From behaviour change to public health improvement: re aiming our efforts

1,180 views

Published on

Professor Laurence Moore - Director of the Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow - gave a talk at the University of St Andrews (13/02/2014).

Abstract:

Behaviour change research is largely concerned with the detailed study of individual level behaviour change mechanisms with the goal of identifying interventions which, when delivered in a standardised way to receptive participants, can be highly efficacious in achieving behaviour change. However, translating such interventions into policy and practice is challenging and does not necessarily achieve the desired effects. In this presentation, I will discuss a number of perspectives which illuminate why this might be the case, and identify suggestions for future research. Perspectives will include:

1) Concepts, models and frameworks such as dual process theory, complexity theory and the socio-ecological framework are consistently supported by reviews of effectiveness across diverse behavioural domains in suggesting that many of the critical determinants of behaviour lie outside the individual in the social, environmental, organisational, community, policy contexts within which people live their lives, both by directly influencing behaviour or by more indirectly creating the conditions for behaviour change or reinforcement.

2) As a response to a focus on efficacy, the RE-AIM framework is based on the notion that a research agenda to improve public health might additionally aim to determine the characteristics of interventions / policies / programmes that can: reach large numbers of people, especially those who can most benefit; be widely adopted by different settings; be consistently implemented by staff members with moderate levels of training and expertise; be maintained to achieve replicable and long-lasting effects (and minimal negative impacts) at reasonable cost (Glasgow RE et al Am J Public Health. 2003;93:1261–1267).

Further Info: http://bit.ly/1hSnkbu

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,180
On SlideShare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

From behaviour change to public health improvement: re aiming our efforts

  1. 1. From behaviour change to public health improvement: re-aiming our efforts Laurence Moore MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  2. 2. • Motivations • Frameworks / perspectives • Food – vindaloo, bake-off, masterchef, paella • Key points • Way forward MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  3. 3. Motivations • Frustration with mis-match between • behaviour change science (individual, efficacy, inequalities) • public health policy and practice (complex, upstream, impact) • Observation of risk of continued divergence of • Discipline-led science (reductionist) • Complexity of solutions (holistic, system, interdisciplinary) • Not to be too dull MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  4. 4. Frameworks / Perspectives • • • • • • Dahlgren and Whitehead Socio-ecological theory RE-AIM Complexity theory (complex adaptive systems) Automaticity A focus on change MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  5. 5. The main determinants of health MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  6. 6. Policy debates • Individual level action vs » Macro level policy • Social, Community, Organisational intervention often overlooked • Critical interdependencies between levels often overlooked • Synergistic, multiple actions at multiple levels not prioritised • Search for silver bullet (at best silver pellet) MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  7. 7. Socio-ecological model (Bronfenbrenner, 1979) MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  8. 8. SOCIO-ECOLOGICAL FRAMEWORK (McLeroy et al 1988) Levels of change Approach and target Intrapersonal Individual characteristics that influence behaviour such as attitudes and beliefs Interpersonal Interpersonal and group influences such as social networks and social support, family Organisational Rules, regulations, policies and ethos that may promote or endanger health Community Shared identities, relationships Environment/Policy Policies, advocacy, environments and structures that impact on health MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  9. 9. Evidence base conundrum • Good quality trials successfully conducted, evaluating • Individually-focussed • Highly standardised interventions. Small or zero effect sizes; interventiongenerated inequalities. Even where efficacious, not often translated / reproduced in real world. • Theory-driven, complex, higher- and multiple-level interventions and policies poorly evidenced and continue to be under-evaluated. MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  10. 10. RE-AIM framework Adoption Efficacy Effectiveness Building Programs and Policies with a Large Public Health Impact Reach Implementation Maintenance 10 MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  11. 11. RECOMMENDED PURPOSE OF TRANSLATION/EFFECTIVENESS RESEARCH To determine the characteristics of interventions / policies / programmes that can: • Reach large numbers of people, especially those who can most benefit • Be widely adopted by different settings • Be consistently implemented by staff members with moderate levels of training and expertise • Produce replicable and long-lasting effects (and minimal negative impacts) at reasonable cost Glasgow RE et al Am J Public Health. 2003;93:1261–1267 MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  12. 12. MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  13. 13. Cynefin framework MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. (Snowden and Boone, 2007)
  14. 14. Simple, complicated, complex… Simple Complicated Complex Flat pack furniture Rocket to the moon Raising a child The components and instructions are essential Formulae are critical and necessary Formulae have limited application. Adaptation and flexibility are key If all the bits are there and instructions are followed in order, the result is consistent Sending one rocket to the moon increases assurance that the next will be okay Raising one child provides experience but no assurance of success with the next No particular expertise is required but helpful to be good with an allen key High levels of expertise in a variety of fields are necessary for success Expertise can contribute but is neither necessary nor sufficient Produces standardised furniture Rockets are similar in critical ways Every child is unique and must be understood and responded to as an individual The designed furniture will be reproduced There is a high degree of certainty of outcome Uncertainty of outcome remains MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. Adapted from Rogers, 2008
  15. 15. Complexity theory A system is said to be complex (as opposed to simple or complicated) when: • It is composed of many elements which interact dynamically, and non-linearly. • The behaviour of the system as a whole cannot be predicted from, or reduced to, the parts of the system in isolation. • Volition, or agency, can come to be understood as a phenomenon of relationality, rather than being assumed to be originary [viz. automaticity] • New focus for “interventions” – create conditions for change MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. From Robin Durie
  16. 16. Automaticity……dual process theory • • • • Deliberation v automaticity Reason v reaction Reflective v habitual Slow v fast • Deliberative, reflective, reasoned behaviour represents a small minority of all behaviour • Majority of behaviour is automatic, reactive, habitual • Need to stop reliance on targeting reflective processes • Need to alter environments (physical, [social, cultural, economic, media, policy]) • Or target automatic associative processes (priming) MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. Marteau et al 2012, Kahneman 2011, Neal et al 2006
  17. 17. A focus on change • Discipline-led focus on measuring, understanding, explaining behaviour • Psychology • Sociology • Epidemiology • Economics, organisational science, anthropology.. • May provide great insights in understanding behaviour • Not necessarily useful in delivering behaviour change MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  18. 18. Phases of RCTs of complex interventions: MRC April 2000
  19. 19. A focus on change • Discipline-led focus on measuring, understanding, explaining behaviour • Psychology • Sociology • Epidemiology • Economics, organisational science, anthropology.. • May provide great insights in understanding behaviour • Not necessarily useful in delivering behaviour change • Interdisciplinary problem / solution driven is required • Focus on sustained change and all aspects of REAIM MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  20. 20. Evidence base conundrum • Good quality trials successfully conducted, evaluating • Individually-focussed • Highly standardised interventions. Small or zero effect sizes; interventiongenerated inequalities. Even where efficacious, not often translated / reproduced in real world. • Research methods and applied interdisciplinary research groups to develop sophisticated interventions that can achieve impact at scale • Theory-driven, complex, higher- and multiple-level interventions and policies poorly evidenced and continue to be under-evaluated. MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  21. 21. Examples • FFIT (Wyke et al Lancet 2014) • Core programme materials informed by BC theories • Organisational context for delivery – football club • Gender specific throughout, with clear targeting (SES, BMI) • Social support, common bond of club • Effective and strong on all REAIM dimensions • ASSIST school based smoking prevention (Campbell et al Lancet 2008) • Core programme materials informed by BC theories • Identified most influential pupils • Who spread information, norms through social networks • Didn’t depend on curriculum time, teacher delivery • Quality assured licensing of external trainers MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  22. 22. Population impact of hypothetical BCI 0.15 Behaviour is reflective 0.33 Relative risk reduction 0.2 Target population reached 0.2 Adopted by x% of Local Authorities 0.7 Fidelity of implementation MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  23. 23. Population impact 0.15 Behaviour is reflective 0.33 Relative risk reduction 0.2 Target population reached 0.2 Adopted by x% of Local Authorities 0.7 Fidelity of implementation 0.0014 0.14% MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  24. 24. Population impact 0.15 Behaviour is reflective 0.05 0.33 Relative risk reduction 0.1 0.2 Target population reached 0.1 0.2 Adopted by x% of Local Authorities 0.1 0.7 Fidelity of implementation 0.5 0.0014 0.000025 0.14% 0.0025% MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  25. 25. Reliance on individual focussed BCIs MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  26. 26. As much impact as a strand of cress in a vindaloo MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  27. 27. MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  28. 28. State responsibility for health and wellbeing The success or failure of any government in the final analysis must be measured by the well-being of its citizens. Nothing can be more important to a state than its public health; the state’s paramount concern should be the health of its people. Franklin D. Roosevelt • If research agenda and evidence base is dominated by interventions that target the individual, those responsible for the environment / context / conditions for change get off the hook. MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  29. 29. Ingredients? • Flour, eggs, fat, milk, sugar • Bake-off cakes • Pancakes • Yorkshire pudding • Pastry • Bread…………………… • Masterchef • Standard ingredients challenge • Hugely varied dishes produced MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  30. 30. Recipes are key [theories] • • • • • How the ingredients are brought together And delivered Consistently Cost effectively At scale • Not a fantastically complex recipe • Greggs! • M&S ready meal MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  31. 31. Recipes for sustained behaviour change at scale • Can still develop focused understanding and action, but recognise that it is just one ingredient? • Look outward, interdisciplinary • Look to the complex real world and less to the clean laboratory • Look upstream • Look at behaviour change rather than simply behaviour • Understand and tackle processes, contexts, conditions that determine population impact MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  32. 32. Theory • Theory of the problem • Causal processes • Intervention theory • Key components and their impact [logic model] • Program (implementation) theory • How will the intervention bring about change, interact with context, setting, system MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  33. 33. Transdisciplinary solutions! MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  34. 34. Variations • • • • Seafood paella Vegetarian paella Valencian paella Mixed paella • Select the right disciplines / team for the purpose MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  35. 35. Making it happen • What is the sofrito? (onion, tomato, garlic) • How to facilitate the combination of ingredients to create a satisfying meal? • How to facilitate cross-disciplinary working to tackle applied issues? • ..the rice…. • How to provide substance and glue to the meal / collaboration? MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  36. 36. From disciplines to solutions… …laboratory to policy • Ingredients to recipes • Reductionist to big picture • Explanation to intervention • Engage in interdisciplinary / transdisciplinary work • Or at least understand dependencies on other disciplines / levels – contextualise • Work with policy, practice, public partners throughout • Focus on not just efficacy / effectiveness, but reach, adoption, implementation, maintenance • More paella, less cress MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  37. 37. Thank you……what’s for dinner? MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
  38. 38. • • • • • Marteau TM et al. Changing Human Behavior to Prevent Disease: The Importance of Targeting Automatic Processes Science 21 September 2012: Vol. 337 no. 6101 pp. 1492-1495 DOI: 10.1126/science.1226918 Kahneman D. Thinking, Fast and Slow. Penguin Books Neal DT et al (2006) Habits- a repeat performance https://dornsifecms.usc.edu/assets/sites/208/docs/Neal.Wood.Quinn.2006. pdf Rogers P. Using programme theory to evaluate complicated and complex aspects of interventions. Evaluation 2008 14(1) 29-48 http://www.rismes.it/pdf/rogers_complex.pdf Snowden DJ Boone ME A leader’s framework for decision making. Harvard Business Review (2007) http://www.mpiweb.org/CMS/uploadedFiles/Article for Marketing - Mary Boone.pdf MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.

×