Behaviours such as smoking, dietary intake, activity levels and alcohol use are risk factors for a wide range of diseases, deaths and disability, globally 1, 2. Behaviours can also influence the effectiveness of healthcare: the behaviour of people who are ill can influence their outcomes e.g. by delay in seeking medical help, non-adherence to effective medical regimens; and the behaviours of healthcare professionals may also influence outcomes e.g. by errors in prescribing 3, failure to implement evidence-based practice in conditions such as diabetes 4, 5. It is, therefore, increasingly recognised e.g. by NICE 6 , the Academy of Medical Sciences 7 as well as the Academy for Social Sciences 8 , that behaviour change is important for health and key to public health.
Behaviour Change Theories
Health psychology has an enormous number of theories that explain behaviour change but the complexity and overlap makes them difficult to use in a public health context. Two approaches to making theories accessible are: the Theoretical Domains Framework 9,10 which reduces the number of overlapping theoretical constructs to ‘domains’; and the COM-B model11 which identifies three main determinants of behaviour, Capability, Opportunity and Motivation. Both approaches are helpful in identifying factors influencing behaviour, but unlike full theories, do not describe the relationships between these factors. For example, both approaches include ‘capability’ without relating it to other constructs; by contrast theories such as Bandura’s Social Cognitive Theory 12 or the Theory of Planned Behaviour 13 emphasise the links between capability and motivational constructs in determining behaviour; in common sense terms, we wouldn’t do what we were capable of if we didn’t want to – and we wouldn’t do what we wanted to if we weren’t capable. The full theories can also lead to better explanations of key behaviours, e.g. showing that planning has an effect on clinicians’ management of diabetes due to the development of habits 5.
Behaviour Change Methods
In order to gain from the methods developed in health psychology, it is important to think of the behaviours that need to change as ‘behaviours’. If terms such as ‘lifestyle’ or ‘quality of life’ are used, the wealth of health psychology and behavioural science may be missed. If different health-related behaviours are kept in strictly separate silos, for example as ‘topics’ in public health departments, then the gains in understanding from evidence about other behaviours may be ignored. And healthcare staff trained to deliver behaviour change for one behaviour may be prevented from working on other behaviours, despite having many of the required competencies. The Health Behaviour Change Competency Framework (HBCCF) 14 developed for Scottish government identities Foundation and Basic Behaviour Change competencies that cross all behaviours. The third competency domain, Behaviour Change Techniques (BCTs) 15, 16, identifies some techniques that are common across behaviours, but also some likely to be specific for different behaviours or situations.
Linking Behaviour Change Theories and Methods
Having identified the theoretical determinants of the behaviour one wishes to change, one needs to identify appropriate BCTs. The HBCCF 14 proposes the ‘MAP’, three routes to behaviour change with different techniques used: to address Motivation; to enable Action in those who are motivated; and to Prompt behaviour without having to engage in thinking. More recently the Theories and Techniques project 17 has systematically investigated how theory and techniques a) have been linked in published studies and b) are linked in expert consensus.
Health Psychology has developed theories and methods which can contribute to the behaviour changes necessary to improve global health. This process may be optimised by using recent developments in simplifying theory, clarifying techniques and competences, and in linking theory and techniques.
- Lim, S. S., Vos, T., Flaxman, A. D., Danaei, G., Shibuya, K., Adair-Rohani, H., ... & Aryee, M. (2013). A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet, 380(9859), 2224-2260.doi.org/10.1016/S0140-6736(12)61766-8
- Loprinzi, P. D. (2016). Health behavior characteristics and all-cause mortality. Preventive Medicine Reports
- Ryan, C., Ross, S., Davey, P., Duncan, E.M., Francis, J.J., Fielding, S., Johnston, M., Ker, J., Lee, A.J., MacLeod, M.J. and Maxwell, S., 2014. Prevalence and causes of prescribing errors: the PRescribing Outcomes for Trainee doctors Engaged in Clinical Training (PROTECT) study. PLoS One, 9(1), p.e79802.
- Presseau, J., Johnston, M., Francis, J. J., Hrisos, S., Stamp, E., Steen, N., ... & Eccles, M. P. (2014). Theory-based predictors of multiple clinician behaviors in the management of diabetes. Journal of behavioral medicine, 37(4), 607-620.
- Potthoff, S., Presseau, J., Sniehotta, F. F., Johnston, M., Elovainio, M., & Avery, L. (2017). Planning to be routine: habit as a mediator of the planning-behaviour relationship in healthcare professionals. Implementation Science, 12(1), 24.
- https://www.nice.org.uk/guidance/ph6/chapter/1-public-health-need-and-practice: https://www.nice.org.uk/guidance/ph49
- Academy of Social sciences (2017) The Health of People: how the social sciences can improve population health.
- Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D., & Walker, A. (2005). Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality and safety in health care, 14(1), 26-33.
- Cane, J., O’Connor, D., & Michie, S. (2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation science, 7(1), 37.
- Michie, S., Atkins, L., & West, R. (2014). The behaviour change wheel: a guide to designing interventions. Needed: physician leaders, 26.
- Michie, S., & Johnston, M. (2013). Behavior change techniques. In Encyclopedia of behavioral medicine (pp. 182-187). Springer New York.
- Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., ... & Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of behavioral medicine, 46(1), 81-95.
Professor Marie Johnston, Aberdeen Health Psychology Group Institute of Applied Health Sciences College of Life Sciences and Medicine