This document was produced for a Webinar for the Association of Directors of Public Health (ADHP www.adph.org.uk ) on 27th April 2017 in partnership with Public Health England (PHE www.gov.uk/phe) Hertfordshire County Council (www.hertfordshire.gov.uk) and the Health Psychology in Public Health Network (HPPHN www.hppn.org.uk ).

1. The Application of Behavioural
Science to Public Health
ADPH Webinar
Prof Jim McManus Hertfordshire County Council
Dr Angel Chater University of Bedfordshire
Dr Tim Chadborn PHE Behavioural Insights Team
Dr Amanda Bunten PHE Behavioural Insights Team
Michelle Constable Hertfordshire County Council

2. Objectives
Gain an overview of behavioural science.
Understand relevance and applicability of behavioural science in
public health.
Gain awareness of the Behavioural Science Strategy development
and relevance to ADsPH.
2

3. Timings
Time Description Presenter
11.00 Introductions and welcome Prof Jim McManus
11.05 Setting the scene Dr Tim Chadborn
11.10 Current directions in behaviour change theory Dr Angel Chater
11.20 Examples of the application of behavioural science Dr Amanda Bunten
11.30 Embedding behavioural science in Public Health Michelle Constable
11.40 Overview of the Behavioural and Social Science Strategy Dr Tim Chadborn
11.45 Respond to questions submitted All
12.00 Close Prof Jim McManus
3

4. What are the
facilitators and
barriers to the
uptake of weight
management
services?
How can we
design the
built/ lived
environment
to influence
health-related
behaviours?
Typical questions from policy teams
What are the drivers
of the provision of
brief advice to
patients by healthcare
professionals?
4

5.  Draws on insights from psychological research; primarily
behavioural economics and health psychology
 Can be applied at the individual, professional, community or
population level
 Used upstream and downstream in prevention and treatment
 Central role of robust evaluation to demonstrate effectiveness
 Small changes can have widespread impact
 Previous behaviour is best predictor of future behaviour
– not intentions or beliefs
Behavioural Science
5

6. 6
Behavioural ‘Definitions’
Behaviour is anything a person does
in response to internal or external events.
(Hobbs, Campbell, Hildon & Michie, 2011)
Behaviour should be differentiated from its
determinants (self-efficacy, emotion) and its
outcomes (quality of life, cholesterol level).

7. Traditional Theories of Behaviour
• The Health Belief Model – Becker (1974) Importance of beliefs, perceived benefits &
barriers to action, self-efficacy, stimulus/ cue to action. Limitations: focused on
conscious decision making and ignores habits.
• Social Learning Theory, Social Cognitive Theory – Bandura (1977) Importance of
social environment, modelling and self efficacy Limitations: emphasis on conscious
decision making and reflective processes
• Theory of Reasoned Action / Theory of Planned Behaviour – Ajzen (1985)
Limitation: assume people act in a rational way at all times, not all behaviour is
planned.
• Stages of Change Model / Transtheoretical Model – Prochaska and DiClemente
(1997) Limitation: assumes behaviour change occurs in a linear fashion, progression
through a series of stages.
Limitations:
• Effectiveness of predicting behaviour change
• Intention-behaviour gap
• Not addressing automatic motivation, habits and impulsive behaviour.
Public Health England - Behavioural Insights MasterclassPublic Health England - Behavioural Insights Masterclass7

8. “..this review suggests that intentional
control of behaviour is a great deal
more limited than previous meta-
analyses of correlational studies have
indicated”
Changing Behaviours:
The limitations of changing minds
“Changing behaviour by changing
minds is unscaleable, increases
inequalities, not very effective”
(Professor Theresa Marteau)
(Slide adapted from one by Theresa Marteau)8

9. Resist Environments Change Environments
Change minds to…
(Slide adapted from one by Theresa Marteau)
Before After
Changing behaviours:
Two (not mutually exclusive) approaches
9

10. Two interacting systems
Dual Process Theory
Reflective
Slow
Effortful
Self-aware
Complete a tax form
17 x 24
Automatic
Fast
Effortless
Unconscious
Driving on an empty road
2 + 2
Kahneman, D. (2011). Thinking, fast and slow. Macmillan.
10

11. Health Psychology

12. Health Psychology and Behaviour Change
• The science of human behaviour and experience
• Aims to:
• Promote and maintain health
• Enhance the well-being of those affected by illness
• Improve the health care system and support health
policy formation
• Understanding how people think, feel and learn
can help us understand and predict how they will
act
If we can UNDERSTAND human behaviour, it
gives us insight into how to CHANGE human
behaviour
At the heart of behaviour [change] is the
person…
Bio-Psycho-Social Model
(Engel,1977,1980)
Strength of Health
Psychology lies in the
application of theoretically-
driven, evidence-based
science
Behavioural Science
12

13. Importance of Theory
• Key questions to ask when developing interventions
(individual, community or population based levels):
1. What things should be considered when trying to
understand and change behaviour?
• What bio-psycho-social factors might be important?
2. What factors might influence uptake/engagement?
• What barriers/ facilitators might influence behaviour?
• Must move away from ‘common sense’ models of
behaviour change and draw on theory
Imagine you wanted to change physical activity behaviour
in an obese population to reduce diabetes and CVD risk…
What would you need to consider?? Hold that thought…
13

14. Now imagine a population of
Homer Simpsons!
Theory: COM-B
Capability
Motivation
Opportunity
Behaviour
Problem = Obesity
Target behaviour = Physical Activity
(Michie et al., 2011)
14

15. Behaviour
Capability
Psychological capability
Physical capability
Motivation
Reflective motivation
Automatic motivation
Opportunity
Social opportunity
Physical opportunity
Amore holistic model of
behaviour change – COM-B
 Capability, motivation and opportunity all need to be present for a behaviour to occur
 They all interact as part of a system
 Motivation must be stronger towards the target behaviour than competing behaviours
(Michie et al., 2011)
15

16. COM-B model
components
Definition
Psychological
capability
Knowledge, psychological skills (such as planning, attention,
strength and stamina) to engage in the necessary mental
processes (interpersonal skills, memory, attention, decision
processes).
Physical capability Physical skills, strength or stamina
Reflective motivation Active thought processes – attitudes and beliefs about what is
good or bad, the costs and benefits of doing something,
beliefs about consequences, goals, plans, and intentions.
Automatic motivation Less conscious thoughts processes that drive behaviour -
emotional reactions, desires (wants and needs), impulses,
drive states, habits, reinforcement, associative learning and
reflex responses.
Social opportunity Opportunity afforded by the social environment, social cues
and cultural norms, social acceptability and expectations.
Physical opportunity Opportunity afforded by the environment involving time,
resources, locations, cues.
16
(Michie et al., 2011)

17. Behavioural Economics

18. Standard Economic
Theory
• Consistently rational
(not emotional)
• Self-interested (not
altruistic)
• Utility maximisers
(the greatest amount
of value possible for
the budget)
• Takes the optimal
route to achieve
goals
• Subject to biases
• Subject to irrationalities
• Use heuristics (shortcuts) to
make decisions
• Context and time
dependent
(inconsistent)
• Emotional
‘Homo-economicus’ In reality
Behavioural Economics
18

19. 19
Heuristics
Mental shortcuts or rules of
thumb to aid in problem solving
Cognitive Biases
Systematic thinking errors that
affect decisions and judgement
Anchoring
Availability
Loss Aversion
Status Quo

20. How can Behavioural Science be Utilised?

21. 21
Defaults
We tend to ‘go with the flow’ of
a pre-set option
Salience
Our attention is draw to what
is novel and appears relevant
to us
Substitution
Easier to substitute a
behaviour than eliminate an
entrenched one
We are expecting you
at St Barts Hospital on
Sep 26 at 2.30. Not
attending costs NHS
£160 approx. Call
02077673200 if you
need to cancel or
rearrange.

22. What can it do for you?
 Help to achieve local and national public health outcomes
 Provide theoretically-driven, evidence-based programmes
 Provide low cost ways of enhancing existing systems or
processes
 Improve the effectiveness of delivery and outcomes of
training
 Provide rigorous, scientifically led evaluations
22

23. Analyse Advise Design Trial Train
 Behavioural
Analysis
 Policy  Interventions  RCTs  Masterclasses
 Literature
review
 Systematic
review
 Programmes
 Communication
 Mode of
delivery
 Programmes  Quasi-
experimental
studies
 Evaluation
 Qualitative
research
 Workshops
 Seminars
How can Behavioural Experts help?
Translation of evidence into practice

24. Building the Evidence

25. Health Checks
Increasing uptake of NHS Health
Checks
Health issue: Diabetes, CVD (heart attack and stroke), Kidney Disease and Dementia
Behavioural target: Increasing uptake of NHS Health Checks
Method: Altering the standard invitation letter and sending SMS messages
25

26. Control Treatment
DH led trial
NHS Health Check
You will receive a letter
about your NHS Health
Check.
Your NHS Health Check
is due tomorrow at
13.30.
vs.
+
Primer
Reminder
26

27. NHS Health Check: Results
18%
30%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Standard letter and no texts Revised letter and primer and prompt
messages
Percentage uptake of NHS Health Checks
All reported results are statistically significant at p< 0.05 level.27

28. Antimicrobial Resistance
Reducing inappropriate antibiotic
prescribing
Health issue: Antimicrobial resistance
Behavioural target: Reducing inappropriate prescription of antibiotics in primary care
Method: Letter sent to the top 20% GP prescribers
28

29. AMR
29
“The great majority
(80%) of practices in
INSERT NHS AREA
prescribe fewer
antibiotics per head
than yours.”

30. 30
Reduction of 3·3% in top 20% - equates to 0.83% across all GPs
Estimated 73,406 fewer antibiotic items dispensed
Cost of £4,335 - saving £92,356 in just prescription costs
Quality Premium allocated up to £23m to reduce prescriptions by 1%
2014 2015
Letter reduced
prescriptions
Letter
Letter reduced prescriptions
in control group
Rateofantibioticsdispensedper1,000weightedpopulationforstudyperiod,with95%CI
AMR: Results
Hallsworth, M., Chadborn, T., Sallis, A., Sanders, M., Berry, D., Greaves, F., Clements, L. and
Davies, S.C., 2016. Provision of social norm feedback to high prescribers of antibiotics in general
practice: a pragmatic national randomised controlled trial. The Lancet, 387(10029), pp.1743-1752

31. Food Environment
Encouraging Healthy Food and Drink
Purchasing
Health issue: High rates of obesity
Behavioural target: Make the Healthy choice the Easy Choice
Method: Product placement and pricing promotions on sales of food and drink within 3
NHS food environments
31

32. Three studies of choice architecture
32
Sales of water by 22 bottles a day
Proportion of total water sales by
12%
23% in confectionary sales
63% in water and 67% in
fruit sales
No effect on crisps 12%
Approx reduction of 14
kcals per drink

33. Embedding Behavioural Science
in Public Health

34. NICE Guidance
Public Health commissioning - lifestyle factors
NICE Guidance PH6, PH49 and LGB7
o Develop a local behaviour change policy and
strategy
o Commission interventions at population,
community, and individual levels
o Embed behaviour change all programmes from initial planning to
evaluation
34

35. National Developments
Health Psychology in Public Health Network
o Network launched in 2014 to build on the synergy between
health psychology and public health agendas.
 Behavioural Sciences Strategy for Public Health
o Strategy for all public health organisations being developed by a
range of partners: ADPH, PHE, HPPHN, FPH, LGA, BPS
 Campaign for Social Sciences – The Health of People
o Launched in 2017 - How the social sciences can improve
population health
35

36. Local Opportunities
Explore shared agendas
Different approaches to embedding behaviour change in
England
oJointly funded posts – Warwickshire
oEmploy a behaviour change specialist – Herts, Solihull
oFund a PhD
oInterns, MSc & PhD training placements, secondments
oDiscrete pieces of research for MSc or Doctoral
students
oCommission research, consultancy, training
oJoint funding bids
oAcademic evaluations
36

37. Interventions and Collaborations
37
Hertfordshire – Active Herts
 Joint Sport England funding bid – PH, CCGs,
Herts Sports Partnership
 Systematic review (Howlett et al. 2016)
 Evidence based intervention developed
 Behaviour Change training for those delivering
interventions
 Academic evaluation of behaviour change
constructs, level of activity, wellbeing and fidelity

38. Interventions and Collaborations cont.
38
Hertfordshire Health Improvement Service
 Stop Smoking Service delivering weight management
intervention
 Health Psychologist input:
o Development of service spec.
and evaluation of bids ensure behaviour
change embedded in intervention
o Developing training plan including
behaviour change
(Dixon & Johnston 2011)
o Comprehensive evaluation framework

39. ABehavioural and
Social Sciences Strategy

40. 40
Proposal
• develop a framework strategy for maximising
the contribution of behavioural science to the
protection and improvement of the public’s
health and wellbeing in England;
• with a particular focus on enhancing the
effectiveness of public health interventions
and reducing health inequalities through
better application of behavioural science.

41. 41
Toward a behavioural sciences strategy
for public health and wellbeing in
England
A prospectus for conversation
and development
February 2017
Conversation Event – Fri 17th March 2017

42. 42
Potential objectives
1. Enhanced pre-service curricula
2. Strengthened in-service training
3. Guidance on approaches and frameworks
4. Inclusion in governance processes
5. Improving access to evidence
6. Capacity through networks and procurement
7. Community of evidence and practice
8. Advise on research priorities

43. Questions and Next Steps

44. Further learning opportunities
Health Psychology in Public Health Network: http://www.hpphn.org.uk
Online training http://www.bct-taxonomy.com/
Teaching, training & events http://www.ucl.ac.uk/behaviour-change
Public Health England’s Behavioural Insights Masterclasses: Tim.Chadborn@phe.gov.uk
Behavioural Economics Seminars at the London School of Economics
http://www.lse.ac.uk/LSEHealthAndSocialCare/events/BehavioralEconomicsSeminars.aspx
Behavioural Economics Events http://be-events.org/
Campaign for Social Sciences: YouTube: The Health of People: Part 2
Recommended Reading
Chater, A. & Cook, E. (2014). Health Psychology. London: Pearson.
(Chapter 3, Intervention Design: Changing Health Behaviour.)
Kahneman, D. (2011). Thinking, fast and slow. Macmillan.