Table 7 BCTs to target key barriers to and facilitators of NHS Health Check behaviours

HCPs delivering NHS Health Check

Behavioural intervention before pharmacological intervention

Prompts/cues: A stimulus to prompt or cue the behaviour, e.g. screen pop-up reminding HCP to offer behavioural support first.

COM-B: Psychological capability

Conserving mental resources: Minimising demands on mental resources. This BCT may not be relevant in this context.

TDF: Memory, attention decision processes

HCP familiarity with relevant evidence-based guidelines

Biofeedback (definition: provide feedback about the body using an external monitoring device): Pedometer linked to app.

COM-B: Psychological capability

Instruction on how to perform behaviour: provide HCPs with electronic summaries of relevant guidelines.

TDF: Knowledge

Information about antecedents (definition: provide information about social and environmental situations and events, emotions, cognitions that predict performance of the behaviour): Text on website or app suggesting HCPs be mindful of the situations, such as busy clinics, where guideline content may be over-looked.

Information about health consequences: Electronic content explaining to HCPs that adhering to EBGs can improve patient health outcomes or presenting data (if available) on improvements in health outcomes as a result of adhering to EBGs.

Salience of consequences (definition: use methods specifically designed to emphasise the consequences of performing the behaviour with the aim of making them more memorable such as by using imagery or metaphor): Include a picture of relevant guidelines with text underneath ‘if you know the contents of this’ and picture of person having heart attack with text underneath ‘then you are more likely to prevent this.’

Information about social and environmental consequences: Electronic content providing data on costs saved to workforce by adhering to EBGs to prevent heart attacks.

HCP confidence in discussing and initiating behaviour change

Instruction on how to perform behaviour: Electronic summaries of strategies to bring about behaviour change with examples (summary of strategy = setting a goal, example = agree with the patient they will walk for 30 mins three times a week).

COM-B: Reflective motivation

Demonstration of the behaviour: Video of consultation or role play.

TDF: Beliefs about capabilities

Behavioural practice/rehearsal: Text on website/ app (ideally near video demonstrating delivery of behaviour change strategies) encouraging HCPs to participate in role play with patient / colleague / family / friend.

Focus on past success: Text on website/ app encouraging HCP to think of examples where they have successfully supported a patient to change their behaviour.

Framing CVD risk messages

Information about health consequences: Provide data or text summary on website/app linking improved patient outcomes to understanding CVD.

COM-B: Reflective motivation

Salience of consequences: This BCT may not be relevant in this context.

TDF: Beliefs about consequences

Information about social and environmental consequences: On website/app include text explain to HCPs that the majority of HCPs approve of appropriate risk framing messages.

Anticipated regret: On website/app include text asking HCPs to imagine how they would feel if patients did not act to reduce their CVD risk based on inaccurately framed messages.

Information about emotional consequences: Quotes or videos from patient talking about how HCPs inaccurately conveying CVD risk made them overly anxious.

Pros and cons: On website/app include text asking HCPs to list the advantages and disadvantages of over or underplaying CVD risk (or provide these lists and ask HCPs to think of more).

Comparative imagining of future outcomes: On website/app include text asking HCPs to compare what would happen if they appropriately framed the communication of risk compared with what they currently do.

Material incentive (behaviour): Inform HCPs that a financial payment will be made for each Health Check where risk is framed appropriately, e.g. according to an agreed protocol.

Incentive (outcome): Inform HCPs that a financial payment will be made if a patient changes their behaviour as a result of an appropriately framed CVD risk message.

Reward (outcome): Arrange for a financial payment to HCPs if a patient changes their behaviour as a result of the HCP appropriately framing CVD risk.

Time/resources to deliver Health Checks

Social support (practical): On website/app include text suggesting HCPs arrange for colleagues to take on some of the HCP’s duties to free up their time to deliver Health Checks.

COM-B: Physical opportunity

Prompts/cues: This BCT may not be relevant in this context.

TDF: Environmental context and resources

Remove aversive stimulus: This BCT may not be relevant in this context.

Restructuring the physical environment: On website/app include text suggesting HCPs ask service managers to restructure clinics to offer longer appointment times for Health Checks.

Restructuring the social environment: This BCT may not be relevant in this context.

Avoidance/reducing exposure to cues for the behaviour: This BCT may not be relevant in this context.

Adding objects to the environment: Provide HCPs with electronic schedules to guide timely delivery of Health Checks, e.g. ‘spend no more than 2 min on…... ‘

Patient behaviour change after NHS Health Check

Knowledge of CVD risk and implication

Biofeedback: This BCT may not be relevant in this context.

COM-B: Psychological capability

Instruction on how to perform behaviour: Provide patients with electronically available summaries of information necessary to interpret their risk scores.

TDF: Knowledge

Information about antecedents: This BCT may not be relevant in this context.

Information about health consequences: Provide patients with electronic information on the implications of their risk score, e.g. ‘x out of x people with a QRisk score of 11 are likely to experience stroke/other cardiovascular event.’ (risk score calculator?)

Salience of consequences: On website/app include text include diagrams of arteries of individuals with low to high cholesterol.

Information about social and environmental consequences: On website/app include text about how their risk might impact on their friendships, family or work.

The NHS Health Check as a Wake-up call for change

Goal setting (behaviour): Include space on an app/website to set a goal, e.g. get off the bus two stops early and walk the rest of the way to work)

COM-B: Reflective motivation

Information about health consequences: Quotes and/or videos from patients talking about the health benefits of the changes they have made.

TDF: Intentions

Incentive (outcome): On website/app include text informing patients that a financial payment will be made only if their QRisk score changes as a result of dietary/physical activity changes.

Support from others to change

Social support (unspecified): On website/app include text suggesting patients to ask a colleague to agree in advance to take the ‘healthy option’ lunch in the work canteen.

COM-B: Social opportunity

Social support (practical): On website/app include text encouraging patients to ask friends for help with arrangements to accommodate their health goals, e.g. asking a friend to look after patient’s children while they go swimming.

TDF: Social influences

Social comparison: Quotes and/or videos from patients talking about how they have increased their physical activity.

Information about others’ approval: Include quotes and/or videos from other patients talking about how supportive family/friends have been of the changes they have made. If functionality allows - invite family/friends to post encouraging messages (video or text).

Social reward: If an app/website is tracking patients progress, sending a message of congratulations for any changes made.

The extent to which patients believe change is achievable

Problem solving: In app/website provide a list of common barriers to change and some possible solutions and encourage patient to generate their own, e.g. lack of motivation could be addressed with going to the gym with a buddy.

COM-B: Reflective motivation

Instruction on how to perform behaviour: Provide patients with a list of lines to initiate conversation with a partner about changing diet and tips on how to avoid, e.g. partner being resistance to change.

TDF: Beliefs about capabilities

Demonstration of the behaviour: Video of patient talking to their partner about changing diet and negotiating possible barriers.

Behavioural practice/rehearsal: Text on website/ app (ideally near video demonstrating talking about change with a partner) encouraging patients to practice with a friend.

Graded tasks: Include text/video conveying that change is more likely if you build on small successes and suggesting how this might be done, e.g. walk for 100 yards a day for the first week, then half a mile a day after they have successfully achieved 100 yards, then two miles a day after they have successfully achieved one mile.

Verbal persuasion about capability: Include text/video of a patient who has successful changed their behaviour telling the patient they can also successfully increase their physical activity.

Focus on past success: Include text/video encouraging the patient to think of examples where they have successfully changed their behaviour.

Self-talk: Include text/video prompting the patient to tell themselves that a walk will be energising.