Uptake of behavior change techniques - a key focus for process analysis and for intervention delivery: a comment on Hankonen et al.

Abstract

“There’s many a slip twixt cup and lip.” In interventions to change health behavior, even the most carefully crafted interventions can be undermined by a lack of fidelity in intervention delivery [1], or by a lack of ‘enactment’ (the degree to which participants engage with and use the intended behavior change techniques) [2]. The article by Hankonen and colleagues in this issue [3] describes a novel method for exploring the mechanisms of change in behavioral interventions. The authors measured the level of enactment of behavior change techniques by 210 participants in the intervention arm of a lifestyle intervention for people with newly diagnosed type 2 diabetes (the ADDITION-Plus trial). They found that increased use of the targeted behavior change techniques was associated with an increase in weight loss. Although the intervention overall did not generate weight loss, individuals who reported using all 16 of the intervention’s intended behavior change techniques lost significantly more weight than those who used 10 or less. This suggests that the intervention model and selected behavior change strategies may have been valid (when the techniques were used, change occurred), but that the lack of overall weight loss may have stemmed from suboptimal promotion of the use of these strategies (participants were not inspired to use the techniques suggested). The picture is limited to some extent by the sensitivity and precision of the measures used for enactment and for dietary and physical activity behaviors. However, the analyses suggest that some specific behavior change techniques were associated with changes in diet and physical activity. A particularly interesting aspect of this type of process analysis is that it prompts us to consider the use of behavior change techniques as a behavioral target in itself. This introduces a ‘second order’ question to the field—how can we increase the uptake and use of behavior change techniques? What ‘meta behavior change techniques’ (MBCTs) or intervention-delivery techniques (IDTs) are effective in motivating, supporting, and maintaining the use of the BCTs targeted by the intervention? For instance, to prompt selfmonitoring of physical activity, is it sufficient to simply give people a pedometer and some instructions? Can we use existing techniques, such as ‘prompting practice’ or encouraging social support (e.g., asking partners to remind or encourage the participant to use the pedometer)? Or, do we need novel techniques to promote the uptake and maintenance of BCTs (e.g., explaining the process of behavior change [4]; providing evidence on the link between use of the technique and successful behavior change)? Hakonen et al.’s article demonstrates that enactment-based process evaluation can add considerable explanatory value to the evaluation of behavior change interventions. It also prompts deeper thinking about how we can best promote the uptake and sustained use of behavior change techniques. This is a major contribution to the field.