Small choices, big outcomes: Alexandra Caulfield’s reflections on the Health Behaviour Change short course
10 April 2025
Alexandra Caulfield reflects on her experience taking the Health Behaviour Change short course at Oxford, exploring how everyday health choices shape our lives and how behavioural science can be applied in primary care to support positive change.
About the author
Dr Alexandra Caulfield is an Academic Clinical Fellow in Primary Care, and a student on the PGDip in Health Research programme.
The Everyday Impact of Health Behaviours: Small Choices, Big Outcomes
Health behaviours are woven into the fabric of our daily lives, often unnoticed yet profoundly influential. Did you brush your teeth this morning? Take your tablets? Buckle your seatbelt? These actions, seemingly mundane, are small threads in the vast tapestry of health choices we make every day. At times, we become more conscious of them – perhaps wearing a cycle helmet feels urgent after hearing about a friend's accident or a podcast on ultra-processed foods prompts a closer examination of our weekly shop. Whether conscious or automatic, these behaviours shape our health and are shaped in turn by the environments around us.
In primary care, we are particularly well-placed to understand the broader context of our patients’ health behaviours. The Oxford Health Behaviour Change course offers valuable insight into the fields of psychology, philosophy, public health and behavioural science that form the foundation of health behaviour change. Developing the skills to effectively motivate health behaviour change in practice was a driving factor in my decision to take the course.
What Are Health Behaviours?
At their core, health behaviours are any actions that influence our health, either positively or negatively. They can be intentional or unintentional, and are deeply embedded in our social and physical contexts.
Historically, landmark studies like the 1965 Alameda County Survey highlighted the power of personal habits in shaping health outcomes. Researchers identified seven key behaviours which influenced health outcomes:
- adequate sleep
- maintaining a healthy weight
- regular physical activity
- moderate alcohol consumption
- not smoking
- eating regular meals
- avoiding snacking
Fast forward to today, and findings from the Global Burden of Disease study reinforce this: lifestyle choices like managing blood pressure or staying physically active can significantly reduce the risk of disease. Yet, these choices are often unevenly distributed. For example, a 2017 survey revealed that 27% of adults in the most deprived socioeconomic group in England had three or more behavioural risk factors, compared with only 14% in the least deprived group. Health behaviours do not exist in a vacuum – they reflect the broader inequities and barriers people face.
Individual influences on our behaviours include our family and friends, peers, colleagues and healthcare providers. At a societal level, multinational companies, policymakers and the public health sector seek to influence our health behaviours. This influence operates across both physical and virtual landscapes, with social media emerging as a powerful driver of health behaviours in today’s digital age.
What key messages did you take from the course?
Changing behaviour is hard, but understanding why people act as they do is the first step. The challenge lies in identifying what drives a behaviour, then tailoring interventions accordingly. Two key learning points from the course for me were:
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The importance of ‘framing’ in health behaviour communication.
The way health messages are framed plays a crucial role in influencing behaviour, as demonstrated by Tversky and Kahneman’s Framing Effect, which highlights how decisions are shaped more by presentation than by facts. Whilst every situation is different, gain-framed messages, such as ‘quitting smoking saves £2,000 a year’ are generally more effective than loss-framed ones like 'smoking kills'. Gain-framed messaging creates positive emotions, fosters stable attitudes and enhances motivation, while fear-based or loss-framed approaches can evoke anxiety or negativity, potentially leading to demotivation or disengagement.
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The role of ‘nudges’ in shaping healthier behaviours.
‘Nudges’, or subtle changes to an individual’s environment, can encourage healthier behaviours without restricting choice. A classic example? The fly etched into urinals at Schiphol Airport, which improved cleanliness through motivating better aim. In health contexts, nudges might include making healthy snacks more visible in supermarkets or using personalised text messages to remind people of vaccination appointments.
From Insight to Action: Lessons for Primary Care
As healthcare providers, we are constantly seeking ways to improve patient outcomes and empower individuals to take charge of their health. The course provided practical insights to apply to primary care:
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As healthcare providers, understanding the ‘why’ behind a patient’s health behaviour is key.
Personalised conversations – focused on barriers, motivators, and practical solutions – are far more effective than generic advice. Interventions that combine education, reminders and habit-building strategies, delivered in accessible ways (eg by pharmacists or through apps) can help patients make sustainable changes. I will be exploring the why behind health behaviours with my patients; in the right context, a simple question such as ‘why do you smoke?’ may open a conversation which can change a patient’s health for years ahead.
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One critical area where health behaviours have profound consequences is medication adherence.
Up to 50% of medications are not taken as prescribed, leading to poor health outcomes, preventable deaths and significant financial costs – over £300 million annually in the UK alone. Non-adherence isn’t a simple problem with a one-size-fits-all solution. It can occur at various stages: failing to start treatment, skipping doses, or discontinuing medication altogether. People may stop taking their medications for practical reasons like cost or side effects or due to personal beliefs, forgetfulness or a lack of understanding about their condition. Research highlights the importance of tailoring interventions to the individual. The Necessity-Concerns Framework, for example, balances a person’s belief in the need for their medication against their concerns about it. Addressing these beliefs through better communication, shared decision-making and culturally competent care can improve adherence, and is an important goal for primary care.
Would you recommend this course?
The Health Behaviour Change course, led by Dr Nicola Lindson and Dr Angela Difeng Wu, is an invaluable resource for anyone interested in health behaviours. The course combines didactic and interactive teaching to build not only theoretical knowledge but also practical tools to apply in real-world contexts, from primary care to public health and beyond. It has allowed me to develop an evidence-based skillset to motivate health behaviour change in practice
The diverse cohort of participants – spanning nationalities, industries and sectors – sparked enriching discussions about health systems in different local and international contexts. If you’re curious about the science of behaviour change or looking to deepen your understanding of how to influence health behaviours, I would strongly recommend this course.