Open Access Open Access  Restricted Access Subscription Access

Sustainable Change Sequence: A framework for developing behavior change interventions for patients with long-term conditions

Glyn Elwyn, Katy Marrin, Dominick L Frosch, James White



Interactive interventions are increasingly advocated to support behavior change for patients who have long-term conditions. Such interventions are most likely to achieve behavior change when they are based on appropriate theoretical frameworks. Developers of interventions are faced with a diverse set of behavioral theories that do not specifically address intervention development. The aim of our work was to develop a framework to guide the developers of interactive healthcare interventions that was derived from relevant theory, and which guided developers towards appropriate behavior change techniques.


We reviewed theories that inform behavior change interventions, where relevant to the management of long-term conditions. Theoretical constructs and behavior change techniques were grouped according to similarity in aims.


We developed a logic model that operationalizes behavior change theories and techniques into five steps likely to lead to sustained behavior change. The steps are: 1) create awareness of need; 2) facilitate learning; 3) enhance motivation; 4) prompt behaviour change; and 5) ensure sustainability of behaviour change.

Conclusion and Practice implications

A framework that sequences behavioural change techniques along a sustainability model provides a practical template for the developers of interactive healthcare applications and interventions.


Behavioral medicine, chronic illness, logic model, long term conditions, person-centered healthcare self-management interventions

Full Text:



Chodosh, J., Morton, S.C., Mojica, W., Maglione, M., Suttorp, M.J., Hilton, L., Rhodes, S. & Shekelle, P. (2005). Meta-analysis: chronic disease self-management programs for older adults. Annals of Internal Medicine 143, 427-438.

Murray, E., Burns, J., See, T.S., Lai, R. & Nazareth, I. (2004). Interactive Health Communication Applications for people with chronic disease. Cochrane Database of Systematic Reviews CD004274.

Pearson, M.L., Mattke, S., Shaw, R., Ridgely, M.S. & Wiseman, S.H. (2007). Patient Self-Management Support Programs: An Evaluation. Final Contract Report. AHRQ Publication No. 08-0011, Rockville, MD.

Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A., Sandercock, P., Spiegelhalter, D. & Tyrer, P. (2000). Framework for design and evaluation of complex interventions to improve health. British Medical Journal 321, 694.

Campbell, N.C, Murray, E., Darbyshire, J., Emery, J., Farmer, A., Griffiths, F., Guthrie, B., Lester, H., Wilson, P. & Kinmonth, A.L. (2007). Designing and evaluating complex interventions to improve health care. British Medical Journal 334, 455.

European Journal for Person Centered Healthcare

Michie, S., Johnston, M., Francis, J., Hardeman, W. & Eccles, M. (2008). From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Applied Psychology 57, 660-680.

Mohiuddin, S.M., Mooss, A.N., Hunter, C.B., Grollmes, T.L., Cloutier, D.A. & Hilleman, D.E. (2007). Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease. Chest 131, 446-452.

Tashkin, D., Kanner, R., Bailey, W., Buist, S., Anderson, P., Nides, M., Gonzales, D., Dozier, G., Patel, M.K. & Jamerson, B. (2001). Smoking cessation in patients with chronic obstructive pulmonary disease: a double-blind, placebo-controlled, randomised trial. Lancet 357, 1571-1575.

Wedzicha, J.A. & Vestbo, J. (2012). Can patients with COPD self-manage? Lancet 380, 624-625.

Bodenheimer, T., Lorig, K., Holman, H. & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. Journal of the American Medical Asoociation 288, 2469-2475.

French, S.D., Green, S.E., O’Connor, D.A., McKenzie, J.E., Francis, J.J., Michie, S., Buchbinder, R., Schttner, P., Spike, N. & Grimshaw, J.M. (2012). Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Science 7, 38.

Coleman, K., Mattke, S., Perrault, P.J. & Wagner, E.H. (2009). Untangling practice redesign from disease management: how do we best care for the chronically ill? Annual Review of Public Health 30, 385-408.

Gibson, P.G., Coughlan, J., Wilson, A.J., Abramson, M., Bauman, A., Hensley, M.J. & Walters, E.H. (2003). Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews 1 CD001117.

Effing, T., Monninkhof, E., van der Valk, P., van der Palen, J., van Herwaarden, C., Partidge, M., Walters, E.H. & Zielhuis, G.A. (2007). Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews CD002990.

Vermeire, E., Wens, J., Van Royen, P., Biot, Y., Hearnshaw, H. & Lindenmeyer, A. (2005). Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews CD003638.

Bourbeau, J., Julien, M., Maltais, F., Rouleau, M., Beaupré, A., Bégin, R. et al. (2003). Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Archives of Internal Medicine 163, 585-591.

Moskowitz, D. & Bodenheimer, T. (2011). Moving from evidence-based medicine to evidence-based health. Journal of General Internal Medicine 26, 658-660.

Anderson, L.M.L., Petticrew, M., Rehfuess, E., Armstrong, R., Ueffing, E., Baker, P., Francis, D. & Tugwell, P. (2011). Using logic models to capture complexity in systematic reviews. Research Synthesis Methods 2, 33-42.

Elwyn, G., Marrin, K., Epstein, R., Rollnick, S., White, J. & Frosch, D. (2010). From theories to interventions: the conceptualisation and development of interventions for supporting behaviour change for people with long term medical conditions. Boston, MA: Informed Medical Decisions Foundation.

Bandura, A. (1985). Social Foundations of Thought and Action: A Social Cognitive Theory. New York: Prentice Hall.

Prochaska, J. & Velicer, W. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion 12, 38-48.

Nerenz, D. & Leventhal, H. (1983). Self-regulation theory in chronic illness. In: Coping with Chronic Disease: Research and Applications, (Burish, T.G. & Bradley, L.A., eds.) pp.13–37. Burlington, MA: Academic Press Inc.

Elwyn, G., Frosch, D. & Rollnick, S. (2009). Dual equipoise shared decision-making: definitions for decision and behaviour support interventions. Implementation Science 4, 75-78.

Rollnick, S., Butler, C.C., McCambridge, J., Kinnersley, P., Elwyn, G. & Resnicow, K. (2005). Consultations about changing behaviour. British Medical Journal 331, 961-963.

Abraham, C. & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health Psychology 27, 379-387.

Ngo, V., Hammer, H. & Bodenheimer, T. (2010). Health coaching in the teamlet model: a case study. Journal of Internal General Medicine 25, 1375-1378.

Abraham, C., Kok, G., Schaalma, H. & Luszczynska, A. (2010). Health Promotion. In: Handbook of Applied Psychology, (Martin, P.R., Cheung, F.M., Knowles, M.C., Kyrios, M., Littlefield, L., Overmier, J.B. & Prieto, J. M., eds.), pp. 83-111. Oxford: Wiley-Blackwell.

Healthwise, Healthwise Inc. (2008). Which test should I have to screen for colorectal cancer? 2008; Available at: Accessed: June 5, 2012.

Informed Medical Decisions Foundation, Long-term Conditions Programs. (2012). (Accessed: 1st June 2012 at



  • There are currently no refbacks.