Public Health in the ED - Better than Cure? RCEM 15

Editor's Notes

1. Intro slide
2. Prior to last general election, healthcare/NHS was consistently top concern for voters. Worried and confused – top worries (5 of top ten published in Telegraph survey Jan 2015 related to health, aging or physical fitness)
3. Health messages are confusing
4. We pay attention to the messages in the media – in fact I might have had better attendance if this had been the title of my talk
5. Are they having an effect? Well… Are we a healthy nation? Good news: younger adults reporting reduced drinking behaviours, reduced smoking behaviours: reduced starting, increased quitting.
6. However: alcohol related deaths remain the same (highest 60-64 years)
7. Proportion of adults with a normal BMI reduced Increasing obesity 1 in 10 children are obese at starting school (though proportions have plateaued)
8. 67% men and 55% women in 2012 met recommendations for aerobic activity; 26% women and 19% men inactive
9. Overall purchases of fruit and veg decreased from 2009-2012 and spending on fats, oils, butter, sugar, soft drinks and beverages
10. 26K paediatric admissions in 2013-2014 (aged 5-9) for dental intervention (increased 14% since 2010)
11. 48K admissions for under 5s related to injury
12. 2013 – 23% of deaths in England and Wales “avoidable” through good healthcare or public health interventions
13. But we’re better than that – aren’t we?
14. The problem is not one of knowledge – we’ve all heard the healthy living messages, yet we choose to ignore them. Why is this, why does it matter to us in the ED and what can we do about it?
15. More bad news – you are not so smart. We are not logical/rational – see Daniel Kahneman. We have lots of inherent biases and many of these serve useful purposes – if you’re a caveman. We, and in that we I include our patients, are bad at making the best decisions for ourselves in all aspects of our lives, no matter how smart we are.
16. Can doctors change patient behaviour? Let’s first think about how change happens. Several models of behaviour change in healthcare – health belief model, theory of reasoned action/planned behaviour, transtheoretical change model What they have in common is recognising that change is personal and multifactorial but that beliefs surrounding susceptibility, self-efficacy, costs and benefits all play a part
17. Our role in behaviour change is as change architects, as described in Nudge (Thaler and Sunstein)
18. Adults and children can be greatly influenced by small changes in context Libertarian paternalism – free to choose (and to make poor decisions if you want) but architectural design aims to make lives better, healthier, live longer
19. Patients trust us: Ipsos MORI conducts an annual survey in the UK and consistently members of the public feel that doctors are more likely to tell the truth than journalists and in fact since their studies began, doctors have been the most trustworthy profession – over newsreaders, the police, the clergy, members of the public, pollsters, NHS managers and politicians.
20. We know that if we tell our patients to stop smoking, there’s an increased chance they’ll do it: Meta-analysis of 28 trials encompassing 40,000 participants: brief advice intervention will increase quit rate by 1-3% http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000165.pub4/abstract
21. So the world is confusing but we have a chance to speak the truth into it. Behaviour change is the holy grail of public health – it’s multifactorial and it’s tricky. We are stubborn beasts.
22. HOW CAN WE INCREASE OUR IMPACT? Influence is unavoidable so let’s harness it
23. Patient opportunities – risk proximity perception (availability) – vivid and easily imagined causes of death often receive inflated estimates of probability as do recently experienced events. Unrealistic optimism may be “nudged” by context. We know this anyway (conversations about antibiotics for otitis media– we tend to say that it is twice as likely that you will develop diarrhoea than that you will have a reduction in pain but patients find this difficult because the pain is real and proximal and the diarrhoea associated with antibiotic use is by no means a certainty – from cochrane review of acute OM in children <12) – but opportunities exist in reverse. If patients believe their unhealthy behaviours have contributed to their ED attendance, this feeds into their motivation to change. There are several factors and concepts that feed into this.
24. Anchoring? When faced with decision making we interpret information in the light of what we know and adjust our thinking accordingly.
25. Framing – choices depend on the way in which problems are stated
26. Social nudges play a huge part in guiding our actions – bandwagon effect. It can be helpful to inform what other people are doing (positive statistics about proportions of people exercising, for example) but if your patient is doing better than average, don’t tell them (they’re likely to reduce their efforts in response)! Social nudging was a huge motivator for my change in lifestyle.
27. Use intention questions – do you intend to…? Thaler and Sunstein call this the Mere-measurement effect – that simply asking if people intend to do a particular thing increases the proportion who take action to do it. This is probably why asking about smoking cessation works – reproduced by Levav and Fitzsimmons in 2006 who performed experiments using framed questions about intentions relating to health behaviours such as flossing and healthy eating. Adding questions about plans to enact these behaviours increases the effect.
28. Feedback on behaviours is an important motivator to change but long-term behaviours rarely receive meaningful feedback. Couple a behaviour with a trip to the ED and the perception that the two are related and the impact is increased (just remember that feedback is about the receiver, not the giver)
29. WHY IS THE ED THE PLACE TO DO THIS? Balance between perceived cost and benefit of behaviour change, skewed if costs are more proximal than benefits. ED attendances may lend themselves well to this particularly if connected to health behaviour in question. “Present-biased preferences” [(Reprinted) JAMA, November 28, 2007—Vol 298, No. 20 2415]. Benefit proximity and risk proximity are great influencers.
30. Mandate from RCEM and DOH – but I want you to change your behaviour so that’s not going to help – I should tell you that every other department apart from yours is doing it 
31. Mandate from RCEM and DOH – but I want you to change your behaviour so that’s not going to help – I should tell you that every other department apart from yours is doing it  Actually its not a complete lie – an article published online at EMA on 7th Sept suggested 70% of consultants and 75% of trainees believed PH initiatives should be provided in the ED.
32. WHERE CAN WE HAVE THE GREATEST INFLUENCE? The list is endless. We can think carefully about how we frame intention questions
33. We can influence the patients attending our emergency departments. Help them to help themselves “want to lose weight? Buy smaller plates, buy smaller quantities of things you like, don’t keep tempting food in the fridge” (mindless choosing, especially eating – we will eat whatever is in front of us peanuts)
34. We can advise all our smoking patients to stop smoking. We could even go as far as putting “smoking kills” signs in resus, which might be a bit far, but what about in the relatives rooms (along with resources for smoking cessation)? Or how about positive messaging there – 3-5% of smokers successfully stop each year?
35. We should ask our patients about seatbelt and cycle helmet use
36. We can educate parents about trampoline dangers and challenge the belief that nets make trampolines safe when that really isn’t the case – most injuries involve multiple children (or adults!) on the same trampoline at the same time. Kids who get hurt tend to be risk takers so we have an important opportunity to educate and prevent further injury.
37. We can help parents and patients make practical sense of healthy eating messages.
38. IF WE CAN HAVE AN EFFECT WITHIN OUR FOUR WALLS, WHAT ELSE CAN WE DO? Wider public health ED link-ins You’ll see opt-in signage on organ donation around most EDs but as members of the public we can also campaign for opt-out organ donation (harness the power of inertia),
39. Your department can actively engage with local public health programmes, like IMPS (which brings school age children into hospitals to educate and reduce anxiety and works with schools to deliver healthy messaging – in Oxfordshire they reach 81% of junior schools and teach 5000 children/year) and the project Phil Hyde is involved with in Southampton which brings children into departmental simulation for the dual purpose of increasing fidelity and changing health perceptions among the children themselves.
40. We as citizens can engage in campaigning; double summer time (estimates in 2010 report benefits in road traffic deaths with a reduction of 2.6-3.4 % per year and its financial implications, as well as reduction in crime, increased energy efficiency, health benefits in the context of increased outdoor activities during winter months, and increased financial benefits in tourism and leisure).
41. Helmets aren’t the only answer – we can campaign for safer dedicated roadways.
42. Put flies in the urinals
43. So, to recap: humans are complex, lazy, short sighted
44. Like it or not, we need to understand that we have influence and that we can use it positively
45. Think about they way your department can help nudge patient decision making in a positive way
46. CHALLENGE TO CHANGE OWN BEHAVIOUR We’re part of the problem – we know we should wash our hands, but we continually perform audits which show we don’t do it (and we are even less likely to do it if we are busy – Muller et al in Academic Emergency Medicine 2015)
47. Live better, work better Role modelling for next generation
48. So I’ll leave you with 2 Questions: Do you intend to think more carefully about public health in your ED? Do you intend to make healthier decisions for yourself, starting now?
49. So I’ll leave you with 2 Questions: Do you intend to think more carefully about public health in your ED? Do you intend to make healthier decisions for yourself, starting now?