Introduction
Improving the implementation of evidence-based practice and public health initiatives often depends on successful behaviour change interventions. These interventions involve coordinated sets of activities designed to change specified behaviour patterns, such as promoting healthy lifestyles or increasing the uptake of effective clinical services.
However, the design of behaviour change interventions is frequently based on implicit “common-sense” models of behaviour rather than a rigorous analysis of the target behaviour and the factors that influence it. Even when interventions claim to be guided by behavioural theory, in practice they are often only minimally linked to an appropriate model of behaviour change. This limits the ability to select interventions that are likely to be effective in a given context.
To address this gap, a systematic method is needed that incorporates an understanding of the nature of the behaviour to be changed, and an appropriate system for characterising interventions and their components that can make use of this understanding. Existing frameworks for classifying behaviour change interventions tend to lack comprehensiveness, coherence, and clear links to an overarching model of behaviour.
This paper aims to:
- Review existing frameworks of behavioural interventions to establish how far each meets the criteria of usefulness (comprehensive coverage, coherence, and links to a model of behaviour).
- Use this review to construct a new framework of behaviour change interventions that meets these criteria.
- Establish the reliability with which the new framework can be used to characterise interventions in two public health domains.
Methods
Criteria for evaluating frameworks of behaviour change interventions
Based on an analysis of the limitations of existing frameworks, we established three criteria for evaluating their usefulness:
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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 system to offer options for intervention designers that may be effective.
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Coherence: The categories in the framework should be all exemplars of the same type and specificity of entity. The framework should not include some categories that are very broad and others very specific.
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Links to an overarching model of behaviour: The framework should be linked to a model that can explain how behaviour is generated and the factors that influence it.
Developing a new framework
We began with the concept of motivation, defined as “brain processes that energize and direct behaviour”. We then considered the minimum additional factors needed to account for whether change in the behavioural target would occur, given sufficient motivation.
This led us to a model of behaviour involving three essential conditions: capability, opportunity, and motivation – what we term the “COM-B system”. Capability is the individual’s psychological and physical capacity to engage in the activity. Opportunity is all the factors that lie outside the individual that make the behaviour possible or prompt it. Motivation is all those brain processes that energize and direct behaviour, not just goals and conscious decision-making.
We used this COM-B system as the hub of a new framework, the “Behaviour Change Wheel” (BCW), with intervention functions (broad strategies for inducing behaviour change) positioned around it, and policy categories (actions by responsible authorities that could enable those interventions) positioned around the intervention functions.
Systematic review and reliability testing
We conducted a systematic search of electronic databases and consulted with behaviour change experts to identify frameworks of behaviour change interventions. These were evaluated according to the three criteria of usefulness.
We then used the new BCW framework to characterise interventions within two public health domains – the English Department of Health’s 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence’s guidance on reducing obesity. The reliability with which the BCW could be applied was examined through independent coding and discussion to resolve any discrepancies.
Results
The systematic review identified 19 existing frameworks of behaviour change interventions. None of these frameworks 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.
The new BCW framework places a “behaviour system” involving capability, opportunity, and motivation at the hub. Surrounding this are the nine intervention functions aimed at addressing deficits in one or more of these conditions, and around this are seven categories of policy that could enable those interventions to occur.
The BCW was used reliably to characterise interventions within the two public health domains examined. This systematic approach enabled the identification of the specific intervention functions and policy categories relevant to each strategy.
Discussion
The BCW framework provides a comprehensive and coherent system for characterising behaviour change interventions, with clear links to an overarching model of behaviour. This allows for a more rigorous analysis of the target behaviour and the factors that influence it, in order to select the most appropriate interventions.
Applying the BCW to the WelTel interactive digital health outreach platform revealed that its personalized communication component incorporated a range of behaviour change techniques (e.g. goal setting, problem solving, instructions) linked to multiple intervention functions (e.g. environmental restructuring, enablement, education). This suggests the platform may address both unintentional and intentional forms of medication non-adherence by targeting various influences on behaviour.
In contrast, simpler one-way reminder-based interventions may only influence physical opportunity and automatic motivation, limiting their impact on intentional non-adherence. The BCW analysis highlights the value of interactive two-way engagement platforms in promoting behaviour change.
Ongoing research is exploring how the BCW can be developed into a practical tool to guide the design and selection of interventions. Applying this framework across diverse digital health interventions would contribute to a stronger evidence base on their mechanisms of action and optimize their integration into healthcare systems.
Conclusion
The Behaviour Change Wheel provides a systematic method for characterising behaviour change interventions that meets the criteria of comprehensive coverage, coherence, and clear links to an overarching model of behaviour. This framework can be reliably applied to identify the specific intervention functions and policy categories relevant to different public health strategies.
Unpacking the potential active ingredients of effective digital health interventions, such as the WelTel platform, using the BCW offers valuable insights into how they may work to promote behaviour change. Wider application of this framework could strengthen the evidence base on the mechanisms of action underlying diverse mHealth interventions targeting medication adherence and other health behaviours.
https://bmcdigitalhealth.biomedcentral.com/articles/10.1186/s44247-024-00085-w
https://pubmed.ncbi.nlm.nih.gov/21513547/
https://mhealth.jmir.org/2018/4/e87/
