections to attempt-
ing to construct the kind of behavioural model
described and link this to intervention types. The most
obvious criticism is that the area is too complex and
that the constructs too ill-defined to be able to establish
a useful, scientifically-based framework. Another is that
no framework can address the level of detail required to
determine what will or will not be an effective interven-
tion. The response to this is twofold: these are empirical
questions and there is already evidence that characteris-
ing interventions by behaviour change techniques
(BCTs) can be helpful in understanding which interven-
tions are more or less effective [6,17]; and not to
embark on this enterprise is to give up on achieving a
science of behaviour change before the first hurdle and
condemn this field to opinion and fashion.
To achieve its goal, a framework for characterising
interventions should be comprehensive: it should apply
to every intervention that has been or could be devel-
oped. Failure to do this limits the scope of the system to
offer options for intervention designers that may be
Second, the framework needs to be coherent in that
its categories are all exemplars of the same type of entity
and have a broadly similar level of specificity. Thus,
categories should be from a super-ordinate entity (e.g.,
function of the intervention), and the framework should
others very specific. A beautiful example of an incoher-
ent classification system is the Ancient Chinese Classifi-
cation of Animals: those that belong to the Emperor,
embalmed ones, those that are trained, suckling pigs,
mermaids, fabulous ones, stray dogs, those that are
included in this classification, those that tremble as if
they were mad, innumerable ones, those drawn with a
very fine camels hair brush, others, those that have just
broken a flower vase, and those that resemble flies from
a distance(Luis Borges Other Inquisitions: 1937-1952).
In addition, the categories should be able to be linked
to specific behaviour change mechanisms that in turn
can be linked to the model of behaviour. These require-
ments constitute three criteria of usefulness that can be
used to evaluate the framework: comprehensiveness,
coherence, and links to an overarching model of beha-
viour. We limited the criteria to those we considered to
form a basis for judging adequacy. There are others, e.g.,
parsimony, that are desirable features but do not lend
themselves to thresholds. Other criteria can be used to
evaluate its applicability, e.g., reliability, ease of use, ease
of communication, ability to explain outcomes, useful-
ness for generating new interventions, and ability to pre-
dict effectiveness of interventions
In light of the above, this paper aims to:
1. Review existing frameworks of behavioural interven-
tions to establish how far each meets the criteria of use-
fulness, and to identify a comprehensive list of
intervention descriptors at a level of generality that is
usable by intervention designers and policy makers.
2. Use this list to construct a framework of behaviour
change interventions that meets the usefulness criteria
listed above.
3. Establish the reliability with which the new frame-
work can be used to characterise interventions in two
public health domains.
Prior to reviewing the literature on intervention frame-
works, we needed to establish a set of criteria for evalu-
ating their usefulness. Following this, our method
involved three steps: a systematic literature review and
evaluation of existing behaviour change intervention fra-
meworks, development of a new framework, and a test
of the reliability of the new framework.
Establishing criteria of usefulness
From the analysis set out in the Introduction, we estab-
lished three criteria of usefulness:
1. Comprehensive coverage the framework should
apply to every intervention that has been or could be
developed: failure to do this limits the scope of the
Michie et al.Implementation Science 2011, 6:42
Page 3 of 11
system to offer options for intervention designers that
may be effective.
2. Coherence, i.e., categories are all exemplars of the
same type and specificity of entity.
3. Links to an overarching model of behaviour.
We use the term modelhere in the sense defined in the
Oxford English Dictionary: a hypothetical description of a
complex entity or process.For the overarching model of
behaviour, we started with motivation, defined as: brain
processes that energize and direct behaviour) [18]. This is
a much broader conceptualisation than appears in many
discourses, covering as it does basic drives and automatic
processes as well as choice and intention.
Our next step was to consider the minimum number
of additional factors needed to account for whether
change in the behavioural target would occur, given suf-
ficient motivation. We drew on two sources represent-
ing very different traditions: a US consensus meeting of
behavioural theorists in 1991 [19], and a principle of US
criminal law dating back many centuries. The former
identified three factors that were necessary and suffi-
cient prerequisites for the performance of a specified
volitional behaviour: the skills necessary to perform the
behaviour, a strong intention to perform the behaviour,
and no environmental constraints that make it impossi-
ble to perform the behaviour. Under US criminal law, in
order to prove that someone is guilty of a crime one has
to show three things: means or capability, opportunity,
and motive. This suggested a potentially elegant way of
representing the necessary conditions for a volitional
behaviour to occur. The common conclusion from these
two separate strands of thought lends confidence to this
model of behaviour. We have built on this to add non-
volitional mechanisms involved in motivation (e.g.,
habits) and to conceptualise causal associations between
the components in an interacting system.
In this behaviour system,capability, opportunity, and
motivation interact to generate behaviour that in turn
influences these components as shown in Figure 1 (the
COM-Bsystem). Capability is defined as the indivi-
duals psychological and physical capacity to engage in
the activity concerned. It includes having the necessary
knowledge and skills. Motivation is defined as all those
brain processes that energize and direct behaviour, not
just goals and conscious decision-making. It includes
habitual processes, emotional responding, as well as ana-
lytical decision-making. Opportunity is defined as all the
factors that lie outside the individual that make the
behaviour possible or prompt it. The single-headed and
double-headed arrows in Figure 1 represent potential
influence between components in the system. For exam-
ple, opportunity can influence motivation as can cap-
ability; enacting a behaviour can alter capability,
motivation, and opportunity.
A given intervention might change one or more com-
ponents in the behaviour system. The causal links
within the system can work to reduce or amplify the
effect of particular interventions by leading to changes
elsewhere. While this is a model of behaviour, it also
provides a basis for designing interventions aimed at
behaviour change. Applying this to intervention design,
the task would be to consider what the behavioural tar-
get would be, and what components of the behaviour
system would need to be changed to achieve that.
This system places no priority on an individual, group,
or environmental perspective intra-psychic and exter-
nal factors all have equal status in controlling behaviour.
However, for a given behaviour in a given context it
provides a way of identifying how far changing particu-
lar components or combinations of components could
effect the required transformation. For example, with
one behavioural target the only barrier might be capabil-
ity, while for another it may be enough to provide or
restrict opportunities, while for yet another changes to
capability, motivation, and opportunity may be required.
Within the three components that generate behaviour,
it is possible to develop further subdivisions that capture
important distinctions noted in the research literature.
Thus, with regard to capability, we distinguished
between physical and psychological capability (psycholo-
gical capability being the capacity to engage in the
necessary thought processes - comprehension, reasoning
et al.). With opportunity, we distinguished between phy-
sical opportunity afforded by the environment and social
opportunity afforded by the cultural milieu that dictates
the way that we think about things (e.g., the words and
concepts that make up our language). With regard to
motivation, we distinguished between reflective pro-
cesses (involving evaluations and plans) and automatic
processes (involving emotions and impulses that arise
from associative learning and/or innate dispositions)
[7,18,20]. Thus, we identified six components within the
behavioural system (Figure 1). All, apart from reflective
Figure 1 The COM-B system - a framework for understanding
Michie et al.Implementation Science 2011, 6:42
Page 4 of 11
motivation, are necessary for a given behaviour but it is
possible to generate a profile of which should be tar-
geted to achieve the behavioural target.
Systematic literature review of current frameworks
We used the following search terms to identify scholarly
articles containing frameworks of behaviour change
interventions: Topic = (taxonomy or framework or clas-
sification) AND Topic = (behaviour changeor beha-
vior change) AND Topic = (prevention OR intervention
OR promotion OR treatment OR program OR pro-
gramme OR policy OR law OR politics OR regulation
OR government OR institute OR legislation).
Searches of Web of Science (Science and Social Science
databases), Pubmed. and PsycInfo were supplemented by
consulting with eight international experts in behaviour
change, drawn from the disciplines of psychology, health
promotion, epidemiology, public health, and anthropol-
ogy. Given that there may be frameworks described in
books and non peer-reviewed articles, we acknowledged
that it was unlikely that we would arrive at a complete
set, but we sought to canvass enough to be able to under-
take an analysis of how well as a whole they matched the
criteria described earlier and to achieve sufficient cover-
age of the key concepts and labels.
Documents were included if: they described a frame-
work of behaviour change interventions (not specific
behaviour change techniques); the framework was speci-
fied in enough detail to allow their key features to be
discerned; and they were written in English. They were
originally selected on the basis of titles and abstracts. A
subset was then selected using the inclusion criteria for
full review. The nature of the topic meant that this
review could not be undertaken using the PRISMA
guidelines [21].
Once the frameworks were identified, their categories
and category definitions were extracted and tabulated.
This was done independently by MS and a researcher
who was not part of the study team or familiar with this
work. The frameworks were coded according to the cri-
teria for usefulness by RW and SM.
Develop a new framework
The new framework was developed by tabulating the full
set of intervention categories that had been identified
and establishing links between intervention characteris-
tics and components of the COM-B system that may
need to be changed. The definitions and conceptualisa-
tion of the intervention categories were refined through
discussion and by consulting the American Psychologi-
cal Associations Dictionary of Psychology and the
Oxford English Dictionary. The resulting framework was
then compared with the existing ones in terms of the
criteria of usefulness (i.e., met or not met).
organisation of components and links between them
was arrived at through an iterative process of discussion
and testing against specific examples and counter-exam-
ples. Linking interventions to components of the beha-
viour system was achieved with the help of a broad
theory of motivation that encapsulated both reflective
and automatic aspects, and focused on the moment to
moment control of behaviour by the internal and exter-
nal environment which in turn is influenced by that
behaviour and the processes leading up to it [7]. Thus,
for example, interventions that involved coercion could
influence reflective motivation by changing conscious
evaluations of the options or by establishing automatic
associations between anticipation of the behaviour and
negative feelings in the presence of particular cues.
There is not the space to go into details of this analysis
here. These can be found in [7].
Test the reliability of the framework
The framework was used independently by RW and SM
to classify the 24 components of the 2010 English gov-
ernment tobacco control strategy [22] and the 21 com-
ponents of the 2006 NICE obesity guidance [23]. The
level of inter-rater agreement was computed and any
differences resolved through discussion. The areas of
tobacco control and obesity reduction were chosen
because these are among the most important in public
health and ones where health professional behaviour has
consistently been found to fall short of that recom-
mended by evidence-based guidelines [24-26]. In addi-
tion, these documents cover a wide spectrum of
behaviour change approaches. Following reliability test-
ing and discussion of any disagreements, a gold stan-
dardwas established.
Next, reliability of use by practitioners was assessed by
asking two policy experts (the Department of Health
Policy Lead for implementation of the 2010 English gov-
ernment tobacco control strategy and a tobacco
researcher) to independently classify the 24 components
als). Their coding data were compared with the gold
Systematic literature review of existing frameworks
From the systematic literature search, 1,267 articles were
identified from the electronic databases, eight of which
met our inclusion criteria. The expert consultations pro-
duced a further 17 articles, 11 of which met the inclu-
sion criteria resulting in a total of 19 articles describing
19 frameworks. (See Additional file 2 for more detail of
flow of studies through the review process, and
Additional file 3 for reasons for exclusion). Additional
Michie et al.Implementation Science 2011, 6:42
Page 5 of 11
file 4 shows the frameworks and gives a brief description
of each [11,12,16,27-42].
Several things became apparent when reviewing the
frameworks. First of all, it was clear it would be neces-
sary to define terms describing categories of intervention
more precisely than is done in everyday language in
order to achieve coherence. For example, in everyday
language educationcan include training,but for our
purposes it was necessary to distinguish between educa-
tionand trainingwith the former focusing on impart-
ing knowledge and developing understanding and the
latter focusing on development of skills. Similarly we
had to differentiate trainingfrom modelling.In com-
mon parlance, modelling could be a method used in
training, but we use the term more specifically to refer
to using our propensity to imitate as a motivational
device. A third example is the use of the term enable-
ment.In everyday use, this could include most of the
other intervention categories, but here refers to forms of
enablement that are either more encompassing (as in,
for example, behavioural supportfor smoking cessa-
tion) or work through other mechanisms (as in, for
example, pharmacological interventions to aid smoking
cessation or surgery to enable control of calorie intake).
There is not a term in the English language to describe
that we intend, so rather than invent a new term we
have stayed with enablement.
Second, it became apparent that a distinction needed
to be made between interventions (activities aimed at
changing behaviour) and policies (actions on the part of
responsible authorities that enable or support interven-
tions). For example, an intervention that involved incen-
tivising primary care organisations to prioritise public
health interventions could be implemented through dif-
ferent policies such as producing guidelines and/or leg-
islation. A second example is that raising the financial
cost of a behaviour whose incidence one wishes to
reduce (an example of coercion) could be enabled and
supported by different policies, from fiscal measures
(taxation) to legislation (fines). We therefore had to
divide the categories that emerged into interventions
and policies.
Third, any given intervention could in principle per-
form more than one behaviour change function. Thus
the intervention categories identified from the 19 exist-
ing frameworks were better conceived of as non-over-
lapping functions: a given intervention may involve
more than one of these. For example, a specific instance
of brief physician advice to reduce alcohol consumption
may involve the three different functions of education,
persuasion, and enablement, whereas another may
involve only one or two of these. With regard to the
policies, it was possible to treat them as non-overlapping
With this in mind, scrutiny of the frameworks yielded
a set of nine intervention functions and seven policy
categories that were included in at least one framework.
Table 1 lists these and their definitions (their sources
are detailed in Additional file 5). Additional file 6 shows
whether or not the intervention functions and policy
categories were covered by each of the reviewed frame-
works. The inter-rater reliability for coding the frame-
works by intervention functions and policy categories
was 88%.
Additional file 7 shows how existing frameworks met
the criteria of usefulness. It is apparent that no frame-
work covered all the functions and categories and thus
did not meet the criterion of comprehensiveness. Only
three frameworks met the criterion of coherence. Seven
were explicitly linked to an overarching model of
Development of a new framework
Given that policies can only influence behaviour through
the interventions that they enable or support, it seemed
appropriate to place interventions between these and
behaviour. The most parsimonious way of doing this
seemed to be to represent the whole classification sys-
tem in terms of a behaviour change wheel(BCW) with
three layers as shown in Figure 2. This is not a linear
model in that components within the behaviour system
interact with each other as do the functions within the
intervention layer and the categories within the policy
Having established the structure of the new framework,
the next step was to link the components of the beha-
viour system to the intervention functions and to link
these to policy categories using the approach described
in the Methods section. This led to a framework that met
the third criterion of linkage with an overarching model
of behaviour change (Tables 2 and 3).
Testing the reliability of the new framework
The initial coding of the intervention functions and pol-
icy categories of the 2010 English Tobacco Control
Strategy was achieved with an inter-rater agreement of
88%. The inter-rater agreement for the NICE Obesity
Guidance was 79%. Differences were readily resolved
through discussion (see Additional file 8 for details of
the analysis). The percentage agreement between the
identified components and the gold standardwas 85%
for the implementation lead for the 2010 English gov-
ernment tobacco control strategy in the Department of
Health and 75% for the tobacco researcher.
Within 19 frameworks for classifying behaviour change
interventions, nine intervention functions and seven
Michie et al.Implementation Science 2011, 6:42
Page 6 of 11
policy categories could be discerned. None of the frame-
works covered all of these. Only a minority of the fra-
meworks could be regarded as coherent or linked to an
overarching model of behaviour. However, it was possi-
ble to construct a new BCW framework that did meet
these criteria from the existing ones. This framework
could be reliably applied to classify interventions within
two important areas of public health.
We believe that this is the first attempt to undertake a
systematic analysis of behaviour intervention frame-
works and apply usefulness criteria to them. This is also
the first time that a new framework has been con-
structed from existing frameworks explicitly to over-
come their limitations. Moreover, we are not aware of
other attempts to assess the reliability with which a fra-
mework can be applied in practice.
It must be recognised that there are a near infinite
number of ways of classifying interventions and inter-
vention functions. The one arrived at here will no doubt
be superseded. But for the present, it has the benefits of
having been derived from classifications already available
and therefore covering concepts that have previously
been considered to be important, and using an over-
arching model of behaviour to link interventions to
potential behavioural targets. The most important test
of this framework will be whether it provides a more
Table 1 Definitions of interventions and policies
Interventions Definition Examples
Education Increasing knowledge or understanding Providing information to promote healthy eating
Persuasion Using communication to induce positive or negative feelings or
stimulate action
Using imagery to motivate increases in physical activity
Incentivisation Creating expectation of reward Using prize draws to induce attempts to stop smoking
Coercion Creating expectation of punishment or cost Raising the financial cost to reduce excessive alcohol
Training Imparting skills Advanced driver training to increase safe driving
Restriction Using rules to reduce the opportunity to engage in the target
behaviour (or to increase the target behaviour by reducing the
opportunity to engage in competing behaviours)
Prohibiting sales of solvents to people under 18 to reduce use
for intoxication
Changing the physical or social context Providing on-screen prompts for GPs to ask about smoking
Modelling Providing an example for people to aspire to or imitate Using TV drama scenes involving safe-sex practices to increase
condom use
Enablement Increasing means/reducing barriers to increase capability or
Behavioural support for smoking cessation, medication for
cognitive deficits, surgery to reduce obesity, prostheses to
promote physical activity
Using print, electronic, telephonic or broadcast media Conducting mass media campaigns
Guidelines Creating documents that recommend or mandate practice. This
includes all changes to service provision
Producing and disseminating treatment protocols
Fiscal Using the tax system to reduce or increase the financial cost Increasing duty or increasing anti-smuggling activities
Regulation Establishing rules or principles of behaviour or practice Establishing voluntary agreements on advertising
Legislation Making or changing laws Prohibiting sale or use
social planning
Designing and/or controlling the physical or social environment Using town planning
Delivering a service Establishing support services in workplaces, communities etc.
Capability beyond education and training; opportunity beyond environmental restructuring
Figure 2 The Behaviour Change Wheel.
Michie et al.Implementation Science 2011, 6:42
Page 7 of 11
efficient method of choosing the kinds of intervention
that are likely to be appropriate for a given behavioural
target in a given context and a given population.
Just by identifying all the potential intervention func-
tions and policy categories this framework could prevent
policy makers and intervention designers from neglect-
ing important options. For example, it has been used in
UK parliamentary circles to demonstrate to Members of
Parliament that the current UK Government is ignoring
important evidence-based interventions to change beha-
viour in relation to public health [43,44]. By focusing on
environmental restructuring, some incentivisation and
forms of subtle persuasion to influence behaviour, as
advocated by the popular book Nudge[45], the UK
Government eschews the use of coercion, persuasion, or
the other BCW intervention functions that one might
Although awareness of the full range of interventions
and policies is important for intervention design, the
BCW goes beyond providing this. It forms the basis for
a systematic analysis of how to make the selection of
interventions and policies (as in Tables 2 and 3). Having
selected the intervention function or functions most
likely to be effective in changing a particular target
behaviour, these can then be linked to more fine-grained
specific behaviour change techniques (BCTs). Any one
intervention function is likely to comprise many indivi-
dual BCTs, and the same BCT may serve different inter-
vention functions. An examination of BCTs used in self-
management approaches to increasing physical activity
and healthy eating [46], and in behavioural support for
smoking cessation [47,48], shows that these BCTs serve
five of the intervention functions: education, persuasion,
incentivisation, training, and enablement. The other four
intervention functions (coercion, restriction, environ-
mental restructuring, and modelling) place more empha-
sis on external influences and less on personal agency.
Reliable taxonomies for BCTs within these intervention
functions have yet to be developed.
One of the strengths of this framework is that it
incorporates context very naturally. There is a general
recognition that context is key to the effective design
and implementation of interventions, but it remains
under-theorised and under-investigated. The opportu-
nitycomponent of the behavioural model is the context,
so that behaviour can only be understood in relation to
Table 2 Links between the components of the COM-Bmodel of behaviour and the intervention functions
Model of
behaviour: sources
Education Persuasion Incentivisation Coercion Training Restriction Environmental
Modelling Enablement
C-Ph √√
C-Ps √√ √
M-Re √√ √ √
M-Au √√ √ √
O-Ph √√ √
O-So √√ √
1. Physical capability can be achieved through physical skill development which is the focus of training or potentially through enabling interventions such as
medication, surgery or prostheses.
2. Psychological capability can be achieved through imparting knowledge or understanding, training emotional, cognitive and/or behavioural skills or through
enabling interventions such as medication.
3. Reflective motivation can be achieved through increasing knowledge and understanding, eliciting positive (or negative) feelings about behavioural target.
4. Automatic motivation can be achieved through associative learning that elicit positive (or negative) feelings and impulses and counter-impulses relating to the
behavioural target, imitative learning, habit formation or direct influences on automatic motivational processes (e.g., via medication).
5. Physical and social opportunity can be achieved through environmental change.
Table 3 Links between policy categories and intervention functions
Education Persuasion Incentivisation Coercion Training Restriction Environmental
Modelling Enablement
√√ √ √
Guidelines √√ √ √
Fiscal √√√ √
Regulation √√ √ √
Legislation √√ √ √
Service Provision √√ √ √
Michie et al.Implementation Science 2011, 6:42
Page 8 of 11
context. Behaviour in context is thus the starting point
of intervention design. The behaviour system also has
automatic processing at its heart, broadening the under-
standing of behaviour beyond the more reflective, sys-
tematic cognitive processes that have been the focus of
much behavioural research in implementation science
and health psychology (for example, social cognition
models such as the Theory of Planned Behaviour).
An existing framework that has made an important
contribution to making intervention design more sys-
tematic is intervention mapping[16]. A key difference
between this and the BCW approach is that intervention
mapping aims to map behaviour on to its theoretical
determinantsin order to identify potential levers for
change, whereas the BCW approach recognises that the
target behaviour can in principle arise from combina-
tions of any of the components of the behaviour system.
It may appear that some components are more impor-
tant than others because of a lack of variance in (includ-
ing absence or universal presence of) the variables
concerned in the population under study. This can be
illustrated by a study of GP advice to smokers, which
found that a single variable degree of concern that it
would harm the doctor-patient relationship accounted
for significant variance in the rate of advice-giving [49].
Intervention mappingwould suggest that concern be
the target for an intervention (as long as a judgement
were made that this could be modified using interven-
tions that were realistically applicable). The BCW would
analyse the target behaviour in context and note that,
regardless of what covariation might currently exist, the
target behaviour consists of an activity in which capabil-
ity is not at issue, and the reflective motivation is
broadly positive. The problem arises because automatic
motivational factors are currently working against the
behaviour (e.g., lack of emotional reward for giving
advice or punishment for not giving it and lack of cues
to action). Moreover, the physical opportunity is limited
(lack of time) and the social opportunities are also
somewhat limited. It would then consider the full range
of ways in which the frequency of advice-giving could
be increased. Because the target behaviour is part of a
system,a single intervention may have consequences
for other parts of the system - these might work against
sustainable change or in favour of it.
Thus, the BCW approach is based on a comprehensive
causal analysis of behaviour and starts with the question:
What conditions internal to individuals and in their
social and physical environment need to be in place for
a specified behavioural target to be achieved?The
intervention mappingapproach is based on an epide-
miological analysis of co-variation within the beha-
vioural domain and starts with the question: What
factors in the present population at the present time
underlie variation in the behavioural parameter?When
it comes to theoretical underpinnings, the BCW
approach draws from a single unifying theory of motiva-
tion in context that predicts what aspects of the motiva-
tional system will need to be influenced in what ways to
achieve a behavioural target, whereas the intervention
mappingapproach draws on a range of theoretical
approaches each of which independently addresses dif-
ferent aspects of the behaviour in question.
The BCW is being developed into a theory- and evi-
dence-based tool allowing a range of users to design
and select interventions and policies according to an
analysis of the nature of the behaviour, the mechanisms
that need to be changed in order to bring about beha-
viour change, and the interventions and policies
required to change those mechanisms. An ongoing pro-
gramme of research is developing an intervention
design toolbased on the BCW. It starts with a theoreti-
cal understanding of behaviour to determine what needs
to change in order for the behavioural target to be
achieved, and what intervention functions are likely to
be effective to bring about that change. It is being field
tested by a range of staff involved in policy and inter-
vention work applying the framework to develop proto-
type strategies for specific implementation targets. Data
are being collected about ease of use and the potential
of the BCW to generate new insights.
There are a number of limitations to the research
described in this paper. First, it is possible that the sys-
tematic review missed important frameworks and/or
intervention functions. Second, judgement is inevitably
involved in conceptualising intervention functions and
policy categories. There are many different ways of
doing this, and no guarantees that the one arrived at
here is optimal. Indeed, different frameworks may be
more or less useful in different circumstances. Third,
even though the proposed framework appears to be
comprehensive and can be used reliably to characterise
interventions, it is possible that it may prove difficult to
use. However, the systematic way in which development
of the BCW has been approached should enable it to
provide a more robust starting point for development of
improved frameworks than has hitherto been possible.
Additional material
Additional file 1: Applying the Behaviour Change Wheel to
characterise intervention strategies: Coding Materials. Behaviour
Change Wheel Coding materials
Additional file 2: Flow of studies through the review process. Flow
of studies through the review process
Additional file 3: Reports excluded from the review. Reports
excluded from the review
Additional file 4: Intervention frameworks. Analysis of intervention
Michie et al.Implementation Science 2011, 6:42
Page 9 of 11
Additional file 5: Sources of definitions of interventions and
policies. Sources of definitions of interventions and policies
Additional file 6: How existing frameworks map on to intervention
and policy categories. How existing frameworks map on to intervention
and policy categories
Additional file 7: Frameworks analysed by criteria of comprehensive
coverage, coherence and link to a model of behaviour. Analysis by
criteria of comprehensive coverage, coherence and link to a model of
Additional file 8: BCW classification of the English 2010 Tobacco
Control Strategy and the NICE Obesity Guidelines (2006). BCW
classification of the English 2010 Tobacco Control Strategy and the NICE
Obesity Guidelines (2006)
Marie Johnston, University of Aberdeen and Jamie Brown, University College
London, provided astute and helpful comments on an earlier draft of the
paper. Also thanks to Marie Johnston, Queen of acronyms, for COM-B. We
thank Dorien Pieters, Maastricht University, for her work in coding
frameworks into categories to provide a reliability check for data extraction.
Cancer Research UK provided financial support for RW. Matthew West (of
Vasco Graphics) created the artwork.
Author details
Research Dept of Clinical, Educational, and Health Psychology, University
College London, 1-19 Torrington Place, London WC1E 7HB, UK.
University Medical Center, EMGO Institute for Health and Care Research, Van
der Boechorststraat 7, 1081 BT Amsterdam.
Health Behaviour Research
Centre, University College London Epidemiology and Public Health, London,
SM and RW conceived the study, designed the measures, supervised the
systematic review, supervised the analyses and drafted the write-up. MMvS
undertook the systematic review, performed the coding and commented on
the write-up. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 4 January 2011 Accepted: 23 April 2011
Published: 23 April 2011
1. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al:
Changing provider behavior: an overview of systematic reviews of
interventions. Medical care 2001, 39(8 Suppl 2):II2-45.
2. Summerbell C, Waters E, Edmunds L, Kelly S, Brown T, Campbell K:
Interventions for preventing obesity in children. Cochrane Database of
Systematic Reviews 2005, , 3: CD001871.
3. Coleman T: Do financial incentives for delivering health promotion
counselling work? Analysis of smoking cessation activities stimulated by
the quality and outcomes framework. BMC public health 2010, 10:167.
4. Michie S, Abraham C, Eccles MP, Francis JJ, Hardeman W, Johnston M:
Methods for strengthening evaluation and implementation: specifying
components of behaviour change interventions: a study protocol.
Implement Sci .
5. Michie S, Ashford S, Sniehotta FF, Dombroski SU, Bishop A, French DP: A
refined taxonomy of behaviour change techniques to help people
change their physical activity and healthy eating behaviours. The CALO-
RE taxonomy Psychology and Health .
6. Michie S, Fixsen D, Grimshaw JM, Eccles MP: Specifying and reporting
complex behaviour change interventions: the need for a scientific
method. Implement Sci 2009, 4:40.
7. West R: Theory of Addiction. Oxford: Blackwells; 2006.
8. Davies P, Walker AE, Grimshaw JM: A systematic review of the use of
theory in the design of guideline dissemination and implementation
strategies and interpretation of the results of rigorous evaluations.
Implement Sci 2010, 5:14.
9. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A: Making
psychological theory useful for implementing evidence based practice: a
consensus approach. Qual Saf Health Care 2005, 14(1):26-33.
10. Michie S, Prestwich A: Are interventions theory-based? Development of a
theory coding scheme. Health Psychol 2010, 29(1):1-8.
11. Institute for Government: MINDSPACE; Influencing behaviour through
public policy. Institute for Government, the Cabinet Office; 2010.
12. Cochrane Effective Practice and Organisation of Care Group: EPOC
resources for review authors. 2010 [
13. National Institute for Health and Clinical Excellence: Behaviour change at
population, community and individual levels (Public Health Guidance 6).
London NICE; 2007.
14. Information Centre: Statistics on NHS Stop-Smoking Services 2009/10.
London: Department of Health; 2010.
15. Johnston M, Dixon D: Current issues and new directions in psychology
and health: What happened to behaviour in the decade of behaviour?
Psychology and Health 2008, 23(5):509-13.
16. Bartholomew L, Parcel G, Kok G, Gottlieb N: Planning Health Promotion
Programs: Intervention Mapping. San Francisco Jossey-Bass; 2011.
17. West R, Walia A, Hyder N, Shahab L, Michie S: Behavior change techniques
used by the English Stop Smoking Services and their associations with
short-term quit outcomes. Nicotine Tob Res 2010, 12(7):742-7.
18. Mook D: Motivation: The Organization of Action. New York; London W.W.
Norton & Company; 1995.
19. Fishbein M, Triandis H, Kanfer F, Becker M, Middlestadt S, Eichler A: Factors
influencing behaviour and behaviour change. In Handbook of Health
Psychology. Edited by: Baum A, Revenson T, Singer J. Imahwah, NJ Lawrence
Erlbaum Associates; 2001:3-17.
20. Strack F, Deutsch R: Reflective and impulsive determinants of social
behavior. Pers Soc Psychol Rev 2004, 8(3):220-47.
21. Anon: Prisma: Transparent Reporting of Systematic Reviews and Meta-
Analyses. 2009 [].
22. Department of Health: A Smoke-free Future: A comprehensive Tobacco
Control Strategy for England. London; 2010.
23. National Institute for Health and Clinical Excellence: Obesity: the
prevention, identification, assessment and management of overweight
and obesity in adults and children National Institute for Health and
Clinical Excellence. 2006.
24. Haines A, Kuruvilla S, Borchert M: Bridging the implementation gap
between knowledge and action for health. Bulletin of the World Health
Organization 2004, 82(10):724-31, discussion 32.
25. Schuster RJ, Tasosa J, Terwoord NA: Translational research
implementation of NHLBI Obesity Guidelines in a primary care
community setting: the Physician Obesity Awareness Project. The journal
of nutrition, health & aging 2008, 12(10):764S-9S.
26. Gilles ME, Strayer LJ, Leischow R, Feng C, Menke JM, Sechrest L: Awareness
and implementation of tobacco dependence treatment guidelines in
Arizona: Healthcare Systems Survey 2000. Health research policy and
systems/BioMed Central 2008, 6:13.
27. Abraham C, Kok G, Schaalma H, Luszczynska A: Health Promotion. In The
International Association of Applied Psychology Handbook of Applied
Psychology. Edited by: Martin P, Cheung F, Kyrios M, Littlefield L, Knowles L,
Overmier M. Oxford: Wiley-Blackwell; 2010:.
28. Cohen DA, Scribner R: An STD/HIV prevention intervention framework.
AIDS Patient Care STDS 2000, 14(1):37-45.
29. DEFRA: A Framework for Pro-Environmental Behaviours: Report. London:
Defra; 2008.
30. Dunton GF, Cousineau M, Reynolds KD: The intersection of public policy
and health behavior theory in the physical activity arena. J Phys Act
Health 2010, 7(Suppl 1):S91-8.
31. Geller S, Berry T, Ludwig T, Evans R, Gilmore M, Clarke S: A conceptual
framework for developing and evaluating behavior change interventions
for injury control. Health Educ Res 1990, 5(2):125-37.
32. Goel P, Ross-Degnan D, Berman P, Soumerai S: Retail pharmacies in
developing countries: a behavior and intervention framework. Soc Sci
Med 1996, 42(8):1155-61.
33. Knott D, Muers S, Aldridge S: Achieving Culture Change: A Policy
Framework Strategy Unit. 2008.
Michie et al.Implementation Science 2011, 6:42
Page 10 of 11
34. Leeman J, Baernholdt M, Sandelowski M: Developing a theory-based
taxonomy of methods for implementing change in practice. J Adv Nurs
2007, 58(2):191-200.
35. Maibach EW, Abroms LC, Marosits M: Communication and marketing as
tools to cultivate the publics health: a proposed people and places
framework. BMC public health 2007, 7(88).
36. Nuffield Council on Bioethics: Public Health: ethical issues; a guide to the
report. Nuffield Council on Bioethics; 2007.
37. Perdue WC, Mensah GA, Goodman RA, Moulton AD: A legal framework for
preventing cardiovascular diseases. Am J Prev Med 2005, 29(5 Suppl
38. Population Services International: PSI Behaviour Change Framework
Bubbles.Washington DC; 2004 [].
39. Vlek C: Essential psychology for environmental policy making.
International Journal of Psychology 2000, 35:153-67.
40. Walter I, Nutley S, Davies H: Developing a taxonomy of interventions
used to increase the impact of research. St Andrews University of St
Andrews; 2003.
41. West R: Tobacco control: present and future. Br Med Bull 2006, 77-
42. White P: PETeR: a universal model for health interventions. 2010.
43. West R, Michie S: Behaviour change: the importance of seeing the whole
picture and a critique of Nudge: Submission to the House of Lords
Science and Technology Select Committee Call for Evidence: Behaviour
Change. London House of Lords; 2010.
44. Featherstone H, Reed H, Jarvis M, Michie S, Gilmour A, West R, et al:APPG
Enquiry into the effectiveness and Cost Effectiveness of Tobacco
Control: Submission to the Spending Review and Public Health White
Paper Consultation Process. London: Action on Smpoking and Health;
45. Thaler R, Sunstein C: Nudge: Improving Decisions about Health, Wealth
and Happiness. Boston Yale University Press; 2008.
46. Michie S, Abraham C, Whittington C, McAteer J, Gupta S: Effective
techniques in healthy eating and physical activity interventions: a meta-
regression. Health Psychol 2009, 28(6):690-701.
47. Michie S, Churchill S, West R: Identifying Evidence-Based Competences
Required to Deliver Behavioural Support for Smoking Cessation. Ann
Behav Med 2010.
48. Michie S, Hyder N, Walia A, West R: Development of a taxonomy of
behaviour change techniques used in individual behavioural support for
smoking cessation. Addictive Behaviors 2010.
49. McEwen A, West R, Preston A: Triggering anti-smoking advice by GPs:
mode of action of an intervention stimulating smoking cessation advice
by GPs. Patient education and counseling 2006, 62(1):89-94.
Cite this article as: Michie et al.: The behaviour change wheel: A new
method for characterising and designing behaviour change
interventions. Implementation Science 2011 6:42.
Submit your next manuscript to BioMed Central
and take full advantage of:
Convenient online submission
Thorough peer review
No space constraints or color figure charges
Immediate publication on acceptance
Inclusion in PubMed, CAS, Scopus and Google Scholar
Research which is freely available for redistribution
Submit your manuscript at
Michie et al.Implementation Science 2011, 6:42
Page 11 of 11
... Intervention development should draw upon explicit theories and approaches for identifying hypothesized pathways from candidate intervention techniques to desired behaviour changes [64][65][66]. For example, the Behaviour Change Wheel (BCW) provides systematic guidance on developing behaviour change interventions, based on a broad range of multidisciplinary frameworks (figure 1) [67]. The BCW is centred on the R. Soc. ...
... In the light of qualitative findings that these motivational barriers are driven by factors outside of direct journal editor control, information on advocacy with journal publishers and societies might also be beneficial to include, as the power and resources to make changes to journal policies often depends on approval from these authorities. Specifically, the BCW approach suggests that official guidelines on open science standards endorsed by and support services offered by these authorities would support the aforementioned interventions [67]. Our findings also indicate that interventions to implement open science journal policies should target publishers and manuscript submission systems. ...
Full-text available
The Transparency and Openness Promotion (TOP) Guidelines provide a framework to help journals develop open science policies. Theories of behaviour change can guide understanding of why journals do (not) implement open science policies and the development of interventions to improve these policies. In this study, we used the Theoretical Domains Framework to survey 88 journal editors on their capability, opportunity and motivation to implement TOP. Likert-scale questions assessed editor support for TOP, and enablers and barriers to implementing TOP. A qualitative question asked editors to provide reflections on their ratings. Most participating editors supported adopting TOP at their journal (71%) and perceived other editors in their discipline to support adopting TOP (57%). Most editors (93%) agreed their roles include maintaining policies that reflect current best practices. However, most editors (74%) did not see implementing TOP as a high priority compared with other editorial responsibilities. Qualitative responses expressed structural barriers to implementing TOP (e.g. lack of time, resources and authority to implement changes) and varying support for TOP depending on study type, open science standard, and level of implementation. We discuss how these findings could inform the development of theoretically guided interventions to increase open science policies, procedures and practices.
... [7] Of course, awareness rising is not the only global health policy tool to address AMR but is the most efficient step. [8] Since the fight against AMR is a global emergency and similar to other parts of the world, its rate has increased dramatically in our country. Comprehensive interventional strategies are necessary. ...
... A detailed understanding of current behaviors is an essential first step in developing interventions. 12 Most of the medical professionals lack the skills necessary to diagnose and treat NP; it may partly be due to inadequate training during medical schools and residency. Medical schools don't teach enough about chronic pain, and many trainees and graduates lack confidence in their competence to treat patients with this type of pain. ...
An important public health issue is neuropathic pain. It is a common, persistent, and severely disabling condition experienced by those in primary care. An important first step is an accurate diagnosis. It is the first step toward effective pain and disability reduction and management. The history may indicate the presence of pain, and a physical examination may confirm it. Medical professionals lack the skills necessary to diagnose and treat neuropathy pain, in part due to inadequate training during medical school and residency. The primary care physician is critical in avoiding delay in diagnosis, providing proper evaluation and treatment, and improving outcomes while reducing the financial burden on society economy. Citation: Anwar S. Neuropathic pain: The missing link at the general physician level. Anaesth. pain intensive care 2022;26(5):585-587; DOI: 10.35975/apic.v26i5.2021
... In the preferences section, participants were also asked to indicate their preferred times for physical activity by ticking all relevant response options from the following: 'Before 8 a.m.', '8-11 a.m.', '11 a.m.-2 p.m.', '2-5 p.m.', '5-8 p.m.', 'After 8 p.m.', and 'No preference'. In the barriers section, nine new items were added after the pre-pandemic wave of recruitment to ensure coverage of all the domains of the Theoretical Domains Framework [21] and COM-B model of behaviour [22]: 'I don't have anyone to do physical activity with', 'The thought of physical activity makes me worry', 'I don't think that physical activity will benefit me', 'My close contacts don't support or encourage my physical activity', 'I get easily distracted from the physical activity I have planned', 'I don't make plans for doing physical activity', 'I don't think physical activity is important', 'Physical activity is not something I do automatically', and 'Also fear of judgement/stigma because of mental (or physical) health problems' [23,24]. ...
Full-text available
Adults with severe mental ill health may have specific attitudes toward physical activity. To inform intervention development, we conducted a survey to assess the physical activity patterns, preferences, barriers, and motivations of adults with severe mental ill health living in the community. Data were summarised using descriptive statistics, and logistic regressions were used to explore relationships between physical activity status and participant characteristics. Five-hundred and twenty-nine participants (58% male, mean age 49.3 years) completed the survey. Large numbers were insufficiently active and excessively sedentary. Self-reported levels of physical activity below that recommended in national guidelines were associated with professional inactivity, consumption of fewer than five portions of fruit and vegetables per day, older age, and poor mental health. Participants indicated a preference for low-intensity activities and physical activity that they can do on their own, at their own time and pace, and close to home. The most commonly endorsed source of support was social support from family and friends. Common motivations included improving mental health, physical fitness, and energy levels. However, poor mental and physical health and being too tired were also common barriers. These findings can inform the development of physical activity interventions for this group of people.
Unlabelled: There are multifaceted reasons for a social gradient in planned dental visiting involving various psycho-social variables that interact with each other and the environment. Interventions in this area are therefore inevitably complex interventions. While guidance recommends undertaking theory and modelling work before experimental work is done, there is a shortage of descriptions of how this is done, especially in the field of oral health. Objectives: To describe theory, qualitative and public engagement work, and identification of behaviour change techniques (BCTs) to define features of an opportunistic dental visiting intervention for adult users of urgent dental care services. Methods: A systematic review and synthesis of theory, qualitative and quantitative work, along with expert input, generated a list of psycho-social determinants linked to planned dental visiting intentions. Modelling involved ethnographic work in urgent dental care settings and work with members of the community from the targeted demographic. This enabled verification, in the context of their idiosyncratic expression for the target population in question, of behavioural determinants (BDs) identified in the theory phase. It also facilitated generating intervention material which was infused with the identity of the end user. BDs identified were then mapped to BCTs using an accepted BCT taxonomy and an intervention prototype developed. The prototype then underwent iterative testing with target users before it was ready for a feasibility trial. Results: Theory and modelling identified five key intervention focuses: affordable resources (time/ cost), the importance of oral health, trust in dentists, embarrassment of having poor oral health and dental anxiety. Short videos were developed to incorporate role modelling which were well received. Prototype testing resulted in shifting from 'if-then' plans to action planning. Conclusions: Complex intervention development involves an iterative rather than sequential process of combining theory, empirical work and user involvement, of which the article provides an example.
Full-text available
The COVID-19 pandemic has been an historic challenge to public health, and to behavior change programs. There have been challenges in promoting vaccination in LMICs, including Nigeria. One important hypothesis deserving consideration is the ability to obtain vaccination as a potential barrier to vaccination uptake. The MOA (motivation, opportunity, and ability) framework, as illustrated by multiple theories such as COM-B, EAST, and the Fogg model, is a primary theoretical basis for the evaluation of this ability as a factor in vaccination uptake. There is little research on measuring the ability to get vaccinated in LMICs, including on the role of all of the MOA framework. The aim of this study was to develop and evaluate an ability factors index measured through social media-based data collected in Nigeria in late 2021 and early 2022. We present findings from an online survey of 8574 Nigerians and highlight new social media-based data collection techniques in this research. This study found that a new ability factors index comprising 12 items was associated with vaccine uptake independent of measures capturing other components of the MOA framework. This index may serve as a valuable research instrument for future studies. We conclude that a person’s perceived ability to get vaccinated, measured by a newly validated index, is related to vaccination uptake and hesitancy, and that more research should be conducted in this area.
Full-text available
Background: Chronic back pain (CBP) is common among patients in primary care and is associated with significant personal and socioeconomic burden. Research has shown that physical activity (PA) is one of the most effective therapies to reduce pain. However, for general practitioners (GP) it remains challenging to advise and encourage individuals with CBP to exercise regularly. Aim: To provide insight into views and experience on PA in individuals with CBP and GPs. To reveal facilitators and barriers for engaging in PA. Design and Setting: Qualitative semi-structured interviews with 14 individuals with CBP and 12 GPs in Germany between June and December 2021. Method: Interviews were coded separately by consensus and analysed thematically. Findings of the two groups were compared and summarised. Results: Opinion and experience on PA in individuals with CBP were similar both within and across the GP and patient groups. Interviewees expressed their views on internal and external barriers affecting PA. They provided strategies to address these barriers and concrete recommendations to increase PA. However, our study revealed a conflictual doctor-patient-relationship that ranged from paternalistic to partnership-based to service provision. This might lead to negative perceptions on both sides such as frustration and stigma. Conclusion: To the best of our knowledge, this is the first qualitative study exploring opinion and experience of PA in individuals with CBD and GPs in parallel. Our study reveals a complex doctor-patient-relationship and provides an important insight into motivation for and adherence to PA in individuals with CBP.
Despite the well-known benefits of breastfeeding, breastfeeding rates remain suboptimal, particularly for women with lower socioeconomic position. Although popular, breastfeeding apps are often poor quality; their impact on breastfeeding knowledge, attitudes, confidence and intentions is unknown. A mixed method pre-post feasibility study was conducted to: 1) explore the feasibility of the My Baby Now app in providing perinatal breastfeeding support; 2) examine the impact on breastfeeding knowledge, attitudes, confidence and intentions; 3) to examine any differences in acceptability and impact of the app according to maternal education. The My Baby Now app was offered to pregnant women 20-30 weeks gestation. Breastfeeding knowledge and intentions were collected at baseline (T1) and 36-38 weeks gestation (T2); attitudes and confidence were collected at baseline, T2 and T3 (8-12 weeks post-partum). App engagement was measured via app analytics. Qualitative interviews were conducted with a purposeful sample following T3. Of 266 participants recruited, 169 (64%) completed T2 and 157 (59%) completed T3. Mothers without university education rated the app to be higher quality, more useful and impactful than mothers with university education. From T1-T2, breastfeeding knowledge (59.6% vs. 66.5%, p < 0.001) and exclusive breastfeeding intentions (76.6% vs. 80.9%, p < 0.001) increased. Breastfeeding attitudes and confidence scores also increased significantly across T1-T2 and T1-T3. App engagement during pregnancy predicted changes in breastfeeding attitudes from T1-T2 among participants without university education. App engagement did not predict changes in breastfeeding knowledge, confidence or intentions. Future randomised controlled studies should examine the effectiveness of mHealth interventions on breastfeeding outcomes.
Background: Concussion is a common condition that can lead to a constellation of symptoms that affect quality of life, social integration, and return to work. There are several evidence-based behavioral and psychological interventions that have been found to improve postconcussion symptom burden. However, these are not routinely delivered, and individuals receive limited support during their concussion recovery. Objective: This study aimed to develop and test the feasibility of a digital health intervention using a systematic evidence-, theory-, and person-based approach. Methods: This was a mixed methodology study involving a scoping review (n=21), behavioral analysis, and logic model to inform the intervention design and content. During development, the intervention was optimized with feedback from individuals who had experienced concussions (n=12) and health care professionals (n=11). The intervention was then offered to patients presenting to the emergency department with a concussion (n=50). Participants used the intervention freely and input symptom data as part of the program. A number of outcome measures were obtained, including participant engagement with the intervention, postconcussion symptom burden, and attitudes toward the intervention. A selection of participants (n=15) took part in in-depth qualitative interviews to understand their attitudes toward the intervention and how to improve it. Results: Engagement with the intervention functionality was 90% (45/50) for the symptom diary, 62% (31/50) for sleep time setting, 56% (28/50) for the alcohol tracker, 48% (24/50) for exercise day setting, 34% (17/50) for the thought diary, and 32% (16/50) for the goal setter. Metrics indicated high levels of early engagement that trailed off throughout the course of the intervention, with an average daily completion rate of the symptom diary of 28.23% (494/1750). A quarter of the study participants (13/50, 26%) were classified as high engagers who interacted with all the functionalities within the intervention. Quantitative and qualitative feedback indicated a high level of usability and positive perception of the intervention. Daily symptom diaries (n=494) demonstrated a wide variation in individual participant symptom burden but a decline in average burden over time. For participants with Rivermead scores on completion of HeadOn, there was a strong positive correlation (r=0.86; P<.001) between their average daily HeadOn symptom diary score and their end-of-program Rivermead score. Insights from the interviews were then fed back into development to optimize the intervention and facilitate engagement. Conclusions: Using this systematic approach, we developed a digital health intervention for individuals who have experienced a concussion that is designed to facilitate positive behavior change. Symptom data input as part of the intervention provided insights into postconcussion symptom burden and recovery trajectories. Trial registration: NCT05069948;
Full-text available
Since the 1990s there has been an increasing role for evidence in public sector policy and practice. The Modernising Government agenda demands that policy be evidence-based, and this has been accompanied by similar calls for the use of evidence by practitioners to support a rational and optimal approach to public service delivery. However, it is increasingly recognised that simply improving the content and availability of the evidence base is not sufficient to secure such changes. Explicit and active strategies are required to ensure that research really does have an impact on policy and practice. A wide diversity of approaches to enhance the impact of research has emerged in response to this need. Strategies vary in terms of the scale of the project and resources involved, the targets for research impact, the nature of impact intended and the implementation context. We can also distinguish between approaches in terms of those activities undertaken within the research community to "push" research out to potential users, and those undertaken in practice and policy contexts to encourage demand for and uptake of research findings. To help systematise current thinking about research impact and draw together evidence of effectiveness of different approaches, it is useful to develop some categorisations of these diverse initiatives and practices. This paper presents a taxonomy of interventions to enhance the impact of research on public sector policy and practice which has been developed by the Research Unit for Research Utilisation (RURU) at the University of St. Andrews. One taxonomy already widely used in the research impact field is that developed by the Effective Practice and Organisation of Care (EPOC) review group within the Cochrane Collaboration (see Appendix I). This categorisation reflects the nature and concerns of EPOC's remit to address how to improve the practice of healthcare professionals. RURU's taxonomy, by contrast, is cross-sectoral and is concerned more specifically with increasing the impact of research. It covers a wide range of policy, practice and organisational targets for research impact. Further, it is not solely concerned with interventions to change behaviour, but also includes approaches which encourage more conceptual or "enlightenment" uses of research in changing knowledge, understanding and attitudes.
Full-text available
In this article major environmental problems and their different levels and global spheres of impact are surveyed. Environmental exploitation is discussed as an inherent characteristic of free market economies under limited cognitive-motivational inclinations of individual actors. A conceptual modelling of environmental problem solving is presented, which comprises the commons dilemma paradigm as well as a needs-opportunities-abilities (NOA) model of consumer behaviour, a categorization of human needs, a simple taxonomy of behavioural processes, and seven strategies for behaviour change. Six lines of psychological research are identified, ranging from environmental attitudes to environmental policy-decision support systems. An ecological critique of mainstream psychology is summarized and some suggestions are made to resolve this. Conclusions are drawn about needed research, policy making, and international diplomacy.
Full-text available
This paper addresses issues and research needs in the domain of behavior modification for injury control. Although much of the discussion focuses on traffic safety, the concepts and principles are applicable to all areas of injury control (e.g. on the job and in the home). Field research that has increased safety belt use is reviewed briefly to illustrate a tripartite classification of injury control factors (i.e. environmental, individual, or behavioral variables), and to introduce a heuristic framework for categorizing and evaluating behavior change strategies. A multiple intervention level hierarchy depicts a progressive segmentation of the target population as more effective (and costly) interventions are implemented; and a taxonomy of 24 behavior change techniques includes a scoring system for predicting short and long term effects of intervention programs. It is presumed that more risk-prone individuals require higher-level interventions, which are those that provide specific response information and extrinsic controls, while also eliciting active participant involvement, social support, and perceptions of autonomy. Although extrinsic controls increase the immediate impact of an intervention program, these techniques may jeopardize response maintenance when the program is withdrawn.
BACKGROUND. Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies. Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals. OBJECTIVES. To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care. RESEARCH DESIGN. An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998. RESULTS. Forty-one reviews were identified covering a wide range of interventions and behaviors. In general, passive approaches are generally ineffective and unlikely to result in behavior change. Most other interventions are effective under some circumstances; none are effective under all circumstances. Promising approaches include educational outreach (for prescribing), and reminders. Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions. CONCLUSIONS. Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions. Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.