Influences on NHS Health Check behaviours: a systematic review

Background National Health Service Health Checks were introduced in 2009 to reduce cardiovascular disease (CVD) risks and events. Since then, national evaluations have highlighted the need to maximise the programme’s impact by improving coverage and outputs. To address these challenges it is important to understand the extent to which positive behaviours are influenced across the NHS Health Check pathway and encourage the promotion or minimisation of behavioural facilitators and barriers respectively. This study applied behavioural science frameworks to: i) identify behaviours and actors relevant to uptake, delivery and follow up of NHS Health Checks and influences on these behaviours and; ii) signpost to example intervention content. Methods A systematic review of studies reporting behaviours related to NHS Health Check-related behaviours of patients, health care professionals (HCPs) and commissioners. Influences on behaviours were coded using theory-based models: COM-B and Theoretical Domains Framework (TDF). Potential intervention types and behaviour change techniques (BCTs) were suggested to target key influences. Results We identified 37 studies reporting nine behaviours and influences for eight of these. The most frequently identified influences were physical opportunity including HCPs having space and time to deliver NHS Health Checks and patients having money to adhere to recommendations to change diet and physical activity. Other key influences were motivational, such as beliefs about consequences about the value of NHS Health Checks and behaviour change, and social, such as influences of others on behaviour change. The following techniques are suggested for websites or smartphone apps: Adding objects to the environment, e.g. provide HCPs with electronic schedules to guide timely delivery of Health Checks to target physical opportunity, Social support (unspecified), e.g. include text suggesting patients to ask a colleague to agree in advance to join them in taking the ‘healthy option’ lunch at work; Information about health consequences, e.g. quotes and/or videos from patients talking about the health benefits of changes they have made. Conclusions Through the application of behavioural science we identified key behaviours and their influences which informed recommendations for intervention content. To ascertain the extent to which this reflects existing interventions we recommend a review of relevant evidence.


Background
In England in 2017, more than 124,000 people died from cardiovascular disease (CVD). 1 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 min (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 (Fig. 1); the Theoretical Domains Framework (TDF) (Fig. 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 (Fig. 1).
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 ( Fig. 2; see Additional file 2 for labels and definitions and Additional file 3 for links between influences on behaviour and potential intervention content. How intervention functions are delivered can be described using a 93-item taxonomy of behaviour change techniques (BCTTv1) [6]. 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: 1. 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. 2. influences on the behaviours identified and categorise them using two theoretical models: COM-B and TDF. 3. types of intervention and component behaviour change techniques (BCTs) likely to change these influences.

Search strategy and selection criteria
We conducted a systematic review in accordance with PRISMA guidelines. Electronic databases Medline, EMBASE and PsycINFO were searched for publications reporting barriers to and facilitators of behaviours relevant to uptake and follow up of the NHS Health Check. We included empirical qualitative and/or quantitative research and systematic review articles of behaviours and of barriers to and facilitators of behaviours relevant to NHS Health Checks. We included all papers with title and abstract written in English. Searches were limited to 2008 -December 2018 as this corresponded to the introduction of NHS Health Checks. The full search strategy is provided in Additional file 5.

Stakeholder consultation
We assembled a panel of stakeholder experts to suggest relevant literature not identified by the electronic searches.

Study selection and quality assessment
Titles and abstracts were screened against the inclusion and exclusion criteria by two researchers. For selected abstracts and those where there was uncertainty at first screening, full papers were screened against the same inclusion and exclusion criteria. Any papers for which the decision was not clear were discussed with other members of the review group. We used the Mixed Methods Appraisal Tool (MMAT) [11] to assess quality of qualitative, quantitative and mixed methods studies (Additional file 6).

Data extraction tools
Study characteristics extracted were: setting; participant; target behaviour; how the target behaviour was measured and barriers and facilitators to the target behaviour. Quotes and author interpretations of barriers and facilitators were coded using COM-B and TDF.

Data analysis
We conducted a six-step framework [12] and thematic [13] analysis to synthesise and explain influences on NHS Health Check related behaviours identified in the systematic review: i) Framework analysis by deductively coding extracted data on barriers/facilitators into the COM-B and TDF domain(s) they were judged to best represent. ii) Thematic analysis within each domain, grouping similar data points and inductively generating summary theme labels. iii) Recording the frequency of each theme, i.e. how many studies each theme was identified in. iv) Classifying each theme as either barrier, facilitator, or both. v) Classifying each domain as either barrier (all identified themes within that domain are barriers), facilitator (all identified themes within that domain are facilitators) or both (if themes within the domain are a combination of barriers and facilitators). vi) Selecting key themes within domains using: i) established criteria -frequency (number of studies), elaboration (number of themes) and evidence of conflicting beliefs within domains (e.g. if some participants report lack of knowledge of guidelines whereas others report familiarity with guidelines) [14]; ii) PHE stakeholder input to identify strategic priority areas to target.
TDF provides a greater level of detail than COM-B and was used primarily to classify influences on behaviours.
Using the Behaviour Change Wheel, based on COM-B and TDF coded influences on behaviours, we signposted to functions interventions might serve [15] and BCTs to deliver those functions [16]. The following steps were taken to translate the list of potentially relevant BCTs into the recommendations for intervention design and refinement: i) Stakeholders with relevant perspectives on the delivery of these BCTs selected BCTs for a prototype intervention.To permit a systematic approach to selecting which BCTs are appropriate to each context, the APEASE criteria [13] were used. These form a checklist of considerations when selecting intervention content and mode of delivery, i.e. is it Affordable -can it be delivered to budget?; Practicable -can it be delivered to scale?; Effective/ Cost-effective -is there evidence it is likely to be (cost)effective?; Acceptable -is it acceptable to those delivering, receiving and commissioning it?; are there any Side-effects/Safety issues?; will it increase Equity, i.e. does it disadvantage any groups? See Additional file 7. ii) Having produced a prototype intervention, further feedback (again guided by the APEASE criteria) was obtained from a wider group of stakeholders including HCPs (GPs, practice nurses, practice managers and commissioners) and patients (NHS Health Check attenders and non-attenders).

Results
Thirty-seven studies met the inclusion criteria (see Fig. 3). The majority were conducted in primary care (n = 28) and collected data from patients (n = 25). Table 1 provides a summary of the setting, participants and behaviours investigated. Study quality details are presented in Additional file 6. Table 2 describes the setting, participants, behaviour and data collection method for individual studies.

Systems map of NHS health check behaviours
Behaviours reported in the systematic review of barriers to and facilitators of NHS Health Check-related behaviours are provided in the behavioural systems map Fig. 4. Studies identified in the systematic review typically focussed on barriers to and facilitators of HCPs delivering NHS Health Checks (n = 18 studies), patients attending NHS Health Checks (n = 16 studies) and patients changing behaviour following NHS Health Checks (n = 15 studies). The map is divided into behaviours occurring at five sequential time periods: i) HCPs inviting patients to attend NHS Health Checks; ii) patients attending NHS Health Checks; iii) HCPs delivering NHS Health Checks; HCPs recording NHS Health Check data; service managers and/or commissioners synthesising and disseminating NHS Health Check data; iv) patients attending specialist referral; v) patient changing CVD riskrelated behaviours; patients attending repeat NHS Health Check.

Barriers to and facilitators of NHS health check behaviours
Domains and themes identified as relevant to each NHS Health Check behaviour is provided in Table 3. Barriers, facilitators or both barriers and facilitators for each behaviour is summarised in Table 4.

Key barriers to and facilitators of NHS health check behaviours
Domains and themes identified as key in influencing NHS Heath Check behaviours are summarised for each behaviour below and in Fig. 5 and Table 5  pharmacies. Both themes were coded as both barriers and facilitators. iii. 'Social influences'i) having a family history of illness was coded as both a barrier and facilitator as it discouraged some from attending and encouraged others to attend; ii) the impact of interactions with GP with which they did not have a good relationship and being told to change was coded as a barrier. iv. 'Beliefs about consequences'i) There were a range of views on the extent to which NHS Health Checks were perceived as beneficial for early detection, this was coded as both barrier and facilitator reflecting opposing views within this theme; ii) NHS Health Checks provided the opportunity to be proactive about health -this was coded as a facilitator. v. 'Emotion'i) anxiety at receiving high risk result; ii) reassurance as a motivation to attend. Both themes were coded as facilitators as anxiety and reassurance encouraged attendance. 3. HCPs delivering NHS Health Checks. Nine key domains were identified across 18 studies: i. 'Knowledge'i) HCPs perceptions of patients understanding of CVD risk was coded as both barrier and facilitator as some HCPs considered that patients understood their risk, but this view was not shared by all; ii) HCPs lack of familiarity with guidelines and associated tools which was coded as a barrier. ii. 'Cognitive and interpersonal skills' -HCPs perceived the need for i) training to deliver behavioural support and, ii) to communicate risk. The former was coded as both barrier and facilitator as some but not all perceived the need for training to improve behavioural support skills, the latter was coded as a      barrier as all reported the need to improve risk communication skills. iii. 'Memory, attention and decision processes' -HCPs had different views on whether behavioural intervention should be offered before pharmacological intervention to reduce CVD risk so this was coded as a both a barrier and facilitator. iv. 'Environmental context and resources'i) availability of resources and time to deliver NHS Health Checks was coded as both barrier and facilitator reflecting different access to resources and different amounts of time to deliver NHS Health Checks; ii) lack of appropriate space to deliver NHS Health Checks was coded as a barrier; iii) having computer systems which support delivery of NHS Health Checks was coded as both barrier and facilitator. v. 'Social influences'taking account of patients' social context when providing behavioural support was coded as both barrier and facilitator as some but not all HCPs considered patients' social context. vi. 'Social/professional role and identity'i) some but not all HCPs thought there was role clarity within teams when delivering NHS Health Checks, so this was coded as a barrier and facilitator; ii) all pharmacy staff reported that delivering NHS Health Checks positively promoted diversification of their professional role so this was coded as a facilitator. vii. 'Beliefs about consequences'i) holding the belief that NHS Health Checks are beneficial in terms of preventive healthcare; ii) believing appropriately framing messages is important. Both themes were coded as both barrier and facilitator reflecting opposing beliefs within each theme. viii.'Beliefs about capabilities' -HCPs varied in their level of confidence to discuss and initiate behaviour change in patients, so this was coded as both a barrier and facilitator. ix. 'Optimism' -HCPs are varyingly optimistic about whether patients will change their behaviour after the NHS Health Check, this was coded as both a barrier and facilitator. 4. HCP referral to specialist service. The key domain, 'environmental context and resources' was identified in three studies and contained the theme, lack of funded services to refer patients to. This was coded as a barrier. 5. Patients attending specialist referral. One key domain, 'beliefs about consequences' was identified in one study and contained the theme, holding the belief that regular attendance at referral appointments would help to reduce CVD risk. This was coded as a facilitator. 6. Patients changing CVD risk-related behaviours.
Eight key domains were identified across 15 studies:  i. 'Knowledge' -Patients' understanding of CVD risk was coded as both barrier and facilitator as some HCPs considered that patients understood their risk, but this view was not shared by all. ii. 'Environmental context and resources'i) time and cost as a barrier to patients changing behaviours related to CVD riskthis was coded as both barrier and facilitator as some reported not having time or funds to change behaviour whilst others reported sufficient time and funds; ii) HCPs perceived there to be greater adherence to behavioural support when CVD risk was communicated using electronic calculators than paper risk chartsthis was coded as a facilitator iii. 'Social influences'support from family and friends was reported by patients as a facilitator of behaviour change to reduce CVD risk. iv. 'Social/professional role and identity' -Patients perceived the role of the HCP to influence their engagement with changing behaviour to reduce CVD risk, as there were differing views of which role would most effectively encourage patients to change (e.g., GPs, practice nurses, community HCPs) this was coded as both barrier and facilitator. This is a summary of all themes and domain coding for barriers and facilitators may differ to Table 4 which are colour coded according to domains and or themes within domains identified as key. For example, Environmental context and resources was identified as a domain relevant HCP recording programme data and contained three themes (a mixture of barriers and facilitators). However, the theme identified as key was a barrier and is presented as such in Table 4

Signposting to relevant intervention content
Intervention content (intervention types, policy categories and BCTs) which is theoretically linked to identified influences on NHS Health Check behaviours which could be considered for inclusion in intervention design and refinement is suggested in Table 6. Example suggestions for how BCTs could be delivered to target key barriers to and facilitators of NHS Health Check behaviours are provided in Table 7.

Discussion
We identified nine behaviours related to NHS Health Checks and barriers to and facilitators of eight of these behaviours): i) HCPs inviting patients to attend NHS Health Checks -It can be time consuming identifying eligible patients; ii) patients attending NHS Health Checks -Family history of illness, the need to reduce anxiety and be reassured may increase attendance. Since patients need to perceive the NHS Health Check as relevant to them, this may be facilitated by patients understanding the purpose of NHS Health Checks as an opportunity to be proactive about CVD.; iii) HCPs  Environmental context and resources (physical opportunity) Timing and location of NHS HCs increased attendance "I mean we have the healthcare assistants are here at 8:30, so they can have early bloods done before they go to work, and the nurse can see them before they go to work, so we're trying to offer those facilities to people to catch them." [28] "It's very difficult for me to (go to the appointment) and hold on to a nine-to-five job. It means I have to take personal time off from my employer to do this. They don't give you an option where you can go in the evening. I would have to take it off as annual leave, and do it in my own personal time." [39] Conducting NHS HCs in pharmacies "Oh, very easy, I mean I just walked in there and booked myself in.. . I think I'd gone in the morning and I'd booked in for early afternoon and then went to do some shopping and went back." [39] "Some [pharmacies] are really struggling because they are out of town and in locations close to GP practices -which is where the pharmacies get a lot of their business from." [48] Social influences (social opportunity) Family history of illness ". . family history is obviously, you know, a huge determinant of various things. OK not completely conclusive, but you know, law of averages, I thought I'm probably OK. So, it just slipped and then I never took up on it." [39] "I suppose the fact that my father died relatively young of a heart attack, probably made me fairly aware of the need to try and be healthy.. . I suppose I was thinking everybody needs to be careful when they get to their mid-fifties." [39] Interactions with GP/ being told to change "I didn't want to find out I had more medical problems, I have epilepsy. And I don't need a doctor to tell me I need to stop smoking and lose weight." [39] Beliefs about consequences (reflective motivation) NHS HCs not always perceived beneficial for early detection Virtually all of the service users (96; 99%) felt that the screening had been of benefit to them, with 29 (30.5%) stating that the screening had identified problems of which they were previously unaware [52].
"I don't think there is an awful lot of value. I think you'll pick up a few people a little bit earlier. Now whether that's worth the cost, obviously it's great for those individual patients, whether that's worth the cost of running a programme like this. I'd be amazed if it was.
" [46] NHS HCs provided opportunity to be proactive about health "I just think it makes you more aware and if you do have any problems you have the chance to actually, you know, be proactive to it rather than reactive when maybe things are a bit too late." [29] Emotion (automatic motivation) Anxiety at receiving high risk result "I got a letter from the doctor's saying 'as you are at a high risk of a stroke or heart attack'...well I nearly died, and I thought 'well what have my results come up as?' And so of course I made an appointment and I went on.
" [26] Reassurance as a motivation to attend "Well in one way it's a reassurance if there's nothing wrong. It's an opportunity to be reminded that you should take care HCPs perceptions of patients understanding of CVD risk Several GPs made the point that the important message to convey to patients was to reduce their risk factors and the accuracy of the figures was less important than this central message [30].
Participants believed that most patients knew what constituted health-enhancing behaviours and the impact of risk behaviours on their health. Therefore, HCPs perceived little need to explain the importance of changing behaviour to patients [17].
HCPs familiarity with guidelines and associated tools 59% had either not heard of (30%) or were very unfamiliar with CMO's PA guidelines [20].
Cognitive and interpersonal skills (psychological capability) HCPs perceived need for training to deliver behavioural support "[Training] would be good. As I say, we just learnt from our healthcare assistant what to do; basically, it was like kind of on the job training… It would be nice to understand it in depth more, wouldn't it?" [28] GPs reported a lack of specific training to implement behaviour change interventions, but some GPs believed that they did not need special training to implement behaviour change interventions. It was viewed as being intrinsic to their medical training [17].
HCP training to communicate risk "You'll have all the staff who may not be aware of what harm they could be doing…So I think the person would have to have the skill to know this patient doesn't wish to know." [19] Memory attention decision processes (psychological capability Behavioural intervention before pharmacological intervention Health professionals thought that patients were more likely to take medication rather than make lifestyle changes to reduce risk, as this was easier [30].
There was a view that as lifestyle change is possible, opting for medication as a first line treatment is not the best strategy [25].
Environmental context and resources (physical opportunity) Limited time/ resources to deliver NHS HC The 10-min consultation was considered too short to perform the risk assessment, give patient-centred lifestyle advice, and fully explain any prescribed medication [19].
Appropriate space to deliver NHS HC "I don't think you come across very professional when you're sitting in a kitchen and all huddled round and all on top of each other. And it's not very nice for the patients, because…quite personal information." [46] Computer systems supporting NHS HC delivery Difficulties with information technology and computer software were mentioned in over half of the studies; 39% of practice managers in one study reported difficulties with the clinical system, software or errors in the existing data [32].
Social influences (social opportunity) Taking account of patients' social context Nurses considered it important to understand people's social context, so that conversations about risk could always be individually appropriate [19].
Ten felt that the nurse/HCA failed to provide tailored advice that took into account their individual capabilities… or their particular circumstances such as availability of recreational spaces and childcare issues [27].
Social/professional role and identity (reflective motivation) Role clarity in delivering NHS HCs Some participants felt advocating for behaviour change was an essential part of their job, which by itself was an enough of an incentive [17].

Diversification of pharmacy staff role
The focus was on the benefits of delivering NHS Health Checks in pharmacies, with all feeling it offered immense job satisfaction, promoted the image of the pharmacy and provided a good opportunity for staff development [46].
Beliefs about consequences (reflective motivation) Belief that NHS HCs were beneficial in terms of preventive healthcare "I think it's a very good idea. We have a very high proportion of our patients who suffer with diabetes, almost 10% of our patients are diabetic so I thought this was an excellent opportunity to screen those earlier and pick them up and then you know be able to do something about it, you know, lifestyle management." [41] "I think really this is mass screening and there's not a great deal of proof behind it…. Not entirely convinced with being told we have to offer a check to everyone." [46] Message framing A frequently reported style was downplaying. Here health care professionals appeared to downplay the individual's high- Table 5 Key domains, themes and illustrative quotes (Continued) Illustrative extract risk score by using phrases such as, 'it is only slightly higher' if the risk score was, for example, between 20 and 25%. As a consequence, some patients concluded that the risk was not particularly significant [26]. One strategy that many described was to concentrate on risk reduction without actually talking to a patient about risk scores explicitly at all. Thus, lifestyle advice and behaviour change were frequently raised not in terms of a patient's cardiovascular risk per se, but in more general terms around the idea of maintaining or improving health [19].
Beliefs about capabilities (reflective motivation) HCP confidence in discussing and initiating behaviour change There is a strong belief in the ability of healthcare professionals to motivate patients to change their lifestyle [25].
Pharmacy staff had also required a lot more training than initially anticipated and, even after being given this support, lacked confidence in delivering the new service [48].
Optimism (reflective motivation) HCPs varyingly optimistic about patient behaviour change after NHS HC There was a clear rejection of pessimism about the possibility of lifestyle change [25].
Even if you access them, even if you find out that they're a really high-risk score then getting these people to take on board you know the lifestyle changes, changes to their diet, exercising more. It's very difficult to get them to take those changes on [28].
Referral to specialist service (HCP) Environmental context and resources (physical opportunity) Lack of funded services to refer patients to Healthcare professionals expressed the importance of making referrals to external lifestyle services to support patients through the behaviour change process, but these services had difficulties with long waiting lists, budget cuts causing the discontinuation of some services and were not always offered at times that suited the working population [17].
Attending referral (patient) Beliefs about consequences (reflective motivation) Regular attendance is important The belief that attending regular appointments would reduce CVD risk predicted adherence to the programme [35].

Patient changing behaviour (patient)
Knowledge (psychological capability) Patient understanding of CVD risk and its implications after NHS HC Two-thirds of patients ...rating their understanding of the CVD risk score highly (4 or above on a scale of 1 to 5, 5 indicating a high level of understanding) [18].
"The conclusion was I have a 6% chance of getting heart disease, which on one hand sounds good because 6 people out of 100, but then if I'm one of those 6 … so I feel very unclear about it. I thought, well how close to 10 is 6?" [40] Environmental context and resources (physical opportunity) Time and cost as a barrier to adherence A number of patients, especially from lower socio-economic groups, encountered barriers in adopting healthy eating, citing the cost of eating fresh fruit and vegetables [27]. Social and material factors were not seen as real impediments to lifestyle change [25].
Adherence to behavioural support influenced by mode of communication of risk A higher proportion [of HCPs] thought that most patients complied with advice received during a consultation with the electronic calculator than the paper risk charts [30].
Social influences (social opportunity) Support from others to change Participants also spoke about the importance of family and friends in supporting the changes they made. The significance of family networks, particularly immediate family relatives, reveals that social ties are an aspect of people's everyday lives that could enable or constrain desired changes in behaviour [50].
Social professional role and identity (reflective motivation) Patient engagement is influenced by HCP role In some interviews, participants discussed how different clinicians influenced the success of behaviour change interventions. Some thought that if the intervention was delivered by a GP it would have a bigger influence on patients. Others argued that patients might be more open and engaged with interventions delivered by nurses and HCAs, due to the ease of the relationship. One manager thought that patients would be more open in community settings rather than with their Illustrative extract healthcare provider [17].
Beliefs about capabilities (reflective motivation) Changes perceived to be achievable For many participants, making small and sustainable changes to their diet by consuming less salt and fat was achievable, as long as it did not cause too much disruption to their daily routines [34].
Beliefs about consequences (reflective motivation)

Contradictory guidelines
People showed reluctance to make changes to their lifestyle, noting that any guidance they were given was likely to be subject to change…. stating that previous guidance about healthy eating suggested that the consumption of eggs should be restricted; then the reverse was promoted [26].
Perceptions of what constitutes healthy behaviour A number of people in this group reported drinking well in excess of the recommended units of alcohol but were unconvinced about how many units were considered harmful:  [45]. Several people chose not to try and lower their cardiovascular risk because they believed death from a heart attack would be preferable to dying from a protracted illness or living into extreme old age: "I am not afraid of death. If I go, I go but I want it to be quick." [26] Optimism (reflective motivation) Fatalistic views about disease "You can be as careful as you want; you can eat as healthily as you want; you can do all the exercise you want and you could still get ill. It is like J's mother who lived to be 101, smoked like a trooper, never had a cigarette out of her hand and she died of something silly." [26] Attending repeat NHS HC (patient) Intention (reflective motivation) Likelihood of attending future NHS HC "I think, well, I eat healthily, you know, and I believe in a healthy lifestyle. I know there are other internal things which could go wrong. But yeah, I would definitely have it again if it came up next week, you know, I didn't realise it was all about different things." [29] Recording NHS HC data (HCP) Environmental context and resources (physical opportunity) Accuracy of recording is compromised by multiple methods of invitation The combination of opportunistic NHS HCs and the delay in time between patients receiving an invitation and attending an NHS HC also caused problems for participants when reporting quarterly data: 'a health check received doesn't correlate for a health check offered [37].       Social support -practical (advise on, arrange, or provide practical help (e.g. from friends, relatives, colleagues, 'buddies' or staff) for performance of the behaviour) Prompts/cues (introduce or define environmental or social stimulus with the purpose of prompting or cueing the behaviour normally occurring at the time or place of performance) Remove aversive stimulus (advise or arrange for the removal of an aversive stimulus to facilitate behaviour change) Restructuring the physical environment (change, or advise to change the physical environment in order to facilitate performance of the wanted behaviour or create barriers to the unwanted behaviour (other than prompts/cues, rewards and punishments) Restructuring the social environment (change, or advise to change the social environment in order to facilitate performance of the wanted behaviour or create barriers to the unwanted behaviour (other than prompts/cues, rewards and Social support -unspecified (advise on, arrange or provide social support (e.g. from friends, relatives, colleagues,' buddies' or staff) or non-contingent praise or reward for performance of the behaviour. It includes encouragement and counselling, but only when it is directed at the behaviour) Social support -practical (advise on, arrange, or provide practical help (e.g. from friends, relatives, colleagues, Salience of consequences (use methods specifically designed to emphasise the consequences of performing the behaviour with the aim of making them more memorable (goes beyond informing about consequences)) Information about social and environmental consequences (provide information (e.g. Table 6 Suggested intervention functions and BCTs to target key themes influencing NHS Health Check behaviours (Continued)  Behavioural practice/rehearsal (prompt practice or rehearsal of the performance of the behaviour one or more times in a context or at a time when the performance may not be necessary, in order to increase habit and skill) Graded tasks (set easy-to-perform tasks, making them increasingly difficult, but achievable, until behaviour is performed) Verbal persuasion about capability (tell the person that they can successfully perform the wanted behaviour, arguing against self-doubts and asserting that they can and will succeed) Focus on past success (advise to think about or list previous successes in performing the behaviour (or parts of it)) Self-talk (prompt positive self-talk (aloud or silently) before and during the behaviour)    Behavioural practice/rehearsal (prompt practice or rehearsal of the performance of the behaviour one or more times in a context or at a time when the performance may not be necessary, in order to increase habit and skill) Graded tasks (set easy-to-perform tasks, making them increasingly difficult, but achievable, until behaviour is performed) Verbal persuasion about capability (tell the person that they can successfully perform the wanted behaviour, arguing against self-doubts and asserting that they can and will succeed) Focus on past success (advise to think about or list previous successes in performing the behaviour (or parts of it)) Self-talk (prompt positive self-talk (aloud or silently) before and during the behaviour) Beliefs about consequences (reflective motivation)     Social reward: If an app/website is tracking patients progress, sending a message of congratulations for any changes made.

Contradictory guidelines
The extent to which patients believe change is achievable Problem solving: In app/website provide a list of common barriers to change and some possible solutions and encourage patient to generate their own, e.g. lack of motivation could be addressed with going to the gym with a buddy.

COM-B: Reflective motivation
Instruction on how to perform behaviour: Provide patients with a list of lines to initiate conversation with a partner about changing diet and tips on how to avoid, e.g. partner being resistance to change.
TDF: Beliefs about capabilities Demonstration of the behaviour: Video of patient talking to their partner about changing diet and negotiating possible barriers. Behavioural practice/rehearsal: Text on website/ app (ideally near video demonstrating talking about change with a partner) encouraging patients to practice with a friend.
Graded tasks: Include text/video conveying that change is more likely if you build on small successes and suggesting how this might be done, e.g. walk for 100 yards a day for the first week, then half a mile a day after they have successfully achieved 100 yards, then two miles a day after they have successfully achieved one mile. Verbal persuasion about capability: Include text/video of a patient who has successful changed their behaviour telling the patient they can also successfully increase their physical activity. Focus on past success: Include text/video encouraging the patient to think of examples where they have successfully changed their behaviour. Self-talk: Include text/video prompting the patient to tell themselves that a walk will be energising.