FormalPara Learning Outcomes

This chapter contributes to achieving the following learning outcomes:

  • BC1.1 Differentiate between health behaviour and behaviour determinants.

  • BC2.1 Describe the approach of different models and theories to behaviour change in health.

  • BC2.2 Provide a rationale for using behaviour change models/theories.

  • BC2.3 Explain how different models and theories predict self-management behaviours in chronic disease and allow an understanding of interventions that can change these behaviours.

Population ageing and the increasing burden of chronic diseases require the health system to support self-management (Araújo-Soares et al., 2019). Many have argued that behaviour change support is central to the needs of persons with chronic diseases. Although modifiable health behaviours are recognised as a major influence in the management of chronic conditions, there are several barriers to effective behaviour change support by health and other professionals, such as compartmentalisation in silos of healthcare provision, lapses in communication between different teams and lack of training (Vallis et al., 2019).

Ultimately, to meet the real needs of persons living with chronic diseases, professionals need education fostering the development of behaviour change competencies, as described by the interprofessional competency framework presented in Chap. 1. In particular, health and other professionals need to acquire concepts and definitions from behavioural science, to better understand how to support people living with chronic diseases.

In this chapter, we address the concepts of health behaviours, the difference in relation to behaviour determinants and, briefly, key behaviour change models and theories that can inform self-management interventions in chronic disease.

2.1 Health Behaviours and Behaviour Determinants

Chronic diseases are the result of the interplay between genetic, physiological, environmental and behaviour determinants. This means that health-related decisions that people make will impact on their health outcomes. Some have even argued that, in the case of chronic conditions, health outcomes are more influenced by the choices the individual makes than by the care directly provided by health professionals (Vallis et al., 2019).

The interest in behaviours that have an impact on health and well-being is shaped, particularly, by the assumption that such behaviours are modifiable (Conner, 2002). Health behaviour has been defined in various ways, as illustrated in Table 2.1.

Table 2.1 Definitions of “health behaviour”

As opposed to acute conditions, in chronic diseases the role of health and other professionals is more focused on supporting and empowering persons to adopt and maintain behaviours, such as medication adherence, not smoking, keeping a healthy weight, being physically active, consuming substances in moderation, eating healthily and getting adequate sleep. It has long been recognised that these health-protective behaviours have a significant impact in preventing both morbidity and mortality, also impacting “(...) upon individuals’ quality of life, by delaying the onset of chronic disease and extending active lifespan” (Conner, 2002). More recently, a European multicohort study in 116,043 people free of major chronic diseases at baseline, from 1991 to 2006, suggests that various healthy lifestyle profiles, such as regular physical activity, BMI less than 25, not smoking and moderate alcohol consumption, appear to yield gains in life-years without major chronic diseases, including type 2 diabetes, coronary heart disease, stroke, cancer, asthma and chronic obstructive pulmonary disease (Nyberg et al., 2020).

It is therefore important to distinguish between health-impairing (or health-risk) and health-enhancing (or health-protective) behaviours:

“Health impairing behaviours have harmful effects on health or otherwise predispose individuals to disease. Such behaviours include smoking, excessive alcohol consumption, and high dietary fat consumption. In contrast, engagement in health enhancing behaviours convey health benefits or otherwise protect individuals from disease. Such behaviours include exercise, fruit and vegetable consumption, and condom use in response to the threat of sexually transmitted diseases.” (Conner, 2002)

Table 2.2 depicts examples of health outcomes associated with the core health-risk behaviours; as already pointed out, these outcomes may be influenced by other factors than individual behaviours per se, such as genetics or environmental issues.

Table 2.2 Relationship between health behaviours and health outcomes

Behaviour determinants are factors that influence the behaviour, either in a positive or in a negative way, i.e. facilitators of and barriers to the performance of the behaviour, respectively. These determinants can be individual, such as biological/demographic (i.e. age, health history) and psychological factors (i.e. motivation, humour, previous experiences), or non-individual, such as aspects related to the behaviour itself (i.e. time needed to see changes), environmental/social issues (i.e. interpersonal relationships, such as social support) and health policies (i.e. policies targeting the health problem and making it easier/harder to change).

In fact, behaviour determinants can be categorised in a multitude of ways, one of which is a widely used model of behaviour change – the COM-B model (Michie et al., 2011, 2014a) – which will be further described in this chapter. This model groups determinants into three major categories: capability (physical and psychological), motivation (reflexive and automatic) and opportunity (social and physical) (Michie et al., 2011, 2014a).

Due to the complexity of health-related human behaviour, for which usually various determinants are responsible for the adoption and sustainability of the behaviours, behavioural science has dedicated much of its research to the development, testing and refinement of models and theories that aim to explain, predict, model and change behaviour. These are described in the next section.

2.2 Behaviour Change Theories and Models

There are various definitions of theories. In behavioural science, a theory has been defined as “a set of concepts and/or statements which specify how phenomena relate to each other, providing an organising description of a system that accounts for what is known, and explains and predicts phenomena” (Davis et al., 2015, p. 327). In brief, theories are a systematic way of understanding phenomena (e.g. health behaviour(s)), in which a set of concepts and variables (e.g. determinants of behaviours such as motivation, self-efficacy and social influences) and prepositions about their relationships are established (Glanz et al., 2002).

In the context of health behaviour change, theories “(...) seek to explain why, when, and how a behaviour does or does not occur, and to identify sources of influence to be targeted in order to alter behaviour” (Michie et al., 2018, p. 70). They are important to understand disease patterns and to explain why individuals and communities have certain behaviours (Simpson, 2015), as well as to support clinical practice and professionals in day-to-day interventions. Using a theory when developing and evaluating interventions allows the identification of what needs to change (i.e. the determinants of the behaviour), the barriers and facilitators to changing those influences and the identification of mechanisms of action that operate along the pathway to change. Further, many theories identify ways in which the behaviour determinants can be modified, i.e. which techniques can be implemented in interventions to, for instance, increase motivation, increase the capability to perform the behaviour and form habits.

There is therefore consensus that health behaviour change interventions should be informed by theory. For example, the UK’s Medical Research Council recommends the identification of relevant theories for designing complex interventions (Skivington et al., 2021), as does the US Department of Health and Human Services and National Institutes of Health (Rimer & Glanz, 2005). Guideline PH49 from the National Institute for Health and Care Excellence (NICE) on individual-level health behaviour change interventions recommends that staff should be offered professional development on behaviour change theories, methods and skills (NICE, 2014).

There are many theories of behaviour and behaviour change; a multidisciplinary literature review has identified 83 theories containing a total of 1725 concepts (Davis et al., 2015). A summary of these theories, their concepts and relationships are available in a theory database (Hale et al., 2020).

We present an overview of the main theories that have been applied to self-management of chronic diseases. Table 2.3 presents a brief description and key references for key social-cognitive, motivation and integrative theories (see Michie et al., 2014b, for more details about these theories). Examples of applications are presented in accompanying papers.

Table 2.3 Overview of core behaviour change models and theories in the self-management of chronic disease

2.3 COM-B Model: A Model to Guide Interventions

Given the multiplicity of theories of behaviour that exist and the need for a simplified model to support the design of behaviour change interventions, Michie and colleagues developed the COM-B model (Michie et al., 2011), which defines behaviour as a result of the individual’s capability, opportunity and motivation to follow a certain course of action. Capability is an attribute of a person that reflects the psychological and physical abilities to perform a behaviour, including knowledge and skills. Motivation is an aggregate of mental processes that energise and direct behaviour; it involves the automatic and reflective motivation, such as the individual’s goals, plans and beliefs and their emotions, habits or impulses, respectively. Opportunity is an attribute of an environmental system, corresponding to the external factors that may facilitate or make it harder for an individual to adopt a specific behaviour, such as the physical and social environment (Michie et al., 2011; West & Michie, 2020). Table 2.4 presents definitions of the COM-B components (West & Michie, 2020).

Table 2.4 Definition of COM-B model components
Fig. 2.1
A flow chart of the C O M B model illustrates the influencing factors which lead to behavior: capability, motivation, and opportunity, with two types for each module.

Illustration of the COM-B model (West & Michie, 2020)

For particular behaviours, people, context or phase of the behaviour change process, certain barriers or facilitators will have more influence than the others. The analyses of these determinants play a crucial role in selecting which strategies will work better to achieve the desired behaviour, as described in Chap. 4.

This model has been successfully used in designing behaviour change interventions (e.g. Issac et al., 2021; Wheeler et al., 2018), to support behaviour change in practice. We present an example related to behaviour change in the self-management of a chronic disease. Wheeler et al. (2018) researched the feasibility and usability of a mobile intervention for persons with hypertension, using the COM-B model as a framework for the development of a knowledge model to support the intervention. Knowing that each person has a behaviour source that relies on different factors, the intervention was tailored to the user’s individual profile, based on the initial contact. Using the COM-B model, the authors identified different profiles via a self-evaluation questionnaire on determinants for sodium intake and physical activity. Examples of these determinants are synthesised in Table 2.5, based on Wheeler et al. (2018).

Table 2.5 Examples of behaviour determinants for increasing physical activity using the COM-B model

As depicted in Fig. 2.1, according to this model, all three categories of determinants influence the adoption and maintenance of health-protective behaviours, and consequently the successful self-management of chronic diseases.

Key Points

  • A health behaviour is any behaviour that can affect a person’s health either by enhancing it (health-protective behaviour) or impairing it (health-damaging or health-risk behaviour).

  • Behaviour determinants are individual or non-individual aspects which can influence the behaviour either in a positive or a negative way, i.e. barriers or facilitators for the adoption of the behaviour.

  • Theories and models of behaviour change provide a deeper understanding about behaviour patterns, responses and their determinants; they can guide effective behaviour change support.

  • The COM-B model presents an integrative approach, in which a behaviour is considered to be influenced by physical and psychological capability, reflective and automatic motivation and physical and social opportunity.