1. The Behaviour Change Wheel: a systematic method for designing behaviour change interventions
Susan Michie
Professor of Health Psychology
Director of Centre for Behaviour Change
University College London
@SusanMichie
Innovation in Health Promotion, Budapest, Hungary
September 2015

2. This talk The Behaviour Change Wheel A health promotion example
Make a behavioural diagnosis using COM-B
Link this diagnosis to intervention functions and policies
Link intervention functions to specific behaviour change techniques
A health promotion example
Improving hospital staff hand hygiene

3. Effective interventions
NICE Guidance for Behaviour change at population, community and individual levels (2007)
Effective interventions
Intervene at many levels
simultaneously & consistently
Community-level
Population-level
Individual-level
Update for Behaviour change: individual level (2014)

4. Interventions are complex
Several, potentially interacting, techniques
Vary in
content or elements of the intervention
delivery of the intervention
the mode of delivery (e.g., face-to-face)
the intensity (e.g., contact time)
the duration (e.g., number sessions over a given period)
characteristics of those delivering the intervention
characteristics of the recipients,
characteristics of the setting (e.g., worksite)
adherence to delivery protocols
Davidson et al, Annals of Beh Med, 2003

5. How to design an intervention that is likely to be effective?

6. Traditional approaches to intervention design
‘It Seemed Like A Good Idea At The Time’
ISLAGIATT principle
Martin Eccles, implementation researcher, UK

7. A systematic method …
Understand the behaviour you are trying to change
Use a framework that points to the types of intervention that are likely to be effective
Consider the full range of options open to you
Use a systematic method for selecting behaviour change techniques

9. Key steps in intervention design…
Identify your target behaviour precisely
Who need to do what, when, where, how
Recognise that behaviours are part of a system
of other behaviours within and between people
Make a “behavioural diagnosis”
A good behavioural diagnosis is more likely to lead to effective interventions
The most effective interventions target many levels simultaneously
The Behaviour Change Wheel is a comprehensive framework for designing interventions

10. Example …. hand hygiene in hospital staff
Nurses and doctors
Cleaning hands in identified situations
Infection control nurses
Conducting audits and feeding back results
Staff responsible for distributing alcohol handrub
Ensuring that dispensers contain alcohol handrub
For each of these, who needs to do
what,
when,
where,
how?

11. 1. Which behaviour to start with?
Questions to ask yourself
If I change this, what is the likely impact?
How easy is it to bring about change?
Preference, acceptability, cost?
Spillover/generalisability to other behaviours and people?

12. 2. Understand the behaviour in context
Why are behaviours as they are?
What needs to change for the desired behaviour/s to occur?
Answering this is helped by a model of behaviour
COM-B
Behaviour is part of a system and itself is a system

13. A thought experiment
For behaviour to change, what three conditions need to exist?

14. The COM-B system: Behaviour occurs as an interaction between three necessary conditions
Psychological or physical ability to enact the behaviour
Reflective and automatic mechanisms that activate or inhibit behaviour
Physical and social environment that enables the behaviour
Michie et al (2011) Implementation Science

15. 3. Make the “behavioural diagnosis” the example of hand hygiene in hospital staff

16. 2004-2011 in the UK Opportunity Motivation Capability
Alcohol hand rub beside every bed
Motivation
Persuasive posters
Encouraging patients to ask
Capability
No intervention

17. Capability Nurses have the capability to clean their hands
But not to
pay attention to this behaviour over other competing behaviours
develop routines for noticing when the behaviour does not occur, and plans for acting in future
Train staff to set goals, observe their behaviour, develop action plans on the basis of feedback
Developed at UCL, based on behavioural theory

19. 4. Intervening: Consider all the options
Frameworks make life easier
good frameworks make you more effective
Need a framework that is
Comprehensive
So you don’t miss options that might be effective
Coherent
So you can have a systematic method for intervention design
Linked to a model of behaviour
So that you can draw on behavioural science
Useable by, and useful to, policy makers, service planners and intervention designers

20. Do we have such a framework?
Systematic literature review identified 19 frameworks of behaviour change interventions
related to health, environment, culture change, social marketing etc. E.g Mindspace, Intervention Mapping
None met all these three criteria
So …. Developed a synthesis of the 19 frameworks
Michie et al (2011) The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions, Implementation Science

21. Behaviour at the hub …. COM-B21

22. Interventions
Interventions: activities designed to change behaviours

23. From diagnosis to intervention
Make a ‘diagnosis’ of the problem i.e. the behaviour to be changed
Profile of what needs to change using COM-B
Identify intervention functions
using matrix of COM-B x 9 intervention functions
Identify policy categories
using matrix of intervention functions x policy categories
Select specify behaviour change techniques

24. Hand Hygiene example: Capability
Nurses have the capability to clean their hands
But not to
pay attention to this behaviour over other competing behaviours
develop routines for noticing when the behaviour does not occur, and plans for acting in future

25. Selecting relevant intervention functions
Education
Persuasion
Incentivisation
Coercion
Training
Restriction
Environmental restructuring
Modelling
Enablement
Physical capability
Psychological capability
Physical opportunity
Social opportunity
Automatic motivation
Reflective motivation  

26. Intervention to increase: Capability
Train staff to
set goals and
make action plans
Enable:
observe their behaviour and give feedback
support development of action plans
Based on behavioural theory (Control Theory)

27. MONTHLY FEEDBACK INTERVENTION Co-ordinated by infection control team
= individual level component
Observe two staff member’s behaviour for 20 minutes
Give immediate verbal feedback
< full compliance = immediate goal-setting and action planning regarding observed non-compliance & repeat observation next month
Full compliance = certificate for use at staff appraisal OR
Feedback displayed, and given at ward meeting
< full compliance = ward level goal-setting and action planning regarding observed non-compliance/s
Observe one group of staff members for 20 minutes
Praise for compliance OR
= group level component 27

28. MONTHLY FEEDBACK INTERVENTION Co-ordinated by infection control team
= individual level component
= group level component
Observe two staff member’s behaviour for 20 minutes
Give immediate verbal feedback
< full compliance = immediate goal-setting and action planning regarding observed non-compliance & repeat observation next month
Full compliance = certificate for use at staff appraisal OR
Feedback displayed, and given at ward meeting
< full compliance = ward level goal-setting and action planning regarding observed non-compliance/s
Observe one group of staff members for 20 minutes
Praise for compliance OR 28

29. Findings: 60 wards in 16 hospitals in England
Use of soap and alcohol hand rub tripled from 21.8 to 59.8 ml per patient bed day
Rates of MRSA bacteraemia and C difficile infection decreased
Stone, Fuller, Savage, Cookson et al, BMJ, 2012
Giving 1-1 feedback led to staff being % more likely to clean their hands
Fuller, Michie, Savage, McAteer et al, PLoS One, 2012

30. Add policies to maintain change long-term

31. Intervention functions
Policies
Intervention functions
Policies: decisions made by authorities concerning interventions
Michie et al (2011) The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions Implementation Science

32. Local context: The APEASE criteria
Affordability
Practicability
Effectiveness/cost-effectiveness
Acceptability
public
professional
political
Side-effects/safety
Equality

33. Use the Behaviour Change Wheel to …
Design interventions and policies
COM-B links to intervention functions link to behaviour change techniques
“Retrofit” – identify what is in current interventions and policies
Provide a framework for evaluation
How are interventions working?
Structure systematic reviews

34. Some applications of Behaviour Change Wheel
India
Smartphone app to reduce cardiovascular disease risk UK
Smartphone app for parents of overweight children
Kenya
Promote recycling behaviours in university staff and students
Improve paediatric health care
Reduce cardiovascular disease risk in people with severe mental illness
Netherlands
An organisational intervention tool
Improve management of postnatal depression
Thailand
Preventing melioidosis
Smartphone app to promote attentive eating
Internet intervention to promote condom use
USA
Improving colorectal cancer screening
Providing long-acting reversible contraception to adolescents
International Red Cross
Train volunteers
Improve parenting practices for children with challenging behaviour

36. Interventions are made up of many behaviour change techniques (BCTs)
= discrete, low-level components of interventions that on their own have potential to change behaviour

37. “Taxonomies” of techniques (BCTs)
Physical activity/healthy eating/mixed : 26 BCTs Abraham & Michie , 2008
Physical activity & healthy eating: 40 BCTs
Michie et al, Psychology & Health, 2011
Smoking cessation: 53 BCTs Michie et al, Annals behavioural Medicine, 2010
Reducing excessive alcohol use: 42 BCTs Michie et al, Addiction, 2012
Condom use: 47 BCTs
Abraham et al, 2012
General behaviour change: 137 BCTs
Michie et al, Applied Psychology: An International Review, 2008
Competence framework: 89 BCTs
Dixon & Johnston, 2011
Fragmentation rather than integration

38. 93 item BCT Taxonomy v1, Annals of Behavioral Medicine, 2013

39. BCT Taxonomy v1: 93 items in 16 groupings

40. The BCTTv1 smartphone app
Fully searchable version of BCTTv1
Search by BCT label, BCT grouping or alphabetically
Increases familiarity with the taxonomy
Increases speed and recall of BCT labels and definitions
Search for: BCTs
bcts.23.co.uk*
Search for: BCTs*
bcts.23.co.uk*
* You’ll need an internet connection to use the app

42. In summary …. To change behaviour ….
Start by understanding the problem
Identify the behaviours to change
Who, what, where, when
Understand the behaviours
COM-B
Before designing the intervention
Consider the full range of effective interventions and supporting policies
Select and implement behaviour change techniques

43. And evaluate ……
….. so it is possible to accumulate evidence to inform future interventions
Plan evaluation in advance using a theoretical framework to increase understanding of
mechanisms of action
reasons for variation
as well as evidence of effectiveness …

44. Acknowledgements Key collaborators in this work Key funders
Prof Robert West, UCL
Prof Marie Johnston, Aberdeen
Health Psychology Research Group
Key funders

45. For more information Susan Michie Books
Books
UCL Centre for Behaviour Change
All proceeds from CBC teaching, training, books and products go to further development

46. ADDITIONAL SLIDES IF NEEDED

47. Using rules to reduce the opportunity to engage in the
behaviour (or to increase
behaviour by reducing
opportunity to engage
in competing
behaviours)
Increasing knowledge or understanding
Using communication to induce positive or negative feelings to stimulate action
Changing the physical or social context
Creating an expectation of reward
Provide an example for people to aspire to or emulate
Increasing means
or reducing barriers to
increase capability (beyond
education or training) or opportunity
(beyond environmental restructuring)
Creating an expectation of punishment or cost
Imparting skills

48. Designing and/or controlling the physical or social environment
Creating documents that recommend or mandate practice. This includes all changes to service provision
Using the tax system to reduce or increase the financial cost
Using print, electronic, telephonic or broadcast media
Ask participants to generate examples of policy categories
Establishing rules or principles of behaviour or practice
Making or changing laws
Delivering a service

49. Selecting interventions and policies

50. Which policy categories should be used?
Intervention Functions
Educ
Persuas
Incent
Coerc
Train
Restric
Envir
Model
Enabl
Comm
Guid
Fiscal
Regul
Legisl
Enviro
Service

51. 1. Effective principles of behaviour change
NICE Guidance for Behaviour Change (2007, 2014)
Maximise to regulate own behaviour
Develop relevant skills (e.g. goal setting, monitoring, feedback)
Develop specific plans to change
Increase to engage in the desired behaviour
Reward change
Develop appropriate beliefs
E.g. benefits of changing, others’ approval, personal relevance, confidence to change
Develop positive feelings about changing
Reduce to continue with the undesired behaviour
Maximise to support self-regulation
Elicit social support
Avoid social and other cues for current behaviour
Change routines and environment

52. Maintaining behaviour change
Changing behaviour is hard
Maintaining that change is harder
Effective strategies
Don’t rely on individual choice and decision-making
Do rely on the environment and making behaviour automatic
environmental support and prompts
building routines
feedback
rewards and incentives