BPS Week 4 Cue Cards
Health Behaviors and Behavior Change Theory
Session focus
Define what we mean by a health behavior.
Explore associations between individuals' health behaviors and disease risks (why change matters).
Provide a brief overview of behavior change theory.
Introduce the COM-B model and the Behavior Change Wheel (BCW).
Key context: biomedical vs biopsychosocial approaches
Revisit the difference between a biomedical and a biopsychosocial approach.
Acute stress responses involve both brain and body;
external threats are perceived as threats to well-being by the brain.
internal threats are symptoms and physiological changes that the brain learns to associate with.
The greater the perceived threat, the more likely a behavioral response will occur.
Sensations are perceptions centrally constructed from body/brain information.
Symptoms are the commonest reason people seek health care.
Delay in seeking help can occur due to multiple factors (not just symptom presence):
poor perception of the symptom (not intense or worrying enough), misinterpretation, concern about a bad diagnosis, fear of being dismissed by health professionals.
other influences: financial constraints, culture, age, gender, symptom type/location/prevalence (e.g., embarrassing symptoms).
influence of others, emotional state, and treatment beliefs.
Symptom-driven behaviors are just one type of health behavior.
How do we define health and health behaviors?
WHO definition of health: physical, mental, and social well-being, not merely absence of disease.
Indigenous definition emphasizes health as a holistic, community-centered, life-course concept.
Health behavior: an overt behavioral pattern or habit related to health maintenance, restoration, or improvement.
Examples of health behaviors include:
smoking and alcohol use, diet and physical activity, sexual behaviors, physician visits, medication adherence, screening, vaccination.
Health behaviors can be categorized as:
Behavioral imagines (protective/healthy habits): e.g., regular exercise, maintaining a healthy weight, nutritious diet, social connections.
Behavioral pathogens (risky/poor health behaviors): e.g., sedentary behavior, smoking, illicit drug use, overweight/obesity, social isolation.
Mechanistic link: behavior, inflammation, and disease risk
Pathway: certain health behaviors contribute to low-grade systemic chronic inflammation.
Inflammation cascade: stresses (acute and chronic) trigger neural/hormonal responses that increase inflammation.
Vascular effects: inflammation affects endothelial function, heart rate, blood pressure, and increases oxidative stress.
Atherosclerosis progression:
endothelial dysfunction → fatty streaks → plaque formation → vessel narrowing and stiffness.
Pathogenic behaviors (smoking, sedentary lifestyle, poor diet, overweight/obesity) exacerbate these stresses.
Downstream disease risks include:
metabolic syndrome, cardiovascular disease, cancer, depression, autoimmune diseases, neurodegenerative diseases, sarcopenia, osteoporosis, immunosenescence.
Visualizing the link: pathogenic behaviors drive chronic inflammation, which then contributes to a broad spectrum of chronic diseases.
The “big six” health modifiable behaviors
Six broad targets you can influence to reduce chronic inflammation and disease risk:
smoking or illicit drug use
sleep
isolation and chronic stress
diet
body weight
physical inactivity
Note: these are described as modifiable factors; they are common targets in population health and patient care.
Why change behavior? current trends and motivation
Population-level data (Australia) show:
Proportion not meeting physical activity guidelines (latest update 2020) indicates a pretty flat or slightly worsening trend.
Overweight/obese prevalence is rising across age groups for both men and women.
Motivations for physical activity may include:
fitness goals, weight loss, appearance, perceived health benefits, self-image, mood improvement, stress reduction, social aspects, and peer/family influence.
Common barriers to increasing physical activity include:
lack of time, cost, access, embarrassment, belief that change is not possible, perceived lack of immediate benefit, lack of support from friends/family.
Behavior change theory: scope and terminology
Behavior change theory: a large field with many theories and models.
Some theories target specific behaviors; others address risk/benefit contexts or operate at individual, community, or population levels.
Disciplines contributing to behavior change theories include biology, behavioral psychology, social sciences, economics, and criminology.
Theory vs model:
Theory: a plausible explanation linking causes to effects.
Model: a schematic representation of relationships between components of a theory.
A widely discussed model you’ve already encountered: the Common Sense Model of Self-Regulation (CS-SRM) – people interpret information and form coping strategies that drive behaviors.
Foundational theories often cited:
Health Belief Model (HBM): constructs include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action.
Transtheoretical Model (TTM): stages of readiness to change (e.g., precontemplation, contemplation, preparation, action, maintenance).
Social Cognitive Theory (SCT): reciprocal determinism; learning from personal experience and by observing others; environment can enable or hinder behavior.
These theories emphasize different leverage points for intervention (individual vs environment vs policy).
The COM-B model and why it matters
COM-B core idea: for a person to perform a specific behavior, they must have:
Capability (C): both physical and psychological abilities/skills needed to perform the behavior.
Opportunity (O): a physical and social environment that enables the behavior.
Motivation (M): reflective (conscious decision-making, planning) and automatic (habits, emotions) processes that energize and direct behavior.
Central formula (conceptual):
Meaning: Behavior (B) arises from interactions among Capability (C), Motivation (M), and Opportunity (O).
The COM-B model highlights that changing behavior could target any of these domains, or their interaction.
Details of the components:
Capability: physical abilities and psychological skills (e.g., strength, balance, knowledge, self-efficacy).
Motivation: conscious goals and plans (reflective) plus automatic processes (habits, emotional reactions, impulses).
Opportunity: physical environment (facilities, time, access) and social environment (norms, support, cultural expectations).
Practical use in physiotherapy: during subjective/objective assessment you gather info to determine client capability, motivation, and opportunities; you infer how to support change.
The COM-B model is the core of the Behavior Change Wheel (BCW).
The Behavior Change Wheel (BCW): structure and purpose
BCW places COM-B at the center and links it to interventions and policy options.
The middle ring (interventions) includes functions such as:
Education, Persuasion, Incentivization, Coercion, Training, Restriction, Environmental Restructuring, Modeling, Enablement.
The outer ring (policy categories) captures broader enablers like guidelines, fiscal measures, communication campaigns, service provision, and regulations.
Visual layout (conceptual):
Center: COM-B
Surrounding ring (blue): Sources of behavior (Capability, Opportunity, Motivation)
Surrounding ring (red): Intervention types
Outer ring: Policy categories
How it helps in practice:
After assessing COM-B for an individual, you identify which intervention functions are most likely to be effective.
It provides a bridge from individual-level factors to practical actions and wider policy supports.
Interventions and practical implications
Intervention examples aligned with COM-B and BCW:
Education: increase knowledge/skills to improve capability.
Persuasion: use communication to influence motivation.
Incentivization: provide rewards to boost motivation.
Training: develop physical or cognitive skills to enhance capability.
Environmental restructuring: modify physical/social environment to enable behavior.
Modeling: demonstrate desired behaviors to influence learning and motivation.
Enablement: remove barriers or provide supports to enable behavior.
Policy-level links: when to apply broader policies to support interventions (e.g., workplace wellness programs, urban design to promote activity).
Clinician role: recognize that many interventions in cardiorespiratory, neurological, or musculoskeletal physiotherapy rely on patients adopting new or improved behaviors (e.g., exercises, walking, balance tasks).
Why study health behavior in physiotherapy practice
All interventions involve some level of patient practice or behavior change; few are purely passive.
Voluntary health behaviors include:
habitual/lifestyle behaviors (the big six) and rehabilitative recovery behaviors (learning new exercise, performing a balance task, relearning walking, improving skill sets).
The COM-B and BCW provide a practical framework to plan, implement, and evaluate behavior-change components of care.
Takeaways and learning objectives
You should be able to:
Define a health behavior and describe its association with disease risk.
Explain why many health behaviors are targets for change and outline common motivations and barriers.
Outline the broad landscape of behavior change theories and models, and distinguish theory from models.
Describe the COM-B model in detail (capability, motivation, opportunity) and explain how these domains interact to produce behavior.
Explain the Behavior Change Wheel structure (COM-B at center, linked to intervention types and policy options).
Discuss how these concepts apply to physiotherapy practice and patient education, rehabilitation, and prevention.
Reflect on ethical, cultural, and practical considerations when supporting behavior change (autonomy, equity, social determinants).
Small glossary and quick references
Health behavior: an overt action/ habit related to health maintenance, restoration, or improvement.
Behavioral imagines: protective health behaviors (e.g., exercise, healthy diet, social connections).
Behavioral pathogens: risky health behaviors (e.g., smoking, physical inactivity, poor diet).
Capability: physical and psychological ability to perform the behavior.
Motivation: reflective and automatic processes driving the behavior.
Opportunity: physical and social environment enabling the behavior.
B = f(C, M, O): Behavior results from interactions among Capability, Motivation, and Opportunity.
BCW: a framework linking COM-B to interventions and policy actions to effect behavior change.
Statistical and historical notes (brief references)
The 2015 scoping review identified
specific behavior change theories (note: many concepts overlap across theories).
Population data reference: Australian Institute of Health and Welfare reports; the most recent physical activity guideline adherence data updated in .
Foundational concept: endothelium dysfunction and atherosclerosis are driven by chronic inflammation linked to lifestyle and behavioral factors.
Example application scenario (brief)
Patient with sedentary lifestyle and overweight:
Assess COM-B: physical capability (exercise tolerance, strength), psychological capability (knowledge of exercises), motivation (goals, mood, habits), opportunity (access to facilities, social support).
Identify target areas: improve capability (education on exercises, skill training), boost motivation (goal setting, self-monitoring, supportive feedback), create opportunity (gym access, walking routes, social groups).
Choose interventions from BCW: training sessions (capability), persuasive messaging (motivation), environmental restructuring (opportunities), enablement (home exercise plan, apps, reminders).
Consider policy and community supports if aiming for population impact (e.g., public health campaigns, community exercise programs).
References for further study (from this session)
Health Belief Model: susceptibility, severity, benefits, barriers, cues to action.
Transtheoretical Model: stages of change.
Social Cognitive Theory: reciprocal determinism, observational learning, environment influence.
COM-B and BCW: core framework for linking behavior determinants to interventions and policy.
Distinction between theory and model in behavior change research.
Real-world barriers to behavior change: time, cost, access, social support, perceived benefits, cultural factors, and stigma.
Physiotherapist's Role in Changing Health Behaviours – Lecture 2
The session explains that physiotherapists (physios) help you get the most out of life by tailoring treatment to your condition, and they are often the first point of contact in healthcare. They work with people of all ages and a broad range of health conditions, not only acute injuries.
Services provided include: helping people recover from injury, increase mobility, manage chronic diseases, provide lifestyle modification and self-management advice, prescribe and supervise exercise, involvement in health promotion and injury prevention.
The profession has a role in behaviour change aimed at reducing disease risk, touching on the big six health behaviours that influence chronic low-grade systemic inflammation.
A nationwide Australian survey explored what people expect physiotherapists to provide regarding physical activity and general health advice. Key takeaways:
Light blue/green respondents: majority believed physios should tell them how to increase physical activity levels, how to increase fitness, and that they need more exercise.
General health questions: respondents also expected information on improving general health, sleep, preventing future illness, and weight loss. About half of respondents agreed physiotherapists should provide information on general health and related topics.
Quitting smoking, alcohol consumption, healthy diet, and sexual function were less commonly asserted expectations, but present as part of overall health guidance.
In summary: clients expect physios to address physical activity and the big health behaviours that increase disease risk.
Practical takeaway: physiotherapy interventions are rarely just actions on patients; they routinely involve advising, instructing, and providing feedback about how to change behaviour as part of the intervention.
What is a behaviour change technique (BCT)?
A BCT is the smallest component of a behaviour change intervention that can, in favourable circumstances, bring about change. They are building blocks for changing behaviour and are components of interventions aimed at changing a target behaviour.
BCTs are not exclusive to health conditions, behaviours, or professions; they’re used across health disciplines.
Michie’s classification (often spelled as "Mickey" in some texts) groups 93 specific BCTs into 16 groups. The key point: each BCT is a generic technique, not tied to a particular condition.
An appendix in the referenced paper provides detailed explanations for each BCT: a definition and an example. This appendix is used in workshops to explore which BCTs are embedded in interventions.
Takeaway: you don’t need to memorise all 93 BCTs, but you should be familiar with the common BCTs because they are used frequently in practice.
Examples of BCT groups with definitions and examples
Goals and planning (one of the groups; includes 9 BCTs):
Goal setting (definition): set or agree upon a goal defined in terms of the behaviour to be achieved.
Example: a walking goal.
Feedback and monitoring: feedback on a behaviour (monitor and provide informative or evaluative feedback on performance of the behaviour).
Example: using a pedometer to monitor progress toward a step-based goal.
Repetition and substitution: includes the graded task technique.
Graded task (definition): set an easy-to-perform task, then gradually increase difficulty until the behaviour is performed.
Example: start by walking 100 meters in week 1, then gradually increase to half a mile, then two miles.
Reward and threat: includes social incentive as a form of reward or threat.
Social incentive (definition): provide a verbal or nonverbal reward if and only if there has been effort or progress in performing the behaviour.
Example: congratulating the patient for every 10 meters walked beyond yesterday, or for meeting a daily activity target.
Identity: adopt a new perspective or identity to change beliefs or emotional representations about performing the behaviour.
Example: framing tasks as reducing sedentary behaviour rather than merely increasing physical activity.
Self-belief (verbal persuasion about capability): build self-efficacy
Verbal persuasion about capability: the clinician conveys confidence in the patient’s ability to perform the behaviour and helps manage self-doubt.
Practical illustrations of BCTs in interventions
Fear reduction in exercise for people with low back pain: the intervention lists the specific BCTs used to facilitate engagement with exercise.
Medication adherence after stroke: a protocol highlighting BCTs such as action planning, information about health consequences, salience of consequences, prompts and cues.
Increasing upper limb exercise in stroke survivors: documenting the BCTs embedded in the intervention.
A study on which BCTs Australian physiotherapists commonly use to improve rehab adherence in musculoskeletal conditions: the orange-highlighted BCTs indicate the most frequently used techniques.
Exercise promotion in older adults using cognitive behavioural interventions: CBT is not a single BCT; it comprises multiple BCTs (the orange items in the CBT intervention).
Important nuance: BCTs and cognitive behavioural therapy (CBT)
In Michie’s taxonomy, there is no single BCT that corresponds to CBT. Rather, CBT contains a set of BCTs.
The orange-highlighted BCTs in CBT-related interventions illustrate which techniques were actually used as part of the CBT approach.
Take-home messages about BCTs for physiotherapy practice
Do not try to memorise all 93 BCTs; focus on the common BCTs that routinely appear in practice.
Recognise that most physiotherapy involves a relatively small, practical repertoire of BCTs; expanding this repertoire enhances your therapeutic toolkit for both professional and personal life.
Recognizing and applying BCTs requires skill and practice; increasing your repertoire expands the options you have for facilitating behaviour change.
How do BCTs appear in everyday physiotherapy work?
Every client interaction involves elements that reflect BCTs:
Shaping knowledge: providing information in a way that changes understanding.
Natural consequences: highlighting outcomes of actions.
Identity: framing the patient’s self-concept regarding activity and health.
Planning and goal setting: setting and negotiating goals reflects goal-setting and planning BCTs, and may include graded exposure when progressively increasing activity.
Feedback: giving feedback about a task or performance exemplifies the feedback and monitoring BCT.
Practice and repetition: repeated practice of a task uses repetition-based BCTs.
Prescribing or progressing activity: graded exposure or progressive activity progression is a common BCT in treatment planning.
Assessment and diagnosis (in a behavioural sense): during subjective and objective assessments, clinicians conduct a behavioural diagnostic—assessing the patient’s means, motivation, and opportunities to change.
The broader point: in treatment planning, physiotherapists are already employing behaviour change strategies, even if not explicitly labelled as such. The goal is to recognize and intentionally apply BCTs to maximize impact.
Resources and practical next steps
There is a dedicated online resource for BCTs and their use in interventions; the appendix mentioned provides detailed definitions and examples for each BCT.
In workshops and training, this resource is used to identify which BCTs are embedded in planned interventions (e.g., fear reduction, medication adherence, upper limb exercise).
The overarching message is that behaviour change techniques are integral to physiotherapy practice and should be consciously integrated and expanded as part of professional development.
Summary
Physiotherapists play a key role in behaviour change, addressing physical activity and broader health behaviours as part of comprehensive care.
Behaviour Change Techniques are the building blocks of interventions; they are categorised in Michie’s taxonomy (often referred to as Mickey’s taxonomy in some texts) with 93 BCTs organised into 16 groups.
Common BCTs include goal setting, feedback and monitoring, graded tasks, social incentives, identity framing, and verbal persuasion about capability.
CBT involves multiple BCTs rather than a single one; CBT-specific techniques are among the BCTs used in practice.
In clinical practice, physios routinely use BCTs—consciously or not—to influence knowledge, beliefs, motivation, and behaviour, and this repertoire can be expanded through study and reflection to enhance outcomes.