. 2018 Apr 24;8(4):e019906. doi: 10.1136/bmjopen-2017-019906

Table 3.

Characterising the BetterBack☺ model of care intervention content and mechanisms of action using the Behaviour Change Wheel,⁴¹ the BCT taxonomy (V.1)⁴⁴ and the TDF⁴³

Target behaviour	Rationale based on barriers to be addressed	BetterBack☺ MOC content to overcome the modifiable barriers				Mechanism of action
Target behaviour	Rationale based on barriers to be addressed	Mode	Content	BCT⁴⁴	Functions	COM-B	TDF
Improved HCP confidence and biopsychosocial orientation in treating LBP through adoption of BetterBack☺ model of care	1. Low confidence in skills/capabilities for improving LBP patient management. 2. Use of a biomedical treatment orientation rather than a biopsychosocial orientation. 3. Low awareness of the model. 4. Beliefs of negative consequences of the model.	1. Multifaceted implementation strategy—workshop education.	Evidence-based model of care and clinical implementation tools (see online supplementary files 1 and 2).	1.2 Problem-solving	Enablement	Psychological capability	Behavioural regulation
				1.4 Action planning	Enablement	Psychological capability	Goals
				2.2 Feedback on behaviour	Training	Reflective motivation	Behavioural regulation
				3.1 Social support	Enablement	Social opportunity	Social influences
				4.1 Instruction on how to perform behaviour	Education	Psychological capability	Knowledge
				5.3 Information about social and environmental consequences	Persuasion	Social opportunity Physical opportunity	Social influences Environmental context and resources
				6.1 Demonstration of behaviour	Modelling	Psychological capability	Social influences
				6.2 Social comparison	Persuasion	Social opportunity	Social influences
				6.3 Information about other’s approval	Persuasion	Social opportunity	Social influences
				8.1 Behavioural practice/rehearsal	Training	Physical capability	Physical skills
				8.7 Graded task	Training	Physical capability	Physical skills
				9.1 Credible source	Persuasion	Reflective motivation	Reinforcement
				9.2 Pros and cons	Persuasion	Reflective motivation	Beliefs about consequences
				9.3 Comparative imagining of future outcomes	Enablement	Reflective motivation	Beliefs about consequences
				13.2 Framing/reframing	Enablement	Psychological capability	Cognitive and interpersonal skills
				15.1 Verbal persuasion about capability	Enablement	Psychological capability Physical capability	Beliefs about capabilities
		2. Multifaceted implementation strategy—report and website	Evidence-based model of care and clinical implementation tools (see online supplementary file 2)	4.1 Instruction on how to perform behaviour	Education	Psychological capability	Knowledge
		2. Multifaceted implementation strategy—report and website		6.3 Information about other’s approval	Persuasion	Social opportunity	Social influences
Decreased patient LBP and disability, as well as improved patient enablement of self-care	1. Maladaptive beliefs on the cause and course of LBP (illness perception)=low outcome expectation, anxiety, catastrophising, fear avoidance, illness beliefs. 2. Low belief in ability to control pain, low belief in ability to perform activities, low baseline physical activity.	1. BetterBack☺ part 1: individualised information at initial and follow-up visits.	Lay language pedagogical explanation of function impairment and activity limitation-related assessment findings and matched goal-directed treatment.	5.1 Information about health consequences	Education	Psychological capability	Knowledge
				9.1 Credible source	Persuasion	Reflective motivation	Reinforcement
		2. BetterBack☺ part 1: patient education brochure.	Lay language education on the spine’s structure and function, natural course of benign LBP and advice on self-care.	4.1 Instruction on how to perform behaviour	Education	Psychological capability	Knowledge
		2. BetterBack☺ part 1: patient education brochure.		5.1 Information about health consequences	Education	Psychological capability	Knowledge
		3. BetterBack☺ part 2: group education.	Pain physiology, biomechanics, psychological coping strategies and behavioural regulation.	1.2 Problem-solving	Enablement	Psychological capability	Behavioural regulation
				3.1 Social support	Enablement	Social opportunity	Social influences
				4.1 Instruction on how to perform behaviour	Education	Psychological capability	Knowledge
				4.3 Reattribution	Education	Psychological capability	Knowledge
				5.1 Information about health consequences	Education	Psychological capability	Knowledge
				6.1 Demonstration of behaviour	Modelling	Psychological capability	Social influences
				6.2 Social comparison	Persuasion	Social opportunity	Social influences
				8.1 Behavioural practice/rehearsal	Training	Physical capability	Physical skills
				8.2 Behaviour substitution	Enablement	Psychological capability	Behavioural regulation
				9.1 Credible source	Persuasion	Reflective motivation	Reinforcement
				9.3 Comparative imagining of future outcomes	Enablement	Reflective motivation	Beliefs about consequences
				10.8 Incentive (CME diploma)	Enablement	Reflective motivation	Reinforcement
				11.2 Reduce negative emotions	Enablement	Reflective motivation	Emotion
				12.4 Distraction	Enablement	Reflective motivation	Memory, attention and decision processes
				12.6 Body changes	Training	Physical capability	Physical skills
				13.2 Framing/reframing	Enablement	Psychological capability	Cognitive and interpersonal skills
		4. BetterBack☺ part 1: individualised physiotherapy.	Physiotherapist-mediated pain modulation strategies and functional restoration strategies. Treatment matched to patient-specific functional impairment and activity limitations. Individualised dosing.	1.1 Goal-setting	Enablement	Reflective motivation	Goals
				1.5 Review behaviour goal(s)	Enablement	Reflective motivation	Goals
				2.2 Feedback on behaviour	Training	Reflective motivation	Behavioural regulation
				6.1 Demonstration of behaviour	Modelling	Psychological capability	Social influences
				7.1 Prompts/cues	Environmental restructuring	Automatic motivation	Environmental context and resources
				8.1 Behavioural practice/rehearsal	Training	Physical capability	Physical skills
				8.7 Graded task	Training	Physical capability	Physical skills
				9.1 Credible source	Persuasion	Reflective motivation	Reinforcement
				12.6 Body changes	Training	Physical capability	Physical skills
				15.1 Verbal persuasion about capability	Enablement	Psychological capability Physical capability	Beliefs about capabilities
		5. BetterBack☺ part 2: group or home-based physiotherapy.	Patient-mediated self-care pain modulation strategies, functional restoration strategies and general exercise. Treatment matched to patient-specific functional impairment and activity limitations. Individualised dosing.	1.1 Goal-setting	Enablement	Reflective motivation	Goals
				1.5 Review behaviour goal(s)	Enablement	Reflective motivation	Goals
				1.8 Behavioural contract	Incentivisation	Reflective motivation	Intentions
				2.3 Self-monitoring of behaviour (training diary)	Training	Reflective motivation	Behavioural regulation
				2.2 Feedback on behaviour	Training	Reflective motivation	Behavioural regulation
				3.1 Social support	Enablement	Social opportunity	Social influences
				6.1 Demonstration of behaviour	Modelling	Psychological capability	Social influences
				6.2 Social comparison	Persuasion	Social opportunity	Social influences
				8.1 Behavioural practice/rehearsal	Training	Physical capability	Physical skills
				8.7 Graded task	Training	Physical capability	Physical skills
				9.1 Credible source	Persuasion	Reflective motivation	Reinforcement
				12.6 Body changes	Training	Physical capability	Physical skills
				15.1 Verbal persuasion about capability	Enablement	Psychological capability Physical capability	Beliefs about capabilities

BCT, behavioural change technique; CME, continued medical education; COM-B, Capability, Opportunity, Motivation and Behaviour Model; HCP, healthcare practitioner; LBP, low back pain; MOC, model of care; TDF, Theoretical Domains Framework.