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Making behaviour change work in the new world…some thoughts for the Evidence into practice conference

I’m speaking as part of a panel tomorrow at the Evidence into Practice conference to support the implementation of the new NICE guidance on behaviour change.  This has prompted me to work out my thoughts on what we do next, and how the various roles for various players in the system might come together.

Opportunity : events coming together

A number of things are coming together at the same time in the field of behaviour change and behavioural sciences in public health.  Public Health is busy embedding into local government. Academics are busy articulating the evidence base and developing it, NICE have developed new guidance, and Public Health England are busy developing their national role in behavioural insights. The opportunities for the Social Sciences in Public Health are also becoming clearer and growing.  Equally a new book on the impact of the Social Sciences out this month shows the real potential for social science contributions to public health alongside other fields.

Seizing the opportunity for behaviour change to be effective

Jane Roberts and I said I our introduction to the January 2014 British Academy Report on some social science contributions to Health Inequalities that there were “Four key variables and their interplay will be salient in determining whether the opportunity created by the [Health and Social Care] Act and The Marmot Review is realised:

  1. first and foremost, the leadership of elected members for better health (political leadership makes a key difference);
  2. the quality and calibre of public health specialist staff;
  3. the use of existing resources; and
  4. the availability of evidence and guidance which policymakers can use to make policy and deliver programmes.

We have a major opportunity with behaviour change. New evidence, the development of the field of health psychology and the development of NICE guidance as well as the parameters national and local leadership roles in building a policy and commissioning context where behaviour change is effective are becoming clearer.

We need to be clearer on the portfolio of interventions

At the same time, the portfolio of which interventions work for which population is still not clear, and we are still in the process of articulating the range of interventions which can be used, and what they can be used for. To take an example, in Hertfordshire we are:

  • using the Penn State resilience approach to young people’s resilience in schools
  • using a range of behaviour change approaches to individuals including do something different
  • using behavioural approaches in drug and alcohol recovery
  • using behaviour change with speeding drivers
  • using behaviour change in primary and social care

But we know we can do more, and the NICE guidance creates an opportunity for us to join this together into a framework.

Leadership tasks in making behaviour change work

I mentioned above that there is a set of leadership tasks which are becoming clearer on how we use behaviour change, now that the new local government guidance is with us. I see these as follows:

  • NICE – articulate the architecture of standards, structures and policy (what good looks like) for local areas in their new behaviour change guidelines
  • NICE – provide evidence-based guidance on what works
  • Academics – develop evidence on effective interventions and support policymakers in making good policy in light of that
  • Public Health England – share knowledge, articulate a framework of what methods (nudge and other population based work; health trainers and other individual based work) apply to which issues
  • Local Authority Directors of Public Health – integrating these various products, insights and roles to create a joined up framework and delivery at local level.

Health Psychologists can support at all of these levels and help implement the new system using their expertise. (So getting a health psychologist’s expertise into local public health systems as well as national ones – whether by secondment, sharing, employment or training) is important.

A conceptual framework

This leads me to some thoughts about a conceptual and contextual framework for behaviour change in local government.

I: Policymakers and commissioners need a clear Context within which Behaviour Change is used

  1. The epidemiology of the UK is such that behavioural sciences can make a significant contribution to primary prevention of non-communicable disease, secondary prevention especially self-management and resilience and tertiary prevention (e.g. coping skills for breathlessness in heart failure.) Behaviour change needs to be seen within this context.
  1. This contribution is alongside not instead of policy and population measures (like regulation of tobacco etc). Behaviour change is not the answer to our public health challenges. It is a part of the answer
  1. A balanced public health strategy will have interventions at policy, environmental, social, sub-population and individual levels (eg the 6 levels of public health action in the Hertfordshire Public Health Strategy taken from Dettels et al,2009 http://slidesha.re/1e4CVzY )  . A joined up, integrated context means behavioural interventions and behaviour change has a context in which to fit in, and is not expected to be all in all or a magic bullet.

Table1: The Six Levels of Public Health Strategy (from the Hertfordshire Public Health Strategy. Adapted from Dettels et al, 2009)

Levels

Example of how they can be applied –  Tobacco

Social – changing social norms about health, e.g. acceptability of binge drinking, acceptability of taking smoking breaks Behavioural economics, social marketing Young people
Biological – immunisation, vaccinations, treatments Nicotine replacement therapy and cognitive tools for cravings
Environmental – encouraging green transport, reducing pollution, changing the public realm Environmental cues, display legislationSmokefree playgrounds
Individual Behavioural – helping individuals to stop smoking Individual and group behavioural change and support
Legislative –  the smoking ban, legislation on alcohol sales The ban on smokingLegislation on displays
Structural – policy changes such as workplace health, school health policies Workplace policiesTobacco control partnerships

II: Policymakers need Clarity of the aims and uses for Behaviour Change

  1. Behaviour change can be used at population or individual or sub-population levels. Different theories, approaches and methods work for different settings. Policymakers should be aware of this.
  1. Including behavioural science skills (e.g. health psychologists) in your service is essential to get it right . They need links with the academics to keep track of the field. We’ve recognised the need for links between public health practice and academic public health starting with our training and running all through our careers. It’s time behaviour sciences had this parity of esteem.
  1. Behaviour change can target “automatic” cognitive/emotive processes (e.g. choice architecture and also eye position tracking on cigarette package warnings) or conscious deliberative ones (e.g. behavioural skills to negotiate safer sex.) You need to be clear which you are using for what, and why

 

III: Policymakers need Clarity of methods, settings and audiences for Behaviour Change

  1. The experts in the field need to work with policymakers to create a framework or architecture within which local areas can understand and roll out behaviour change strategies and methods. A preliminary attempt at this is below

 A first step at a ready reckoner for behaviour change tools and methods

This is a very first step at a ready reckoner. It’s mean to be used at the stage before you get into things like choosing which actual intervention you use, or useful tools like Susan Michie’s behaviour change wheel, for example.

Table 2: a first attempt at a ready reckoner for behaviour change tools and methods

You can download a powerpoint version of this here

A   ready reckoner for behaviour   change tools and methods

Population   Level

Group   Level

Individual   Levels

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

Choice Architecture

Advertising e.g. change4 life

Nudge

Groupwork for behaviour

Targeted social marketing

Choice Architecture Health   Trainers

Motivational interviewing

Behaviourism approaches

Behaviour change support e.g. Health Trainers

Targeted social marketing

We   still have gaps and   weaknesses in science and tools across all of these

(i.e. the science is still   developing)

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