Behaviour change as part of a public health strategy
www.hertsdirect.org Health Improvement and BehaviourChange: changing professional behaviour to improve the public’s healthJim McManus, CPsychol, CSci, AFBPsS, FFPH,Director of Public Health, Hertfordshire
www.hertsdirect.orgThe ChallengeThe Challenge:Creating conditions in whichindividuals andcommunities have controlover their health and livesand participate fully insociety.New Levers:• Healthwatch – full engagement• Health and Wellbeing structures– local democratic engagement• Public health transfer• Health scrutiny function• Duty to tackle health inequality• NHS Outcomes Framework• Public Health OutcomesFramework• EDS
www.hertsdirect.orgSo what’s the role for health improvementand behaviour change, then?Health Improvement• Structural – policy level• Service – configuration ofservices which meet need, areeasy to access and• Societal – social norms (e.g.The smoking ban)• Interpersonal – coping withpressure to behave in way x• Intrapersonal - the cognitiveand motivational aspects ofperforming in a desired wayBehaviour change• Embed behaviour changecapability in our services tohelp people achieve goals• Set achievable and realisticgoals with people• Motivate and continue support• Helps with maintenance ofdesired behaviour• A key dimension of healthimprovement
www.hertsdirect.orgImportant Context• Behaviour alone will not work, but policyintervention alone is usually not sufficient• Need to work in the context of– Contributors to health outcomes– Lifecourse– Individual behaviour and issues
www.hertsdirect.orgThis means• Can rarely work at an individual level only, orsocietal level only• A plan for intervention needs to understand thevarious dimensions of the issue• Need to work on all aspects at once
www.hertsdirect.orgWhat does Lifecourse mean?• From conception to grave, things influence ourhealth all the time– Lower birth weight – disease in later life– South Asian – genetic risk for diabetes– Readiness for school
www.hertsdirect.orgSmoking 10%Diet/Exercise 10%Alcohol use 5%Poor sexual health5%HealthBehaviours30%Education 10%Employment10%Income 10%Family/SocialSupport 5%CommunitySafety 5%Socioeconomic Factors 40%Access to care10%Quality of care10%Clinical Care20%EnvironmentalQuality 5%Built Environment5%BuiltEnvironment 10%Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute.Used in US to rank counties by health statusWhile this is from a US context it does have significant resonance with UK Evidence, though I wouldwant to increase the contribution of housing to health outcomes from a UK perspective.
www.hertsdirect.orgLife course perspective• A way of looking at life not as disconnected stages, but asan integrated continuum• Suggests that a complex interplay of– biological,– behavioral,– psychological,– and social protective and risk factorscontributes to health outcomes across the span of aperson’s life.• The life course perspective conceptualizes birth outcomes as theend product of not only the nine months of pregnancy, but theentire life course of the mother leading up to the pregnancy.
www.hertsdirect.orgThe Lifecourse impact of health
www.hertsdirect.orgExample: Gaps in school readiness at 3 and 5years by family income: UKAveragepercentilescoreWaldfogel & Washbrook 2008
www.hertsdirect.orgSo what does all that mean?• Macro level – Marmot or Ottawa– Service configuration and commissioning• Tactical level – access and design• Individual Level – Assess and interveneappropriately using behavioural techniques
www.hertsdirect.org• Best start in life – conception, weight, vaccs,imms• Readiness for school• Good Housing• Resilient Childhood, Resilient Adulthood• Into employment and education• Lifestyle in working age• Self management in older ageWork for us all here!
www.hertsdirect.orgIncreasing deprivationTarget health outcomeAmount ofintervention neededto get everyone totarget levelCurrent level ofhealth outcomeHigh level ofdeprivationLow level of healthLow level ofdeprivationHigh level of health
www.hertsdirect.orgYears0 1 5 10 15PlanningEducationVitaminSupplementsAir PollutionDecentHomesJobsPrimaryCare20CVDEventsSelf CareVitamin D and TBRicketsCVD EventsAcute Bronchitis AdmissionsRespiratoryMental Health overcrowding educational attainmentLife ExpectancyHealthier space use Changing culture of activityLife ExpectancyMental Health
www.hertsdirect.org• A strong role for every agency• A need to rethink what the specialists bits ofpublic health have done and what they do infuture – how do we embody this approach?• A need to rethink how we transform all ouragencies into public health agencies• Everyone has a PH role
www.hertsdirect.orgThe upshot of this unless we do something is that2/3 of people will be in chronic ill health or disabilitybefore age 68, the new retirement age
www.hertsdirect.orgAnd Hertfordshire shows the same pattern!
www.hertsdirect.orgWhy lifestyle alone will not eliminate healthinequalities 1• Lifestyle is not sufficient – environment, genetic, lifecourseinfluences• It’s too late for some people – those who have disease already –while lifestyle will help manage disease and health they will needtreatment• It will be ten to fifteen years before lifestyle effects sustainedpopulation change. Meanwhile people will still need treatment• Lifestyle is not enough for some people at high risk – othertreatments are needed to• Some risks are not amenable to lifestyle interventions for (e.g.immunosuppresion; infectious diseases which make up 16% ofBirmingham’s deaths)Healthy lifestyle is necessary but not sufficient of itself for significantReduction of health inequalities
www.hertsdirect.orgSo what are the big ticket issues?
www.hertsdirect.orgBig Ticket Issues• At Population Level– Enable public health professionals to takewhole system action– Enable other professionals to do the same– Configure services with stronger behaviouralelement• At personal level– Put in place the skills to do behaviourchange, even during brief interventions
www.hertsdirect.orgSmoking as an example• At Population Level– Enable public healthprofessionals to take wholesystem action– Enable other professionals todo the same– Configure services withstronger behavioural element• At personal level– Put in place the skills to dobehaviour change, evenduring brief interventions• Tobacco controlpartnership with keyactions• Behavioural supportchange and pathway• Individuals haveability to do behaviourchange
www.hertsdirect.orgIn order to perform a given behaviourone or more of the following must be true:1. The person must have formed a strong positiveintention (or made a commitment) to perform thebehaviour;2. There are no environment constraints that make itimpossible to perform the bahviour;3. The person has the skills necessary to perform thatbehaviour;
www.hertsdirect.orgA simple model for behaviour change1. AssessCriticalFactorsMotivationReadinessAbility &Self-Efficacy2. If they are truly ready thenset achievable goals which:a)Deal with barriersb)Sustain motivationc)Are likely to give themsuccessd)Incremental benefit
www.hertsdirect.orgAudiences along a BehaviourAudiences along a BehaviourContinuum: Possible CommunicationContinuum: Possible CommunicationStrategies – Population or Individual?Strategies – Population or Individual?UnawareAware, concerned,knowledgeableMotivated toChangeTries NewBehaviourSustains NewBehaviourRaise awareness.Recommend a solution.Identify perceived barriers and benefits tobehaviour change.Provide logistical information.Use community groups to counsel and motivate.Provide information on correct use.Encourage continued use by emphasisingbenefits.Reduce barriers through problem solving.Build skills through behavioural trials.Social support.Remind them of benefits of new behaviour.Assure them of their ability to sustain newbehaviour.Social support.
www.hertsdirect.orgSo what do professionals need to do?1. When you design a service, identify thebehavioural outcomes, identify the evidence oftheory for those and identify how you will turnthese into practice – a clear plan or protocol2. When you develop service providers applythis and test3. At service delivery level, understand and applya model of behaviour change which works
www.hertsdirect.org 28For another time – intervention mappingBartholomew, K.L., Parcel, G.S., Kok, G., and Gottlieb, N.H.(2006). Planning HealthPromotion Programs: AnIntervention Mapping Approach(2nd ed). Jossey-Bass: SanFrancisco.
www.hertsdirect.orgSome Reading• Engaging and Retaining Clients in HealthyBehaviour Change, Roy Sugarman (2011)• Health Behavior Change, Pip Mason (2010)• Health Psychology, Jane Ogden (2012)• Formulation and Treatment in Clinical HealthPsychology Ana V. Nikcevic, Andrzej R.Kuczmierczyk and Michael Bruch (6 Jul 2006)