Health Psychology Review

ISSN: 1743-7199 (Print) 1743-7202 (Online) Journal homepage: http://www.tandfonline.com/loi/rhpr20

Celebrating variability and a call to limit

systematisation: the example of the Behaviour
Change Technique Taxonomy and the Behaviour
Change Wheel

Jane Ogden

To cite this article: Jane Ogden (2016): Celebrating variability and a call to limit
systematisation: the example of the Behaviour Change Technique Taxonomy and the
Behaviour Change Wheel, Health Psychology Review, DOI: 10.1080/17437199.2016.1190291

To link to this article: http://dx.doi.org/10.1080/17437199.2016.1190291

Accepted author version posted online: 18

May 2016.
Published online: 18 May 2016.

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 1

Publisher: Taylor & Francis & Informa UK Limited, trading as Taylor & Francis Group
Journal: Health Psychology Review
DOI: 10.1080/17437199.2016.1190291

Celebrating variability and a call to limit systematisation: the example of the Behaviour

Change Technique Taxonomy and the Behaviour Change Wheel

Jane Ogden
Downloaded by [Orta Dogu Teknik Universitesi] at 05:03 21 May 2016

Professor in Health Psychology

School of Psychology, University of Surrey, UK

Corresponding author:
Jane Ogden PhD
School of Psychology
University of Surrey
Guildford GU2 7XH, UK.
Tel: 01483 686929
email: J.Ogden@surrey.ac.uk
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Celebrating variability and a call to limit systematisation: the example of the Behaviour

Change Technique Taxonomy and the Behaviour Change Wheel

Within any discipline there is always a degree of variability. For medicine it takes the form

of Health Professional’s behaviour, for education it’s the style and content of the classroom

and for health psychology it can be found in patient’s behaviour, the theories used and

clinical practice. Over recent years attempts have been made to reduce this variability

through the use of the Behaviour Change Technique Taxonomy, the COM-B and the
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Behaviour Change Wheel. This paper argues that although the call for better descriptions of

what is done is useful for clarity and replication this systematisation may be neither feasible

nor desirable. In particular, it is suggested that the gaps inherent in the translational process

from coding a protocol to behaviour will limit the effectiveness of reducing patient

variability, that theory variability is necessary for the health and well being of a discipline

and that practice variability is central to the professional status of our practitioners. It is

therefore argued that we should celebrate rather than remove this variability in order for our

discipline to thrive and for us to remain as professionals rather than technicians.

 3

In the early 1980’s research in primary care identified the problem of doctor variability with

doctor’s offering different advice to different patients for a range of problems including

asthma, diabetes and hypertension (See Marteau and Johnston, 1990 for a review).

Researchers recorded, coded and measured doctor patient interactions to identify the cause of

this problem and a solution emerged in the form of evidence based medicine, clinical

guidelines, decision trees and financial incentives to ‘encourage’ GPs to do the right thing

(Stiles, 1978; Moscovitz, Kuipers and Kassiner, 1988; Roter et al 1997; Sackett, 1995;

Roland, 2004). Thirty years later primary care is in crisis and the recruitment and retention
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of GPs is poor as they chose alternative specialities or leave clinical work to take up teaching,

management or to retire early (GP Taskforce, 2014; BMA, 2015). The causes of this are

varied but reports indicate that GPs struggle with burnout, feel de-professionalised and

lacking in autonomy and complain that the art has been taken out of their science

(Lichenstein, 1998; Appleton et al, 1998; Saunders, 2000; Sibbald et al, 2000; Schimpff,

2015).

Now in health psychology there is a different problem to solve – that of patient

variability. Much research is concerned with promoting healthy behaviours yet people

continue to eat poor diets, obesity is still on the increase, many smoke, most won’t do the

recommended level of exercise and adherence to medication and screening is often poor (eg.

Mokdad et al, 2004). And so solutions were developed. First patients were offered

knowledge through education but soon this was found to be lacking as their beliefs loomed

large and it became obvious that knowing did not translate into doing (see Conner and

Norman, 2015 for a review). Then social cognition models were drawn upon with their

emphasis on beliefs as predictors of patient behaviour but it was quickly recognised that there

was a problematic gap between what people intended to do and what they actually did and

research highlighted the role of all sorts of idiosyncratic, individually specific and chance
 4

events that could knock an intention off its path (Orbell and Sheeran, 1998; Sheeran, 2002;

Webb and Sheeran, 2006). Next interventions were formulated to plug this gap such as self

affirmation tasks, planning or implementation intentions (Gollwitzer, 1993; Gollwitzer and

Sheeran, 2006; Steele, 1988; Epton et al, 2015). These worked to an extent but only for some

of the people some of the time and so it was recognised that there were many more

interventions to offer if the theoretical roots of behavioural and cognitive psychology could

be drawn upon. And so health psychology linked in with the broader world of psychology

and complex interventions became the new tool. Trials were run, interventions offered and
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the mode of intervention was varied to include simple leaflets, face to face interventions and

new technologies such as apps or web based approaches. And papers were published which

unfortunately showed that yet again behaviour can only be changed for some of the people

for some of the time (and not for very long) (eg. NICE, 2013; Bull et al, 2014). The problem

of patient variability was proving to be a tricky one.

But in 2008 there was a new kid on the block in the form of the Behaviour Change

Technique Taxonomy (Abraham and Michie, 2008; Michie et al, 2013). This has burgeoned

over the past 7 years into a multi site, multi disciplinary and hugely successful enterprise

aiming to code protocols, to explore which techniques are used in which interventions, to

identify which techniques are most successful for which behaviours, to train health

professionals to select and use the most effective techniques and to provide a resource for all

to make behaviour change interventions effective (Atkins, Wood and Michie, 2015; Michie

and Wood, 2015). The mission was twofold. First it aimed to code the protocols as a means

to describe and systematise the techniques used to change behaviour so that protocols could

be clearer and studies could be replicated (eg. Michie and Abraham, 2008; Michie et al,

2011a). A useful and constructive contribution to the discipline. Second it aimed to use this

coding exercise to produce a taxonomy which in turn could be used to identify which
 5

techniques are most effective (eg. Michie et al, 2009; 2011b; Michie and Wood, 2015). This

would maximise the effectiveness of our interventions, patients would change their behaviour

and the problem of patient variability would be solved at last. But can what is coded from a

protocol actually predict what people do? And can the problem of patient variability be

solved in this way? If there is a gap between a person’s own beliefs and their own

subsequent behaviour (and there is) then there is certainly a gap between their own behaviour

and that of the health professional (or leaflet / app / intervention) in front of them. There is

also a gap between that health professional’s own beliefs (‘I intend to practice in line with my
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training’) and their behaviour with the patient. Further, there is yet another gap between the

health professional’s beliefs and the training they received to deliver the intervention, not to

forget the gap between the protocol and how it is translated into training or the final gap

between the coder of the protocol and the protocol. This is an awful lot of gaps between the

protocol being coded and the behaviour of the target of that protocol – the patient. If their

own beliefs don’t predict what patients do next it seems unlikely that what was in the

protocol telling the professional what to do with them will do either. Probability theory

teaches us that effect sizes diminish as they are translated down a chain of action. And

psychology research clearly shows that people behave in response to whole array of intra

personal, inter personal and external factors rather than just what is done to them. The

mission of the BCT is admirable and its desire for clarification and replication has to be a

good one. And efforts to get more people to change their behaviour more of the time have to

be applauded. But our effects sizes need to get larger not smaller and it seems that there are

too many gaps in the system for what is in a protocol to have much to do with what a patient

actually does. The problem of patient variability will be around for a while longer yet.

But patient variability is not the only problem facing health psychology. There is also

the challenge of theory variability. Over the past 50 years psychology, and more recently
 6

health psychology, has developed, tested and applied a range of theories including broad

perspectives such as behaviourism and social learning theory to more specific perspectives

(or models) such as the Theory of Planned Behaviour, Health Belief Model, Self Regulation

Theory, Stages of Change, PRIME theory (see Conner and Norman, 2015 for a review)

Furthermore, researchers have drawn upon these theories and (models) to develop a number

of frameworks of behaviour change including more academic perspectives such as

intervention mapping, MINDSPACE and STD / HIV framework as well as those used by the

private sector such as Weight Watchers and Slimming World which similarly draw upon
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psychological theory (see Michie, van Stralen and West, 2011c; Davies et al, 2015; Michie et

al, 2014a for reviews; NICE, 2013). At times this number of theories (models and

frameworks) can seem overlapping, unnecessary and confusing and several researchers have

called for theory integration and the need for parsimonious theories which are clearly

conceptualised, can be tested and have a transparent specification of what constitutes

falsification (Hagger, 2009). For example, Lippke and Plotnikoff (2009) called to integrate

the Protection Motivation Theory with the Stages of Change model; Hagger and

Chatzisarantis (2009) mapped out a means to integrate the TPB and Self Determination

Theory and Gibbons, Houlihan and Gerrard (2009) proposed the prototype- willingness

model as an integration of intentional social cognitive with dual process perspectives. One

integrated model which has transformed research over recent years is the COM-B with its

focus on capability, opportunity and motivation and the associated Behaviour Change Wheel

(Michie, van Stralen and West, 2011c; Michie et al 2014b; Michie and Wood, 2015). This

emerged out of an analysis of 83 theories (or frameworks) and 1659 constructs by a cross

disciplinary team of researchers in terms of three dimensions: comprehensiveness, coherence

and a clear link to an overarching model of behaviour. It has since has been proposed as a

new integrated framework for behaviour change across a number of domains including
 7

physical activity, weight loss, hand hygiene, dental hygiene, diet, smoking, medication

adherence, prescribing behaviours, condom use and female genital mutilation (eg. Jackson et

al, 2014; Brown et al, 2015; Bailey et al, 2015; Chadwick and Benelam, 2013;

Asimakopoulou and Newton, 2015; see Michie and Wood, 2015; Atkins, Wood and Michie,

2015 and Michie et al, 2014b for reviews).

The goal has therefore been to reduce theory variability and identify an integrated

systematised approach which transcends individual perspectives and can be applied to all

behaviours. Such integration is admirable in line with the aims of ‘eliminating gaps in
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theories, reducing redundancy and increasing parsimony’ (Hagger, 2009). It also reflects the

need to ‘present a ‘streamlined’ and ‘accurate’ view of the processes that underpin health

behaviour’ (Hagger, 2009). But although parsimonious, whether the COM-B and the

Behaviour Change Wheel can ever be tested remains to be seen. And although its breadth

has eliminated many gaps in theory, it is unclear how it can be ever falsified if its constructs

remain broad and all encompassing. But more importantly, does such integration help a

discipline? Is it good for research? And does it promote and facilitate creativity in those that

do the thinking? In his classic text ‘The Structure of Scientific Revolutions’ Kuhn (1962)

described the processes involved in ‘normal science’ and argued that whilst those working

within any discipline at any time may believe that they are practicing ‘problem solving’ they

are actually engaged in ‘puzzle solving’ as the answers have already been determined by the

paradigm within which they work. In line with this, the empirical research of those working

within the social studies of science illustrated how laboratory scientists practice and

perpetuate ‘normal science’ which is restricted in its vision due to the limitations imposed by

the paradigm (eg. Latour, 1987; Woolgar, 1988; Mulkay and Gilbert, 1982). Further, they

illustrated how through the strategies of serial publications, authorship, conference

presentations, collaborations, jargon, networks and rhetoric the dominant ideas become
 8

‘black boxed’ and accepted as truths as they move beyond debate or critique. In addition,

Latour (1987) argued that researchers practice ‘action at a distance’ as leaders in a discipline

employ and activate their disciples to carry out research to support and perpetuate those ideas

dominant in a discipline at any given time. Accordingly, new ideas which challenge

dominant views, data which doesn’t fit, and even research groups who try to present opposing

perspectives are marginalised as the black boxed constructs become the only acceptable way

in which any ‘problem’ can be solved (Latour, 1987; Ogden, 2002). In line with this, the

recent move within health psychology to deal with the problem of theory variability by
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streamlining and integrating our existing perspectives into one dominant model may help

remove overlap and redundancy. But at the same time this drive may constrain and limit the

discipline in a such a way that health psychologists become simple ‘puzzle solvers’ not

‘problem solvers’ , that the science becomes ‘normal’ not novel, ideas become ‘black boxed’

and beyond challenge and any creative anomalies are marginalised before they have the

chance to reach fruition. Science requires paradigm shifts if it is to develop and grow. And

scientific revolutions need to occur if scientists are to remain free, independent and creative.

Removing the variability in theory may remove the mess in the system. But this very mess

may be what keeps a discipline alive.

Health psychology has therefore struggled with variability in both patient behaviour

and theory and recently a systematising approach has been developed for both these

problems in the hope that once measured, coded, assessed and integrated these problems will

be solved. But what about variability in practice? Practitioners are trained to have many

different skills and many varied tools in their tool kits. They are also trained to selectively

draw upon these tools given the needs of any particular patient at any particular time and are

therefore inherently flexible in line with notions of tailored interventions and patient

centredness (Kreuter et al, 1999; Mead and Bower, 2000; Richard, Coulter and Wicks, 2015).
 9

Further, clinical research frequently shows that a key component of any clinical interaction is

the therapeutic or working alliance between client and therapist not just what the therapist

‘does’ (Godfrey et al, 2009; Bordin, 1975; Ardito and Rabellino, 2011; Cook et al, 2015).

Yet this variability is also now being ‘solved’ and not only have the BCT and COM-B

become the means to systematise patient behaviour and theory they are also becoming a force

to systematise practice. In particular, not only is the comprehensive list of BCTs a resource

to enable intervention designers to consider techniques ‘other than those that are familiar to

them or those than can be brought to mind’ (Michie and Wood, 2015, p. 368) it is also
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becoming a prescriptive approach which is particularly apparent in a series of papers

specifying which techniques are most appropriate and should be used for which behaviours

(Michie et al, 2009; 2011b), the comprehensive guide published in 2014 (Michie et al, 2014b)

and its associated websites. The goal to promote evidence based practice has to be a good

one; as does the mission to describe what should and is being done so that studies can be

evaluated and replications can be carried out. But the goal to specify which intervention tools

should be used for a specific behaviour ignores the need for flexibility, variability and change

according not to the type of behaviour, or the type of intervention or even the type of patient

but how that individual patient happens to feel, think, look, behave or respond at any

particular time.

So there is variability in the system. And this variability of patients, theory and

practice can be seen as a problem with the BCT, COM-B and behaviour change wheel as the

necessary solutions. But not only do I question whether, although in part admirable, this

goal is feasible, I also wonder whether it is desirable. Health Psychology, whether research

or practice, is a profession made up of professionals making professional decisions. And

such variability makes it a rich profession which can thrive and progress through debate and

difference. But if we remove this variability and systematise to within an inch of our lives
 10

we are no longer professionals but technicians (Friedson, 1994). And like doctors (and

nurses, teachers and lawyers) the art will have gone from our science and maybe our

discipline too will flounder. As Greenhalgh said of doctors ‘The skilled practice of

medicine is not merely about knowing the rules but about deciding which rule is most

relevant to the particular situation in hand ‘ (Greenhalgh, 2013; p. 36). So let us be clear in

our reporting of what we do. But let us also celebrate our variability and keep our discipline

alive.
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