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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 are commonly designed without evidence of having gone through this kind of process, with no formal analysis of either the target behaviour or the theoretically predicted mechanisms of action. They are based on implicit commonsense models of behaviour . 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 variables. For example, the often used Theory of Planned Behaviour and Health Belief Model do not address the important roles of impulsivity, habit, self-control, associative learning, and emotional processing .
Thus, in order to improve intervention design, we need a systematic method 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. These constitute a starting point for assessing in what circumstances different types of intervention 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, 'MINDSPACE' an influential report from the UK's Institute of Government, is intended as a checklist for policymakers of the most important influences on behaviour . These influences provide initial letters for the acronym MINDSPACE: messenger, incentives, norms, defaults, salience, priming, affect, commitment, and ego. The framework does not appear to encompass all the important intervention types. Moreover, the list is a mixture of modes of delivery (e.g., messenger), stimulus attributes (e.g., salience), 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 influences on behaviour with these two systems.
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 requirements constitute three criteria of usefulness that can be used to evaluate the framework: comprehensiveness, coherence, and links to an overarching model of behaviour. 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, usefulness for generating new interventions, and ability to predict effectiveness of interventions
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 sufficient motivation. We drew on two sources representing very different traditions: a US consensus meeting of behavioural theorists in 1991 , and a principle of US criminal law dating back many centuries. The former identified three factors that were necessary and sufficient 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 impossible 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.
This system places no priority on an individual, group, or environmental perspective -- intra-psychic and external 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 particular components or combinations of components could effect the required transformation. For example, with one behavioural target the only barrier might be capability, 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.
Several things became apparent when reviewing the frameworks. First of all, it was clear it would be necessary 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 'education' can include 'training,' but for our purposes it was necessary to distinguish between 'education' and 'training' with the former focusing on imparting knowledge and developing understanding and the latter focusing on development of skills. Similarly we had to differentiate 'training' from 'modelling.' In common 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 'enablement.' 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 support' for smoking cessation) 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.'
Third, any given intervention could in principle perform more than one behaviour change function. Thus the intervention categories identified from the 19 existing frameworks were better conceived of as non-overlapping 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 categories.
Just by identifying all the potential intervention functions and policy categories this framework could prevent policy makers and intervention designers from neglecting 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 behaviour 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' , the UK Government eschews the use of coercion, persuasion, or the other BCW intervention functions that one might use.
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 individual BCTs, and the same BCT may serve different intervention functions. An examination of BCTs used in self-management approaches to increasing physical activity and healthy eating , 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, environmental restructuring, and modelling) place more emphasis on external influences and less on personal agency. Reliable taxonomies for BCTs within these intervention functions have yet to be developed.