Applying behavioural science theories and frameworks in
Dr. Fabiana Lorencatto
Research Lead, UCL Centre for Behaviour Change, UK
4th BeSP Sypmosium
• Why behaviour change in implementation?
• Limitations typical approaches to implementation interventions
• Applying behavioural science
• Frameworks and theories for systematic intervention design
• Behaviour Change Wheel Approach
• Examples from healthcare context
Why behaviour change?
Implementation is challenging….
Tell people about it
The problem – evidence practice gaps:
• Despite training and guidelines, many do not always act in line with
• Netherlands: 30-40% of patients did not receive ‘evidence-based’ health care Grol et
• US: 20-25% received care that was unnecessary or even harmful Schuster et al, 2005
Implementation as behaviour change
• Guidelines do not implement themselves!
• Implementation almost always requires someone to do act or do something differently
• These actions are all forms of human behaviour
Implementation as behaviour change
• Implementation depends on changing behaviour of many different
types of people and roles at different levels in organisations,
networks and systems
• support staff,
• policy makers,
• patients, etc.
• ‘specific methods or techniques used to enhance the adoption, implementation, and
sustainability of a clinical program or practice’ (Proctor et al. 2013)
Many have achieved modest and
• Often not approaching
in terms of behaviour
It Seemed Like
A Good Idea At
Prof. Martin Eccles, implementation researcher, UK
‘just educate’ ‘it worked elsewhere’
Traditional approaches to designing interventions:
Sometimes ISLAGIATT works…more often it doesn’t….
Behavioural science• Disciplines dedicated to scientifically studying human behaviour:
• Offer theories, frameworks, methods for understanding what drives behaviour and how to use this to most effectively change it
no magic bullets or
• Interrelated theories, frameworks and evidence-based principles
• Theoretical basis for linking barriers/facilitators to intervention strategies
• Guide decision making and facilitate systematic, step-by step, transparent
and more effective approach to intervention design
• Policy makers, practitioners, researchers from different disciplines and
levels of experience
Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising
and designing behaviour change interventions. Implementation science. 2011 Dec;6(1):42.
Michie S, Atkins L, West R. The behaviour change wheel. A guide to designing
interventions. 1st ed. Great Britain: Silverback Publishing. 2014.
Behaviour Change Wheel approach
The Behaviour Change Wheel approach: key steps
What behaviour are you
trying to change?
What will it take to bring
about the desired change?
What types of broad
might be relevant?
components should my
• Define ‘problem’ in behavioural terms
• Map out system of behaviours
• Who, needs to do what, when, where?
• ‘Behavioural Diagnosis’
• Understand behaviour in context
• Identify barriers/enablers to change
• Consider range of intervention strategies
• Match choice to behavioural diagnosis
Step 1: Defining the problem in behavioural terms
• Tendency to think in terms of outcomes
• ‘reduce infection rates’ or ‘improve infection control’ ≠ a behaviour
• Product of numerous discrete behaviours
Appropriate prescribing of
treatments for infections
Prescribing antibiotic +
decision around dose,
Timely review of
• Multiple actors (care
assistants, nurses, doctors,
patients, family members)
• At different time points in care
• In different settings
• Vary by type of patient and/or
type of infection
Why does this matter?
• Influences will vary across different:
• Behaviours, actors, settings, time, contexts
• Start by mapping out system
• Do not need to intervene on full system! Focus on one aspect
• Likelihood of change
And therefore so might the
type of intervention(s)
Be specific: AACTT principle:
• Asks: precisely who would do what, differently, to whom, when and where
that would lead to improved outcome?
Action – needs to do what?
Target- to whom?
Presseau J, McCleary N, Lorencatto F, Patey, A, Grimshaw J, & Francis JJ. (2019). Action, Actor, Context, Target, Time (AACTT): A framework for specifying behaviour. Implementation Sci
‘hand hygiene in hosptials’
Duncan et al. "A behavioural approach to specifying interventions: what insights can be gained for the reporting and implementation of interventions to reduce antibiotic use in
hospitals?." Journal of Antimicrobial Chemotherapy (2020).
A (more!) behaviourally specific example:
Nurses (who) in intensive care (where)
should clean there hands with alcohol rub
(what) before and after (when) physical
contact with patients (whom) (Sun et al 2011)
Step 2. Understand the behaviour in context (‘Behavioural diagnosis’)
• Why are behaviours as they are?
• What would it take to implement?
• What would facilitate? What would hinder?
• Clinical practice is a form of human behaviour…
• Answering these Qs helped by a theory of
Prof. Susan Michie
Many theories applied to implementation!
Nilsen P. Making sense of implementation theories, models and frameworks. Implementation science. 2015
Michie SF, West R, Campbell R, Brown J,
Gainforth H. ABC of behaviour change
theories. Silverback Publishing; 2014.
The COM-B system: Behaviour occurs as an interaction between
three necessary conditions
Michie et al (2011) Implementation Science
Psychological AND Physical ability to enact
Knowledge, Memory attention decision
making, physical and social skills
Reflective AND Automatic mechanisms that activate or
inhibit the behaviour
Intentions, Goals, Perceived relevance, identity, Beliefs
about consequences, Self-confidence, Rewards, incentives,
Physical AND Social environmental factors that enables or
inhibits the behaviour
Access, layout, resources, prompts, cues
Social influences (pressure, support)
Theoretical Domains Framework
3. Memory, Attention, Decision
4. Behavioural regulation
5. Social Influences
6. Environmental context and
8. Social professional role and
10. Beliefs about consequences
12. Beliefs about capabilities
Michie et al. 2005 BMJ Qual & Safety
Cane et al 2012 Implementation Sci
Am I aware of what I need to do
How do I decide to do X?
Do you ever forget to do X?
Is doing X part of my clinical role?
What will happen if I do X? What if I
don’t do X?
Is it a priority?
How confident am I?
How worried/ concerned?
Do I have sufficient resources
(time/ staff/ e