1 Recommendations

Recommendation 1 Develop a local behaviour change policy and strategy

National and local policy makers and commissioners of behaviour change services and their partners (see who should take action?) should:

  • Ensure policies and strategies aim to improve everyone's health and wellbeing.

  • Use health equity audit to ensure health inequalities will not increase, and if possible will decrease as a result of the local behaviour change strategy and related programmes and interventions. (See NICE's local government briefing on health inequalities and population health for information about health equity audit.)

  • Develop a commissioning strategy, linked to relevant policies, for an evidence-based behaviour change programme of population, community, organisational and individual-level behaviour change interventions. For example, see NICE guidance on alcohol and obesity. Also note that the NICE guideline on behaviour change: the principles for effective interventions recommends delivering individual interventions in tandem with complementary activities at the population, community and organisational levels.

  • Work with the local community to develop the strategy (see the NICE guideline on community engagement).

  • Ensure the strategy, and any related policies, are sustainable and meet local needs, identified through joint strategic needs assessments (JSNAs) and other local data.

  • Identify the behaviours the strategy will address, and the outcomes it aims to achieve. Bear in mind that some interventions and programmes can address more than 1 behaviour (for example, sexual behaviour and alcohol consumption).

  • Ensure the content, scale and intensity of each intervention is proportionate to the level of social, economic or environmental disadvantage someone faces and the support they need (proportionate universalism).

  • Identify a leader within each local authority area, for example, the director of public health or an elected member of cabinet, to address specific behaviours (such as smoking and physical activity).

Recommendation 2 Ensure organisation policies, strategies, resources and training all support behaviour change

  • Directors in national and local organisations whose employees deliver behaviour change interventions should ensure policies, strategies and resources are in place to provide behaviour change support for staff, as well as service users. This support could take the form of behaviour change services for staff. Or it could involve creating environments that support health-promoting behaviour (for examples, see the NICE guidelines on tobacco use and physical activity).

  • National and local organisations whose employees deliver behaviour change interventions should review job descriptions and person specifications to check that they include behaviour change knowledge and skills (or competencies), if they are a specific part of someone's job (see recommendation 9).

  • Managers of health, wellbeing and social care services should determine which staff in contact with the public are best placed to deliver different levels of a behaviour change intervention (see recommendation 9). They should ensure those staff have the knowledge and skills (or competencies) needed to assess behaviours and individual needs (see recommendation 8) and to deliver the intervention.

  • Employers should ensure staff are aware of the importance of being supportive, motivating people and showing them empathy (see recommendation 12).

  • Directors and managers should ensure staff receive behaviour change training and supervision related to their roles and responsibilities (see recommendation 9). They should also be offered ongoing professional development on behaviour change theories, methods and skills (see recommendation 12).

  • Mentors and supervisors with relevant training and experience (see recommendations 11 and 12) should support staff who are delivering behaviour change interventions. This includes helping them to set their own goals, providing constructive feedback on their practice and encouraging them to be aware of their duty of care. It also involves making them aware of the likely perceptions and expectations of those taking part in behaviour change interventions and programmes.

Recommendation 3 Commission interventions from services willing to share intervention details and data

Commissioners of behaviour change services and their partners (see who should take action?) should:

Recommendation 4 Commission high quality, effective behaviour change interventions

National and local policy makers, commissioners of behaviour change services and their partners (see who should take action?) should:

  • Find out whether behaviour change interventions and programmes that are already in place are effective, cost effective and apply evidence-based principles. (See the NICE guideline on behaviour change: the principles for effective interventions).

  • Ensure that, when commissioning behaviour change interventions and programmes:

    • Evaluation plans tailored for the intervention and target behaviours are built in from the outset.

    • Resources (staff, time and funds) are allocated for independent evaluation of the short-, medium- and long-term outcomes.

    • A quality assurance process is in place to assess whether the intervention was delivered as planned (intervention fidelity), achieves the target behaviour change and health and wellbeing outcomes, and reduces health inequalities. (The frequency of quality assurance checks should be specified.)

    • There are quality assurance checks if an intervention has already been shown to be effective.

    • All information on intervention processes and outcomes is recorded in a form that can be made available if needed (for example, on a secure database).

  • Commission and evaluate a pilot if it is not clear whether an intervention shown to be effective for a specific behaviour, population or setting can be applied to other behaviours, settings or populations (see recommendation 16).

  • Commission an intervention for which there is no evidence of effectiveness only if it is accompanied by an adequately powered and controlled evaluation that measures relevant outcomes (see recommendation 16).

  • Stop running interventions or programmes if there is good evidence to suggest they are not effective or are harmful.

Recommendation 5 Plan behaviour change interventions and programmes taking local needs into account

Commissioners and providers of behaviour change services, and intervention designers (see who should take action?) should:

  • Work together and with other key stakeholders (for example, people who use services, communities and researchers) to select priority areas for interventions, based on local need. They should also identify suitable interventions that are acceptable to the target audiences.

  • Take into account the local social and cultural contexts to ensure equitable access for everyone who needs help and make best use of existing resources and skills.

  • Base behaviour change interventions and programmes on evidence of effectiveness (see recommendations 6 and 7).

  • Take into account:

    • the objectives of the intervention or programme

    • evaluation plans (see recommendation 4 and recommendation 16)

    • the target population (including characteristics such as socioeconomic status)

    • whether there is a need to offer tailored interventions for specific subgroups (for example, see the NICE guideline on preventing type 2 diabetes: risk identification and interventions for individuals at high risk)

    • intervention characteristics: content, assessment of participants, mode of delivery, intensity and duration of the intervention, who will deliver it, where and when

    • the training needs of those delivering the intervention or programme

    • the quality of the behavioural support provided by those delivering the intervention or programme

    • availability of, and access to, services once the intervention has finished

    • follow up and support to maintain the new behaviour

    • plans to monitor and measure intervention fidelity.

Recommendation 6 Develop acceptable, practical and sustainable behaviour change interventions and programmes

Commissioners of behaviour change services and intervention designers (see who should take action?) should:

  • Work together and with other key stakeholders (for example, people who use services, communities and researchers) to develop (co-produce) behaviour change interventions and programmes that are acceptable, practical and sustainable. This should also reduce duplication between services.

  • Develop interventions that:

    • are evidence-based

    • have clear objectives that have been developed and agreed with stakeholders

    • identify the core skills, knowledge and experience (competencies) needed to deliver the intervention (including for the specific behaviour change techniques used)

    • provide details of the training needed (including learning outcomes) for practitioners

    • include a monitoring and evaluation plan developed according to agreed objectives.

  • Before implementing a behaviour-change intervention, describe in detail the principles it is based on. Put these details in a manual. This should include:

    • clearly stated objectives on what the intervention will deliver

    • the evidence base used (such as from NICE guidance on a specific topic)

    • an explanation of how the intervention works (mechanism of action), for example, by targeting capability, opportunity and motivation.

  • Ensure manuals also include a detailed description of the intervention including:

    • resources, setting or context, activities, processes and outcomes (including a pictorial description of the relationship between these variables, such as a conceptual map or logic model)

    • intervention characteristics (see recommendation 5)

    • a clear definition of the behaviour change techniques used so that each component can be replicated (for example, by using a taxonomy)

    • details of how to tailor the intervention to meet individual needs (see recommendation 8)

    • plans to address long-term maintenance of behaviour change and relapse

    • implementation details: who will deliver what, to whom, when and how.

  • Make the manual publicly available, for example, on a website (provide copyright details and 'training before use' requirements). If there are changes to an intervention during delivery, or after evaluation, ensure the manual is updated accordingly.

Recommendation 7 Use proven behaviour change techniques when designing interventions

Providers of behaviour change interventions and programmes and intervention designers should:

  • Design behaviour change interventions to include techniques that have been shown to be effective at changing behaviour. These techniques are described in principle 4 of the NICE guideline on behaviour change: the principles for effective interventions and include:

    • Goals and planning. Work with the client to:

      • agree goals for behaviour and the resulting outcomes

      • develop action plans and prioritise actions

      • develop coping plans to prevent and manage relapses

      • consider achievement of outcomes and further goals and plans.

    • Feedback and monitoring (for example, regular weight assessment for weight management interventions):

      • encourage and support self-monitoring of behaviour and its outcomes and

      • provide feedback on behaviour and its outcomes.

    • Social support. If appropriate advise on, and arrange for, friends, relatives, colleagues or 'buddies' to provide practical help, emotional support, praise or reward.

  • Ensure the techniques used match the service user's needs (see recommendation 8).

  • Consider using other evidence-based behaviour change techniques that may also be effective. See the NICE topic pages on alcohol, diet, nutrition and obesity, physical activity, sexual health and smoking and tobacco for details of specific techniques.

  • Clearly define and provide a rationale for all behaviour change techniques that have been included.

  • Ensure novel techniques – or those for which the evidence base is limited – are evaluated (see recommendation 16).

  • Consider delivering an intervention remotely (or providing remote follow-up) if there is evidence that this is an effective way of changing behaviour. For example, use the telephone, text messaging, apps or the internet.

Recommendation 8 Ensure interventions meet individual needs

Providers of behaviour change programmes and interventions and trained behaviour change practitioners should:

  • Ensure service users are given clear information on the behaviour change interventions and services available and how to use them. If necessary, they should help people to access the services.

  • Ensure services are acceptable to, and meet, service users' needs. This includes any needs in relation to a disability or another 'protected characteristic' in relation to equity.

  • Recognise the times when people may be more open to change, such as when recovering from a behaviour-related condition (for example, following diagnosis of cardiovascular disease) or when becoming a parent. Also recognise when offering a behaviour change intervention may not be appropriate due to personal circumstances.

Trained behaviour change practitioners (see recommendations 12 and 13) should:

  • Before starting an intervention:

    • Assess participants' health in relation to the behaviour and the type of actions needed. For example, they should ensure the level and type of physical activity recommended is appropriate, bearing in mind the person's physical health. (As an example, see the NICE guideline on weight management before, during and after pregnancy.)

    • Ensure the intensity of the intervention matches the person's need for support to change their behaviour.

    • Discuss what the likely impact will be if the participant makes changes to their behaviour (in terms of their health and wellbeing and the health and wellbeing of those they are in contact with).

  • Plan at what point before, during and after a behaviour change intervention a review will be undertaken to assess progress towards goals and then tailor the intervention and follow-up support accordingly.

  • Tailor interventions to meet participants' needs by assessing and then addressing:

    • People's behaviour: if available, use a validated assessment tool appropriate for the specific population or setting. For example, alcohol screening tools used in prisons are different from those used in accident and emergency departments.

    • Participants' physical and psychological capability to make change.

    • The context in which they live and work (that is, their physical, economic and social environment).

    • How motivated they are to change: if many behaviours need to be changed, assess which one – or ones – the person is most motivated to tackle (see capability, opportunity and motivation).

    • Any specific needs with regards to sexual orientation, gender identity, gender, culture, faith or any type of disability.

Recommendation 9 Deliver very brief, brief, extended brief and high intensity behaviour change interventions and programmes

Commissioners and providers of behaviour change services should:

  • Encourage health, wellbeing and social care staff (see who should take action?) in direct contact with the general public to use a very brief intervention to motivate people to change behaviours that may damage their health. The interventions should also be used to inform people about services or interventions that can help them improve their general health and wellbeing.

  • Encourage staff who regularly come into contact with people whose health and wellbeing could be at risk to provide them with a brief intervention. (The risk could be due to current behaviours, sociodemographic characteristics or family history.)

  • Encourage behaviour change service providers and other health and social care staff dealing with the general public to provide an extended brief intervention to people they regularly see for 30 minutes or more who:

    • are involved in risky behaviours (for example harmful drinking [high-risk drinking]- the latest definitions on alcohol limits are described in the glossary of the NICE guideline on alcohol use disorders: prevention)

    • have a number of health problems

    • have been assessed as being at increased or higher risk of harm

    • have been successfully making changes to their behaviour but need more support to maintain that change

    • have found it difficult to change or have not benefited from a very brief or brief intervention.

  • Encourage behaviour change service providers and practitioners to provide high intensity interventions (typically these last more than 30 minutes and are delivered over a number of sessions) for people they regularly work with who:

    • have been assessed as being at high risk of causing harm to their health and wellbeing (for example, adults with a BMI more than 40 – see the NICE guideline on obesity prevention) and/or

    • have a serious medical condition that needs specialist advice and monitoring (for example, people with type 2 diabetes or cardiovascular disease) and/or

    • have not benefited from lower-intensity interventions (for example, an extended brief intervention).

Recommendation 10 Ensure behaviour change is maintained for at least a year

Providers and practitioners involved with behaviour change programmes and interventions should help people maintain their behaviour change in the long term (more than 1 year) by ensuring they:

  • receive feedback and monitoring at regular intervals for a minimum of 1 year after they complete the intervention (the aim is to make sure they can get help if they show any sign of relapse)

  • have well-rehearsed action plans (such as 'if–then' plans) that they can easily put into practice if they relapse

  • have thought about how they can make changes to their own immediate physical environment to prevent a relapse

  • have the social support they need to maintain changes

  • are helped to develop routines that support the new behaviour (note that small, manageable changes to daily routine are most likely to be maintained).

Recommendation 11 Commission training for all staff involved in helping to change people's behaviour

Commissioners, local education and training boards, and managers and supervisors (see who should take action?) should:

  • Commission training for relevant staff to meet the service specification for any behaviour change intervention or programme. This should:

    • cover all the various activities, from a very brief intervention offered when the opportunity arises to extended brief interventions

    • include assessment of people's behaviours and needs

    • address equity issues

    • provide the latest available evidence of effectiveness and describe how an intervention works (mechanism of action).

  • Ensure training programmes on behaviour change provide:

Commissioners and local education and training boards should:

  • Ensure training programmes consider:

    • where programmes and interventions will be delivered

    • training participants' characteristics (such as background)

    • whether behaviour change is part of participants' main role, integral to their role but not the main focus, or an additional task (see recommendation 9).

  • Ensure training includes ongoing professional development on how to encourage behaviour change. This could include regular refresher training to maintain the quality of delivery of behaviour change interventions.

  • Ensure training is evaluated in terms of outcomes (see recommendation 14) and process (for example, via participant feedback).

Recommendation 12 Provide training for behaviour change practitioners

Providers of behaviour change training should:

  • Ensure training objectives include the range of knowledge and skills (competences) needed to deliver specific interventions.

  • Ensure practitioners are trained to adopt a person-centred approach when assessing people's needs and planning and developing an intervention for them.

  • Ensure behaviour change practitioners:

    • understand the factors that may affect behaviour change, including the psychological, social, cultural and economic factors (see recommendation 8)

    • are aware of behaviours that adversely affect people's health and wellbeing, and the benefits of prevention and management

    • can address health inequalities by tailoring interventions to people's specific needs, including their cultural, social and economic needs and other 'protected characteristics'

    • are able to assess people's needs and can help select appropriate evidence-based interventions

    • know how an intervention works (mechanism of action)

    • recognise the specific behaviour change techniques used in the intervention they will be delivering

    • understand how to access, and how to direct and refer people to, specialist support services (for example, they should know how people can get help to change their behaviour after hospitalisation, a routine GP appointment or an intervention)

    • understand local policy and demographics.

  • Ensure behaviour change practitioners have the skills to:

    • assess people's behaviour using validated assessment tools and measures

    • communicate effectively, for example, by giving people health, wellbeing and other information, by using reflective listening and knowing how to show empathy

    • develop rapport and relationships with service users

    • develop a person's motivation to change by encouraging and enabling them to manage their own behaviour (see recommendation 7)

    • deliver the relevant behaviour change techniques

    • help prevent and manage relapses (see recommendation 10).

  • Ensure behaviour change practitioners who provide interventions to groups can:

    • elicit group discussions

    • provide group tasks that promote interaction or bonding

    • encourage mutual support within the group.

  • Give practitioners the opportunity to learn how to tailor interventions to meet the needs and preferences of different groups and to test this ability (both during and after training).

  • Ensure trainers have adequate time and resources to assess participants' motivation, skills, confidence and knowledge when they are delivering interventions to particular groups.

Recommendation 13 Provide training for health and social care practitioners

All those who train or accredit health and social care professionals (see who should take action?) should:

Recommendation 14 Assess behaviour change practitioners and provide feedback

Providers of behaviour change training should:

Employers (this includes workplace managers, supervisors and mentors of trainees) should:

  • Ensure behaviour change practitioners who have received training are regularly assessed on their ability to deliver behaviour change interventions. This ranges from a very brief intervention to a high intensity intervention (the latter typically lasts longer than 30 minutes and is delivered over multiple sessions). Assessment should reflect the intervention content. It should also include practitioners' ability to provide participants with behaviour change techniques and to tailor interventions to participants' needs. In addition, it should include service user feedback.

Providers of behaviour change training and employers should:

  • Ideally, record behaviour change sessions as part of the assessment. Intervention components, such as behaviour change techniques, should be identified in transcripts. Audio or video recording equipment could be used. If this is not possible then, as a minimum, a reliable observation tool should be used to record the intervention. An example of the latter would be a checklist of key intervention components.

  • Obtain the consent of the practitioner and service user for all assessments. They should also ensure the organisation's confidentiality requirements are met.

  • Provide behaviour change practitioners with feedback on their performance, both orally and in writing, starting with feedback on good performance. If necessary, negotiate and set jointly agreed goals and an action plan. Provide them with the option of refresher training.

Recommendation 15 Monitor behaviour change interventions

Recommendation 16 Evaluate behaviour change interventions

  • Before introducing a new intervention, commissioners and providers of behaviour change interventions and researchers should be clear about the objectives and how these will be measured and evaluated. (Researchers could include practitioners and others; for more details see who should take action?) See Medical Research Council guidance on the development, evaluation and implementation of complex interventions to improve health.

  • Commissioners and providers should ensure evaluation is carried out by a team of researchers or an organisation that has not been involved in delivering the intervention.

  • Researchers should work with commissioners and providers to plan evaluation before the intervention takes place. This may entail getting specialist input (for example, from the National Institute for Health Research's research design service).

  • Researchers should use objective, validated measures of outcome and process if they are available. They should ensure the design makes it possible to provide new evidence of effectiveness and, ideally, cost effectiveness – and details on why it is effective (mechanism of action). See principles 7 and 8 in the NICE guideline on behaviour change: the principles for effective interventions.

  • Commissioners, providers and researchers should ensure evaluation includes:

    • a description of the evaluation design

    • assessment of intervention fidelity

    • consistent use of valid, reliable measures (using the same tools to assess behaviours) before, during and following an intervention (that is, ensuring baseline and outcome measures match)

    • rigorous qualitative assessments to evaluate how well interventions will work in practice and how acceptable they are to services users and practitioners

    • assessment of processes and outcomes using both objective and self-reported measures

    • establishing and ensuring routine data collection

    • adequate sample sizes

    • assessment of long-term outcomes (more than 1 year).

  • Providers of existing interventions should work with researchers to ensure they are rigorously evaluated.

Recommendation 17 National support for behaviour change interventions and programmes

  • National organisations that support the monitoring, collection and surveillance of routine data should work together to:

    • determine what routine data health, social care and voluntary organisations should record on health-related behaviours (such as smoking and alcohol)

    • collect these data to monitor the outcomes of activities to improve the public's health (include: behaviour change interventions; national, regional and local policies and initiatives; and communication campaigns)

    • track the prevalence of these behaviours over time, region and social group and report on findings

    • support local implementation of behaviour change interventions based on evidence of effectiveness.

  • National organisations responsible for behaviour change training and curricula (see who should take action?) should work together to:

    • provide a central repository for behaviour change training curricula

    • assess whether behaviour change competency frameworks and training curricula promote an evidence-based approach to behaviour change

    • provide guidance on the suitability of these frameworks and curricula in terms of who they are aimed at and whether their content is evidence based.

  • National organisations responsible for research funding should ensure research related to behaviour change includes, as a minimum, details of:

    • intervention content and how it was delivered

    • who delivered the intervention

    • format (methods by which the intervention was administered)

    • where and when the intervention was delivered

    • recipients

    • intervention intensity and duration

    • intervention fidelity.

  • National Institute for Health and Care Excellence (NICE)