In England in 2017, more than 124,000 people died from cardiovascular disease (CVD). Changing behaviours related to diet, physical activity, smoking and alcohol intake can reduce CVD risk. The delivery of interventions targeting these behaviours also often requires healthcare professional (HCP) behaviours to change.
In 2009, the English National Health Service (NHS) launched ‘NHS Health Check’, a national prevention programme offered to adults 40-74 years old with the aim of helping them reduce their chance of having a heart attack or stroke through behaviour change and, where appropriate, clinical treatment. In brief, eligible patients attending an NHS Health Check will have seven risk factors measured and their 10-year risk of CVD calculated as part of an appointment lasting around 20 minutes (the majority of which are delivered by healthcare assistants in primary care). During the appointment these results are discussed and the individual is supported to make behaviour changes and/or access clinical treatment to reduce their risk of stroke, kidney disease, heart disease, diabetes or dementia. The programme standards have been developed to guide implementation and delivery of NHS Health Checks(1). Cost-effectiveness calculations for this programme were based on an assumed uptake of 75% of all those eligible(2). However, since 2013 when delivery of NHS Health Check became a statutory responsibility of local authorities, <50% of those eligible have received a NHS Health Check(3). Improving the effectiveness and uptake of the programme is a key part of PHE’s strategic priority around predictive prevention to better predict and prevent poor health. Interventions are more likely to be effective if they target influences on behaviour (4). So it needs to be established what the behaviours relevant to NHS Health Checks are, who performs them and the factors influencing these behaviours. To date, research has tended to focused on single populations, e.g. patients or GPs, and specific behaviours, e.g. attending an NHS Health Check. A synthesis of these studies would provide an overarching behavioural picture of those involved in delivery and receipt of NHS Health Checks and so provide the foundations for intervention refinement and development.
Tools such as the Behaviour Change Wheel (BCW)(5), which includes the theoretical model of behaviour COM-B (Figure 1); the Theoretical Domains Framework (TDF) (Figure 2 shows how the TDF domains are linked to each COM-B component (see Additional file 1 for labels and definitions)) (4, 6) and the Behaviour Change Techniques Taxonomy (BCTTv1)(7) can be used for identifying influences on behaviours (COM-B and TDF) and providing recommendations for intervention design based on the influences identified (BCW and BCTTv1). The COM-B model, which sits at the ‘hub’ of the BCW, is a simple model to understand behaviour in terms of the Capability, Opportunity and Motivation needed to perform a Behaviour (Figure 1).
Figure 1. COM-B model
The TDF is used as a framework for synthesising behavioural influences in systematic literature reviews across qualitative and quantitative studies reporting perceived barriers and facilitators of behaviours. These include increasing attendance to diabetic retinopathy screening and triage(8), treatment and transfer of acute stroke patients in emergency care settings(9) and uptake of weight-management programmes in adults at risk of type 2 diabetes(10).
The Behaviour Change Wheel (BCW), a synthesis of 19 frameworks of behaviour change, can be used to characterise interventions. COM-B sits at the ‘hub’ of the Wheel and is surrounded by nine broad types of intervention and seven policy options, i.e. channels through which interventions are implemented (Figure 2; see Additional file 2 for labels and definitions and Additional file 3 for links between influences on behaviour and potential intervention content.
Figure 2. TDF domains linked to COM-B within the Behaviour Change Wheel
How intervention functions are delivered can be described using a 93-item taxonomy of behaviour change techniques (BCTTv1)  . Behaviour change techniques (BCTs) are defined as the active ingredients in interventions designed to bring about change. The Theory and Techniques Tool (https://theoryandtechniquetool.humanbehaviourchange.org/ - see Additional file 4) articulates the strength of evidence between BCTs and their hypothesised mechanisms of action.
The aims of this study were to identify:
- groups of people (actors) and their behaviours that are relevant to increasing uptake and follow up of NHS Health Checks within primary care and community and/or social care, representing these in a conceptual, ‘systems’ map.
- influences on the behaviours identified and categorise them using two theoretical models: COM-B and TDF.
- types of intervention and component behaviour change techniques (BCTs) likely to change these influences.
 British Heart Foundation (www.bhf.org.uk/-/media/files/research/heart-statistics/bhf-cvd-statistics---uk-factsheet.pdf)