Behavior Change Techniques

The  Coventry,  Aberdeen,  and  London—Refined (CALO-RE)  taxonomy  of  behavior  change  techniques builds on initial work on classifying psychological  techniques  used  in  intervention  to  change behavior,  with  a  particular  emphasis  on  physical activity and healthy eating. The taxonomy aims to provide a common language for the organization, identification,  and  adoption  of  behavior  change techniques  in  interventions.  The  taxonomy  is  a tool  for  researchers  designing  effective  interventions that work and practitioners wishing to identify  the  techniques  that  will  be  most  effective  in changing physical activity behavior. The taxonomy is based on Charles Abraham and Susan Michie’s initial  taxonomy  of  behavior  change  techniques refined to eliminate inconsistencies. The taxonomy provides a reference guide for each technique and the psychological constructs it purports to change. Forty-three techniques are specified in CALO-RE. Each  has  a  specific  definition  derived  from  systematic  reviews  of  intervention  research  independently coded and verified by leading experts. The definitions  also  specify  exclusions  and  exceptions ensuring  that  the  techniques  do  not  overlap.  The CALO-RE taxonomy does not specify the theories from which the techniques are derived; this information  was  supplied  by  Abraham  and  Michie. The taxonomy provides a standardized set of common terms to facilitate understanding of interventions, enable better evaluation of the effectiveness of  specific  intervention  techniques,  and  provide insight  into  the  psychological  mediators  that explain the process by which the technique works in changing behavior.

Behavior Change Theory and the Taxonomy

A vast array of psychological factors, such as self efficacy, attitudes, motivation, intentions, and risk perceptions, have been found to be linked to physical activity behavior. Such antecedents are important  as  it  is  assumed  that  such  variables  can  be manipulated or changed through techniques communicated  to  individuals  by  various  means  like one-to-one  consultations  or  via  the  media.  While interventions  targeting  psychological  factors  have led  to  increased  physical  activity  participation, their effectiveness has been shown to be relatively modest. A key reason is that interventions do not adequately  identify  the  intervention  techniques that will be successful in changing the psychological constructs known to be correlated with physical activity. This means that the techniques used may not  be  completely  effective  in  changing  behavior as they do not lead to a change in the psychological constructs, known as psychological mediators, associated with physical activity. Another problem in intervention research is that the reporting of the intervention components adopted to change physical activity behavior is inadequate. This limits the extent  to  which  other  researchers  will  be  able  to replicate the findings and limits the inferences that those aiming to synthesize research can make with regard  to  the  effectiveness  of  specific  techniques in  changing  the  psychological  constructs  and changing  behavior.  A  final  problem  is  that  many interventions adopt multiple behavior change techniques  that  seek  to  target  multiple  psychological mediators. While adoption of multiple techniques can be effective in bringing about behavior change, it  limits  researchers’  ability  to  identify  which  of the techniques was responsible for bringing about the change. Researchers will, therefore, be unable to arrive at a definitive conclusion as to which of the intervention techniques are doing the work in changing behavior.

These  issues  have  led  to  calls  for  (1)  identifying  and  classifying  the  intervention  techniques that target specific antecedents of physical activity through a mapping process, (2) improved reporting  of  behavior  change  techniques  within  reports of intervention trials, and (3) improvements in the design  of  interventions  to  provide  tests  of  individual  techniques  identified  in  the  mapping  process  on  physical  activity  behavior  change.  Recent developments in the taxonomy of behavior change techniques have led to a direct mapping of specific techniques on to the psychological antecedents of behavior  change.  This  has  provided  researchers and  practitioners  with  a  menu  of  strategies  from which  to  choose  when  designing  interventions  as well as identifying any overlaps and gaps.

Methods and Development

The   lists   that   Abraham   and   Michie   used   to develop  their  taxonomy  mixed  general  theoretical  approaches,  modes  of  delivery,  and  intervention settings. Therefore, a refined taxonomy of 26 clearly  defined  behavior  change  techniques  was developed so as to overcome these issues and allow reliable  coding  of  interventions.  Three  systematic reviews  were  then  completed  to  assess  whether the  behavior  change  techniques  could  be  used to  identify  core  components  of  behavior  change interventions.  The  26  behavior  change  technique definitions  resulted  in  93%  agreement  between raters,  and  acceptable  interrater  reliability  levels for most of the definitions.

Since  the  publication  of  the  original  behavior  change  technique  taxonomy,  which  has  been widely  adopted  and  used  in  reviews,  researchers have  identified  further  opportunities  to  improve the   classification.   Researchers   at   Coventry, Aberdeen,  and  London  collaborated  to  identify limitations,  such  as  lack  of  clarity  or  disagreement between raters, with Abraham and Michie’s original taxonomy, and to introduce further classifications.  Research  teams  adopted  an  iterative process  of  coding  one  or  two  research  articles, calculating  interrater  reliability  coefficients,  and revising the taxonomy accordingly through group discussion. This process resulted in the CALO-RE taxonomy,  which  has  fewer  conceptual  problems  and  less  overlap  between  items  and  is  more comprehensive.

The Techniques

The  40  behavior  change  techniques  identified  in the  CALO-RE  taxonomy  define  and  differentiate techniques, offering researchers and practitioners a clear guide as to which techniques may be adopted to  change  physical  activity  behavior  in  interventions. There is no guidance on which techniques to adopt or which will be more effective; the purpose is for identification and classification only. An outline of each technique is provided in the next section along with exercise-specific examples of what each technique might look like in an intervention to promote exercise and physical activity.

  1. Information provision  (general).  In  this  technique,  general  (not  specific)  information  is  provided  about  physical  activity  and  its  possible outcomes. (A poster might provide a statement that “physical activity is enjoyable and fun for all.”)
  1. Information provision  (to  the  individual).  In this technique, specific information relevant to the individual about physical activity and its possible outcomes,   consequences,   benefits,   and   costs   is given. (A physician might inform a patient that “if you participate in regular physical activity, it will help you to get your weight down and help you to feel less stressed at work.”)
  1. Information provision  (others’  approval).  In this technique, information is provided about what others’  might  think  of  their  physical  activity.  (An exercise  specialist  might  tell  a  referred  patient: “You will find that your family and friends will be very  supportive  of  your  new  exercise  program; they will see a fitter, healthier you!”)
  1. Information provision  (others’  behavior).  In this  technique,  information  concerning  what  others typically do with respect to exercise is provided. (A  leaflet  might  inform  a  potential  middle-age person thinking of taking up physical activity that “people over 50 years of age often take up exercise having not ever exercised in the past.”)
  1. Goal setting   (behavior).  In   this   technique, encouragement   to   begin   or   maintain   behavior change  is  provided.  It  does  not  involve  precise planning  to  do  the  behavior.  (A  goal  may  be  to “exercise more next week.”)
  1. Goal setting  (outcome).  In  this  technique,  the individual   is   encouraged   to   set   general   goals achievable  through  performance  of  the  behavior, but distinct from the behavior itself. (A consultant might highlight blood pressure reduction and losing weight as achievable goals derived from regular exercise.)
  1. Action planning.  In  this  technique,  detailed plans  are  made  including  when  (e.g.,  frequency) and where (e.g., in what situation) to act. It is vital that there is a clear link between plans and behavioral  responses  to  specific  situational  cues.  Such plans  are  often  expressed  in  if–then  formats.  (A business executive’s plan might be, “If it is 5 p.m. and everyone is starting to leave the office, then I will  collect  my  gym  bag  and  head  for  the  fitness center.”)
  1. Identifying barriers and problem resolution. In this technique, after the formation of a clear plan, individuals are  tasked  with  identifying  possible barriers   to   performance   and   solutions   to   the possible problems. Barriers may be cognitive, emotional, social, or physical (“I feel too tired to exercise on Fridays—therefore, I will go to sleep earlier on Thursday nights.”)
  1. Setting graded tasks. In this technique, the target behavior is broken into smaller, more manageable tasks, allowing successful progression in small increments—for instance, writing down a sequence of small  steps  to  accomplish  the  overall  behavior over time.
  1. Review of behavioral goals. In this technique, individuals are prompted to review the successful accomplishment of  previously  set  goals  and  contingencies and further plans made for instances in which   goals   were   missed.   (An   individual   may report  not  being  able  to  exercise  5  times  a  week due to other commitments, so reschedules allotted times to exercise at more convenient times or fits it into a work schedule by walking to work.)
  1. Review of outcome goals. In this technique, an individual will review the attainment of previously set outcome goals and be given an opportunity to revise the  goals.  (At  a  routine  check-up,  a  physician  might  encourage  an  exerciser  to  revise  the blood  pressure  or  weight  goal  and  modify  the physical  activity  regime  accordingly  to  enhance chances for success.)
  1. Effort or progress contingent rewards. In this technique, the  person  uses  rewards  or  praise  for attempts at achieving the goal. This is not reward for engaging in the behavior itself and is not contingent on actual success. (A trainer might say to an exerciser, “Well done, you have really tried hard to attain your goal of three visits to the gym this week.”)
  1. Successful behavior-contingent   rewards.  In this technique, rewards for successful performance of  the  target  behavior  are  provided.  The  reward may  be  material  or  verbal  but  must  be  based explicitly   engaging   in   the   behavior   itself—for instance, providing a reward or incentive for doing some physical activity, regardless of outcome.
  1. Shaping. In this technique, graded contingent rewards are provided for movement toward completion of the target behavior. The individual may reward oneself for any increase in physical activity behavior in  the  first  instance  (e.g.,  jogging  for 10 minutes as opposed to no activity). The reward schedule becomes progressively more restricted in later weeks (e.g., rewarding only for 20 minutes of jogging).
  1. Generalization of   target   behavior.  In   this technique, the person is encouraged to find opportunities to try it in other situations, to ensure the behavior does not become situation specific. (After following  a  walking  program  for  2  weeks,  a  personal  trainer  will  ask  the  client  to  try  swimming for the same amount of time at the local swimming pool.)
  1. Self-monitoring of   behavior.  In   this   technique,  the  person  is  asked  to  keep  a  detailed record of activity and use it as a means to change or modify behavior. This could take the form of a questionnaire or diary focusing on duration, time, and  situation  in  which  the  physical  activity  was attempted or completed.
  1. Self-monitoring of  behavioral  outcome.  This technique  is  similar  to  point  16,  but  focus  is  on measurable outcomes of the behavior (e.g., blood pressure or weight reduction).
  1. Focus on past success. In this technique, individuals reflect  on  successful  past  experience  with physical activity as a means to increase motivation to be active in the future. (A person is encouraged to  list  or  write  down  past  successful  experiences with physical activity.)
  1. Provide feedback   on   performance.  In   this technique, individuals receive feedback regarding a recent  physical  activity  success  with  the  aim  of increasing motivation to be more active in future. This may take the form of an exercise trainer commenting  on,  supporting,  or  critiquing  a  client’s physical activity goals.
  1. Informing when  and  where  to  perform  the behavior.  In this technique, individuals are offered advice  and  ideas  on  when  and  where  physical activity could be performed (e.g., providing suggestions on local exercise classes or gyms, local recreation parks, or even to and from the workplace).
  1. Instruction on  how  to  perform  the  behavior.  In  this  technique,  a  person  is  instructed  on exactly how to effectively perform a behavior (e.g., advice on technique in the gym or instruction on correct frequency or duration of cycling to work).
  1. Demonstrate behavior.  In  this  technique,  the person  is  shown  how  to  perform  an  activity.  (A gym instructor might give a customer a demonstration of a particular exercise or piece of equipment.)
  1. Training to  use  prompts.  In  this  technique, individuals are given instruction on use of cues as a  reminder  to  perform  a  behavior.  (Encouraging exercisers  to  use  frequently  occurring  everyday events  like  a  particular  time  of  day  or  mobile phone alerts, reminds them of the need to initiate their physical activity routine.)
  1. Environmental restructuring.  In   this   technique,   the   individuals   are   prompted   to   make changes to their environment in order to facilitate changes in behavior (e.g., informing friends so that they may help prompt physical activity or removing  tempting  snacks  or  treats  to  help  maintain weight loss).
  1. Agreement of   behavioral   contract.  In   this technique,  a  written  agreement  between  the  individual and the practitioner with respect to behavior change is established. (A trainer and client may sign a contract explicitly stating the agreed activities or exercises so there is an explicit record and a sense of commitment on the part of the practitioner and client.)
  1. Prompt practice. In this technique, the person is reminded to rehearse and repeat the behavior, or situations that lead to the behavior, helping make the behavior  more  automated  or  habitual  (e.g., providing  people  with  means  to  rehearse  when they are going to do their exercise routine).
  1. Use of follow-up prompts. In this technique, a set of reminders is delivered to a person that has started a behavior change routine in order to help remind them to continue. Over time, as the person becomes better at performing the behavior, reminders and prompts are reduced. These could include providing people  with  a  personal  alarm,  e-mail, text message, or other reminder to help them recall their physical activity regimen or goal.
  1. Facilitate social   comparison.  In   this   technique,    individuals    are    encouraged    to    draw comparisons   with   others’   behavior   to   increase motivation through modeling. (A person is encouraged to observe other regular exercisers to provide a positive example of technique or commitment.)
  1. Plan social support. In this technique, the person is prompted to elicit social support from other people and close relations in order to facilitate successful completion of the behavior. This may take the form  of  joining  clubs  or  groups  involved  in physical activity.
  1. Prompt identification  as  role  model.  In  this technique,  the  person  is  encouraged  to  view  oneself as an example or role model to others for the behavior.  This  includes  opportunities  for  the  person  to  persuade  others  to  adopt  the  behavior because of the benefits inherent in it (e.g., urging friends  and  family  to  engage  in  more  physical activity).
  1. Prompt anticipated  regret.  In  this  technique, expectations of shame, regret, or guilt for failure to accomplish  the  goal  are  induced.  (The  exercise specialist  might  encourage  an  exerciser  to  think about how guilty one would feel if one missed the next gym session.)
  1. Fear arousal. In this technique, fear-inducing information aimed  at  motivating  change  is  provided. (If weight loss is a goal, practitioners might highlight  the  health  risks  of  being  overweight  or obese.)
  1. Prompt self-talk. In this technique, the person is encouraged  to  use  self-talk  before  and  during activity to provide verbal encouragement and support.  (An  exercise  practitioner  might  encourage individuals to use mantras or motivational words when   they   are   finding   their   exercise   routine difficult.)
  1. Prompt use of imagery. In this technique, the person is provided with instruction on how to use visualization techniques  and  imagery  to  facilitate successful completion of the behavior (e.g., imagining completing a given walking distance or lifting heavier weights).
  1. Relapse prevention. In this technique, the person is prompted to focus on situations or occasions in which one may relapse, and then develop methods to increase chances of success. (A person following a jogging routine may highlight bad weather as a  possible  barrier  to  maintaining  the  exercise; encouragement  to  use  a  treadmill  in  the  gym  on cold or rainy days would be a solution.)
  1. Stress management. In this technique, the person is  encouraged  to  focus  on  reducing  related stress and improving emotional control in order to reduce  these  as  a  barrier  and  promote  health.  (A counselor  or  helper  may  provide  therapy  to  an individual attempting to increase activity levels in order to reduce the effect of negative emotions on their behavior.)
  1. Motivational interviewing. In this technique, specific interviewing techniques to prompt changes by minimizing  resistance  and  resolving  ambivalence to change are used. (A therapist may need to express  empathy  and  provide  opportunities  for the  client  to  express  personal  reasons  to  take  up exercise.)
  1. Time management. In this technique, the person is  assisted  in  managing  time  efficiently  to  be able to engage in the desired activity (e.g., using a diary or organizer to plan time).
  1. Communication skills  training.  In  this  technique,  individuals  are  directed  toward  improving communication  skills  and  improving  interactions with  others  concerning  the  behavior.  This  often involves group work and focuses on listening skills and  assertive  oration.  (An  exercise  specialist  may encourage  clients  to  engage  in  brief  role  play, encouraging  an  exercise  partner  to  come  to  the gym or go to the local swimming pool with them.)
  1. Stimulate anticipation  of  future  rewards.  In this technique, individuals are encouraged to consider future rewards associated with the outcome(s), without  necessarily  reinforcing  behavior  change (e.g., getting people to consider the possible gains of exercise, including extrinsic rewards like money and intrinsic rewards like satisfaction).

Implications of CALO-RE

The  CALO-RE  taxonomy  provides  a  comprehensive  and  standardized  protocol  for  the  identification,  reporting,  and  appraisal  of  behavior-change interventions   for   health   behaviors,   including physical  activity.  The  taxonomy  provides  a  common language for the scientific communication of theoretical-based  interventions,  which  not  only helps researchers effectively describe, interpret, and code  behavioral-change  strategies  in  interventions that directly link to theoretical constructs, but also establishes  a  basis  for  practitioners  to  accurately evaluate  and  apply  behavior  change  techniques derived  from  previous  research.  The  taxonomy assists  in  the  systematic  accumulation  of  knowledge of behavior change techniques from previous research  trials  and  improves  the  precision  for  the implementation of multiple theoretical frameworks applied for the promotion of physical activity.

The  development  of  the  taxonomy  offers  a number of avenues for future research and applied practice   in   behavior-change   interventions   for physical activity. First, CALO-RE provides a rigorous and systematic procedure that helps correctly map theoretical constructs into behavioral change techniques, so it becomes more realistic to test the effectiveness of individual theoretical components within   an   intervention.   Second,   interventions can  be  optimized  by  identifying  and  eliminating overlapping  or  redundant  elements  of  the  behavioral  change  techniques  driven  by  multiple  theoretical  components  or  frameworks.  Third,  the enhanced  connection  between  theoretical  knowledge and behavioral change techniques may enable researchers  to  reveal  the  underlying  mechanisms of the intention and behaviors of physical activity.

References:

  1. Abraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. walls around  a  closed  chamber  to  generate  sufficient  pressure  to  propel  blood  from  the  left  ventricle,  Health Psychology, 27(3), 379–387.
  2. Bartholomew, L. K., & Mullen, P. D. (2011). Five rolesfor using theory and evidence in the design and testing of behavior change interventions. Journal of Public Health Dentistry, 71(Suppl. 1), S20–S33.
  3. Dombrowski, S. U., Sniehotta, F. F., Avenell, A., Johnston, M., MacLennan, G., & Araújo-Soares, A. (2011). Identifying active ingredients in complex behavioural interventions for obese adults with additional risk factors: A systematic review. Health Psychology Review, 6(1), 7–32.
  4. Michie, S., Ashford, S., Sniehotta, F. F., Dombrowski, S. U., Bishop, A., & French, D. P. (2011). A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychology & Health, 26(11), 1479–1498.
  5. Schaalma, H., & Kok, G. (2009). Decoding health education interventions: The times are a-changin’. Psychology & Health, 24(1), 5–9.
  6. Webb, T. L., Sniehotta, F. F., & Michie, S. (2010). Using theories of behaviour change to inform interventions for addictive behaviours. Addiction, 105(11), 1879–1892.

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