Improving the implementation of evidence-based practice 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 interventions' can 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 populations (e.g., delivery of smoking cessation advice by general 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 implement what is considered to be best practice (for example, Cochrane reviews, NICE guidance). While there are many examples of successful interventions, there are also countless examples of ones that it was hoped would be effective but were not [, 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 interventions 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 penalise inappropriate prescribing. Once one has done this, one would decide on the specific intervention components. 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 system for selecting from among them. This requires a system for characterising interventions that covers all possible intervention types together with a system for matching these features to the behavioural target, the target 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 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 .
In addition, often no analysis is undertaken to guide the choice of theories . 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 . 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 .
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.
A second example comes from the Cochrane Effective Practice and Organisation of Care Review Group (EPOC)'s 2010 taxonomy . This categorises interventions to change health professional behaviour into professional, financial, organisational, or regulatory, covering many of the key intervention types. However, the categories are very broad and within each is a mixture of different types of interventions at different conceptual levels. For example, 'professional' includes individual behaviour (distributing educational materials) and organisational interventions (local consensus processes); 'financial' includes individual and organisational incentives and environmental restructuring (changing the available products); 'organisational' includes 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 organisational 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 . 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 delivered specifically to individuals and can be tailored to those individuals. Indeed, the NHS Stop Smoking Services might be considered a typical case of individual-level interventions, but they reach more than 600,000 smokers each year . 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 interventions 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 behaviour. This model should capture the range of mechanisms 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 , a notable exception being intervention mapping . 'Nature of the behaviour' was identified as one of 12 theoretical domains of influence on implementation-relevant behaviours . Whilst this framework of 12 theoretical domains has proved useful in assessing and intervening with implementation problems , the domain of behaviour has remained under-theorised and therefore underused in its application.
There are a number of possible objections to attempting 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 intervention. The response to this is twofold: these are empirical questions and there is already evidence that characterising interventions by behaviour change techniques (BCTs) can be helpful in understanding which interventions 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 developed. Failure to do this limits the scope of the system to offer options for intervention designers that may be effective.
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 not include some categories that are very broad and others very specific. A beautiful example of an incoherent classification system is the Ancient Chinese Classification 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 camel's 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 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
In light of the above, this paper aims to:
Review existing frameworks of behavioural interventions to establish how far each meets the criteria of usefulness, and to identify a comprehensive list of intervention descriptors at a level of generality that is usable by intervention designers and policy makers.
Use this list to construct a framework of behaviour change interventions that meets the usefulness criteria listed above.
Establish the reliability with which the new framework can be used to characterise interventions in two public health domains.