Wellbeing and Health Partnership – Executive Group

Transcription

Wellbeing and Health Partnership
Healthy Lifestyles Strategic Board
Meeting to be held 3 March 2011, 1pm – 3pm, A Committee Room, Civic
Centre
Helen Wilding, Wellbeing and Health Partnership Coordinator
Contact Officer:
Tel: 0191 211 6461
Email: [email protected]
M Khaw, H Lamont, D Robinson, D Tabari, H Golightly, J Adams,
Membership:
T Durcan, C Drinkwater, one VCS rep to be confirmed
J. MacMorran, H. Pearson, J Fraser, D Stobbs
In attendance: H Wilding, L Robinson
AGENDA
Time
Item
1.
1.00
Introductions and Apologies for Absence
2.
1.10
Theories and Practice of Behaviour Change
Lead
Paper
For
FS
Presentation
Discussion
JF
verbal
Information
NICE Behaviour Change Guidance
Applying behavioural insight to health
3.
1.55
Update: Sexual Health Group
(key questions: what can we do to enable
this work? How can learning from this topic
be transferred to other areas?)
4.
2.10
Family based interventions
5.
2.25
What’s new?



Page 1 of 2
Research and data
Policy and guidance
Conference opportunities
and
Discussion
DR
information
6.
2.40
‘Hot topics’ round robin
7.
2.50
Minutes of meeting held 13 January 2011
8.
2.55
AOB
9.
3.00
Date and Time of Next Meeting:
28 April, 1pm – 3pm
Page 2 of 2
Information
Wellbeing and Health Partnership
Healthy Lifestyles Strategic Board
Meeting held on 13 January 2011, 1pm – 3pm, Swan Room, Civic Centre
Minutes
Item No Item
1.
Action
Present:

Meng Khaw, Acting Director of Public Health for Newcastle
(Chair)

Frances Blackburn, Newcastle Hospitals NHS Trust

Judith MacMorran, Smoke Free Newcastle

Dr Jean Adams, FUSE/University of Newcastle

Roger Mould, NCVS

David Stobbs, Eat Well Group

Chris Drinkwater, Healthworks Newcastle
In attendance:

Helen Wilding, Wellbeing and Health Partnership Coordinator

Emma Burton, Administrative Assistant (Minute Taker)

Naomi Warne, PA to Director of Public Health

Claire Horton, NCC

Sarah Cowling, Healthworks Newcastle
Apologies:
Page 1 of 3
2.

Tony Durcan, NCC

Dianne Tabari, Newcastle & North Tyneside Community Health
Health Literacy:

Introduction and overview of discussions at WHO Subnetwork
meeting
 What does this mean for the future?
 What should we do differently?
2.1
3.
CH referred to the Health Literacy report giving the board background
information discussions took place and the following points were
made:

The work of Healthworks is a local example of improving health
literacy

There is a link between health literacy and Social Marketing which
we discussed last time

The groups discussion identified 3 different dimensions – Health
Literacy with respect to using health and social care systems;
health literacy with respect to own lifestyles; health literacy with
respect to understanding and influencing all the factors that
influence your health
Update: Eat Well Newcastle
(key questions: what can we do to enable this work? How can
learning from this topic be transferred to other areas?)
3.1
DS gave the board an update of the newly emerged Eat Well group
which have recently met and elected a Chair. This group will initially
meet every six weeks then moving to quarterly and report to The
Healthy Lifestyles Board. A sub-group will develop the JSNA for The
Eat Well group and this will act as a strategy to help develop the action
plan. It was agreed The Healthy Weight Group report to the Eat Well
Group and link in with Active Newcastle. The group will report to the
Healthy Lifestyles Board.
4.
What’s new?

Research and data

Policy and guidance
 Applying behavioural insight to health
 Public health outcomes framework

Page 2 of 3
Conference opportunities
 Core Cities collaborative Birmingham 31 January
4.1
The Chair informed the board that he had recently met with Mima
Catton to discuss academia or service organisations; it was suggested
to join this up with FUSE. Meng is initiating this and will keep the board
informed.
Action: JB to take back to FUSE to suggest
4.2
Helen referred to the Applying behavioural insight the health document
which was added to agenda for information. Action: It was agreed to
put this on forward plan and include an invite to a health psychologist
4.3
The board were asked to read the information handout provided on
proposals for public Health outcomes framework and report back with
any comments, it was noted we need to rely on other mechanisms to
get information so we can take forward in a smart way.
5.
‘Hot topics’ round robin
5.1
The group were notified ‘No Smoking Day will take place on 9 March
2011 a briefing session has been arranged jointly with North Tyneside
on 4 February. The Board were asked to encourage people to join the
event.
6.
Minutes of meeting held 25 November 2010
6.1
Minutes from the meeting were largely agreed, The Chair referred to
action 2.3 this action is still outstanding. HW to chase up response
from CL
7.
AOB
7.1
CD referred to the Transitional funding of preventive activities in local
communities handout and asked The healthy Lifestyles Board to
support a recommendation that lead commissioners for the Local
Authority and the NHS including GP Consortia and public health
convene an early meeting with Healthworks and the joining Dots
Project to explore a pooled approach to transitional funding of the
preventive element of this programme for the year 2011/12.
Meng welcomed issues raised for discussion but ultimately said that
commissioning decisions cannot be made at this forum.
8.
Date and time of next meeting:
3 March 2011, 1pm – 3pm
Page 3 of 3
JB
HW/JA
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Behavioural Insights Team
Foreword
Many of the most pressing public policy issues cannot be addressed without
thinking about the behaviour of individuals. Behavioural science and
behavioural economics show us that, very often, we do not behave in a way
that we would be expected to if we were perfectly ‘rational’ human beings.
Many of us still have not insulated our lofts, despite the fact that doing so will
reduce our energy bills; we very rarely switch our bank accounts, despite the
fact that we may benefit from higher saving rates elsewhere; and we may not
yet have committed to becoming an organ donor, despite the fact that the
majority of us would be willing to do so if asked.
This paper shows that, by understanding how people react and behave in
different situations, we can design policy to go with the grain of how people
behave rather than against it, both improving outcomes and respecting
people’s autonomy. Improving the health of citizens and communities is a
clear case of where we need to apply this type of thinking. Prompting people
to become organ donors when they register for a driving licence is a great
example of this – and one that will ultimately save lives.
This is not a traditional government document. In many ways it reflects a
new approach, which is as much about government working in partnership
with others as about announcing new policies from Whitehall. An example
of this is the work on smoking cessation, the result of a partnership between
the Behavioural Insights Team, Department of Health and Boots, which will
test new ways of encouraging people to make more effective quit attempts.
This paper contains numerous other examples, which are designed to help
ministers and officials to develop policy that is less intrusive, imposes fewer
costs on business and society and is often more cost-effective than traditional
regulatory or legislative interventions.
One of the key points made in the recent Public Health White Paper is to
give local communities the capacity and confidence to try out and evaluate
the kinds of approaches illustrated by this paper. We therefore hope that
the fresh approach this document brings will spark new ideas and innovation
across our local communities.
Anne Milton
Parliamentary Under Secretary of
State for Public Health
Oliver Letwin
Minister for Government Policy
Applying behavioural insight to health
Summary of contents
Introduction
This sets out the importance of behaviour in policy making, the role of the Behavioural
Insights Team in the Cabinet Office and how behavioural science insights can be applied
to health using the MINDSPACE framework.
Case studies
1. Smoking: drawing on commitment and incentive devices, we are launching a new
smoking cessation trial with Boots.
2. Organ donation: we are introducing a trial of ‘prompted choice’ for organ donation,
which we believe will significantly increase the number of donor registrations.
3. Teenage pregnancy: how teenagers who mentor toddlers are significantly less likely
to become teen parents themselves.
4. Alcohol: Welsh universities will be trialling new methods to encourage students to
drink less alcohol using social norm techniques.
5. Diet and weight: we will be establishing a partnership with LazyTown, the popular
children’s TV show, which will encourage healthier behaviour in children.
6. Diabetes: new devices are helping children to manage their conditions in ways that
are practical and fun.
7. Food hygiene: how the new National Food Hygiene Rating Scheme will empower
people to make better choices when it comes to the hygiene standards of food.
8. Physical activity: numerous innovative schemes have been set up, including the
‘Step2Get’ initiative in London, which incentivises pupils to walk to school.
9. Social care: we have established a partnership to develop a reciprocal time credit
scheme to help catalyse peer-to-peer provision of social care.
Conclusion
These approaches show the effect that behavioural insights can have upon citizens’ health
and wellbeing. We must continue to grow and share our evidence base, evaluating new
approaches as we go.
Acknowledgements
The Behavioural Insights Team would like to thank in particular Department of Health
ministers and officials, whose expertise and support were vital. Thank you also to all the
organisations and individuals who developed these innovative examples and ideas, as well
as the academics who we consulted. If you’d like to share with us ideas and initiatives that
demonstrate an application of behavioural insight to health, please email the Department
of Health team at: [email protected]
This is a discussion paper. Its purpose is to encourage public debate.
3
4
Introduction
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“There has been the assumption
that central government can
only change people’s behaviour
through rules and regulations.
Our government will be a much
smarter one, shunning the
bureaucratic levers of the past
and finding intelligent ways to
encourage, support and enable
people to make better choices
for themselves.”
This new approach, which draws on insights from
behavioural science and behavioural economics
and is embedded in the recently published Public
Health White Paper, represents an important
part of the Coalition Government’s commitment
to reducing regulatory burdens on business and
society, and achieving its policy goals as cheaply
and effectively as possible.
It is also part of the Government’s answer to how
we can spend public money more effectively.
We currently spend over £2.5 billion a year on
treating smoking-related illness, but less than
£150 million on encouraging smoking cessation.
We spend an estimated £2.7 billion on treating the
results of excessive alcohol consumption, but only
£8.7 million on promoting healthy drinking levels
(against £800 million spent on promotion by the
alcohol industry).2
Coalition Commitment, May 20101
Many of today’s most important policy issues have
a strong behavioural component. From crime and
anti-social behaviour, to education and health –
our behaviours as citizens, parents and neighbours
significantly affect the quality of our lives and that
of others.
The Government can influence people’s behaviour
in a number of different ways. Tough laws could
be implemented, with fines for those who fail
to comply with new legislation, and bans could
be introduced that prevent people from eating
certain types of food or engaging in particular
types of activities.
But, as this paper shows, there are many options
between bans and doing nothing – the false
choice implied by some commentators. We can
give citizens more or better information. We can
prompt people to make choices that are in line
with their underlying motivations. And we can
help to encourage social norms around healthier
behaviours in ways that avoid Cialdini’s ‘Big
Mistake’ (see box).
Avoiding Cialdini’s ‘Big Mistake’3
Robert Cialdini, Professor of Psychology and
Marketing at Arizona State University and
author of one of the most widely read books
on the psychology of influence, argues that
policy makers and professionals are prone to
a frequent mistake. In their well-intentioned
desire to highlight and address important
social issues, policy makers often inadvertently
communicate that the ‘problem behaviour’ – be
it not paying your taxes or dropping litter – is
relatively widespread. This signals to people
that, even if we don’t like or approve of the
behaviour, lots of other people are doing it.
And, if we know anything from behavioural
science, it is that behaviour is strongly
influenced by what we think others are up to
(see Section 4 on student drinking).
This paper does not attempt to be comprehensive
or to suggest that behaviour change techniques
are the silver bullet that can solve every problem.
Rather, it sets out numerous examples of where
local authorities, charities, government and private
sector organisations are already developing
responses that encourage healthier behaviours.
It also points to where more could be done. And
finally, in many areas – including organ donation
and smoking cessation – this paper demonstrates
how the Behavioural Insights Team has been
working with partners to introduce new and
innovative policy solutions.
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The Behavioural Insights Team plays a key
role in this agenda by supporting government
departments in designing policy that better
reflects how people really behave, not how they
are assumed to behave. In carrying out this role,
the Behavioural Insights Team draws on academic
and empirical evidence from the world’s leading
behavioural economists and social psychologists.
This academic research is a valuable tool in helping
ministers and officials to develop policy that is less
intrusive, imposes fewer costs on business and
society and is often more effective than traditional
regulatory or legislative interventions.
The Behavioural Insights Team is a small team of
civil servants and academic experts based in the
Cabinet Office. It is led by Dr David Halpern,
and has a steering group chaired by the Cabinet
Secretary Sir Gus O’Donnell. Professor Richard
Thaler, the Ralph and Dorothy Keller Distinguished
Service Professor of Behavioral Science and
Economics at the University of Chicago,4 is an
unpaid adviser to the Behavioural Insights Team.
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“It turns out that the environmental
effects on behaviour are a lot stronger
than most people expect.”
Daniel Kahneman, Nobel Laureate,
Economic Sciences5
This paper is informed by the growing body of
research on what influences behaviour. One
practical issue is that the sheer volume and
technical language of the behavioural science
literature over recent decades can present
a significant barrier to the policy maker. For
this reason, the Institute for Government,
in partnership with the Cabinet Office, was
commissioned to review this literature and draw
together its key findings in an accessible form for
professionals and policy makers. This led to the
publication of the MINDSPACE report, which
brings together the insights of behavioural science
in a simple and practical check-list (see table on
page 6). An explanation of the key elements of
MINDSPACE and the behavioural science behind
each of the examples in the paper is provided at
the end of each section.
5
6
M I N D S PAC E
Messenger
We are heavily influenced by who
communicates information
Incentives
Our responses to incentives are shaped
by predictable mental shortcuts such as
strongly avoiding losses
Norms
We are strongly influenced by what
others do
Defaults
We ‘go with the flow’ of pre-set options
Salience
Our attention is drawn to what is novel
and seems relevant to us
Priming
Our acts are often influenced by subconscious cues
Affect
Our emotional associations can
powerfully shape our actions
Commitment We seek to be consistent with our public
promises, and reciprocate acts
Ego
We act in ways that make us feel better
about ourselves
Behavioural science in an easy format: a summary of the
main influences described in the MINDSPACE report
(Cabinet Office and Institute for Government, 2010) 6
The Behavioural Insights Team draws from this
wide body of research and uses the MINDSPACE
framework to support the work of those making
decisions that impact upon the health and
wellbeing of citizens. These decision makers are
not limited to civil servants in Whitehall, but
extend out to charities, businesses and local
authorities.
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“Behaviour change is the great
challenge for health... The reforms
we are bringing will empower you
– the professionals – to commission
services that work – to apply the
best technology and the best new
insights of social psychology and
behavioural economics to achieve real
improvements in public health.”
Secretary of State for Health Andrew Lansley,
speech to Faculty of Public Health, July 2010
In the UK today, behavioural and lifestyle factors
are thought to be major contributors in around
half of all deaths. Most of these causes are well
known, not just by professionals, but by the
general public. They include smoking, unhealthy
diet, excess alcohol consumption and inactive
lifestyles. Some causes are less well known. For
example, social isolation is associated with more
than a doubling of the risk of many forms of mental
illness, heart disease and early death.7
The lifestyle factors that impact upon people’s
health and wellbeing are often deeply entwined
in the fabric of our everyday lives. In these areas,
passing an Act of Parliament is unlikely to have
the desired effect. Strong-armed regulation is not
the answer to rebalancing our diets, changing our
desire to drink too much alcohol on a Friday night,
or making our lives more active.
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Tobacco
High blood
pressure
As reflected in the Public Health White Paper,
the key players in the future will not be ministers
and civil servants in Whitehall. In many cases, the
key players will not be those in government at all,
but local and national businesses, communities
and charities. They will also be local authority
public health professionals, GP commissioners,
head teachers of schools, and other public sector
professionals such as job centre staff. Generally,
it will also be down to individuals too – smokers
who want to quit, parents who would like their
children to walk to school, adults who would like
to eat and drink a little more healthily.
Alcohol
Cholesterol
Overweight
Low fruit and
vegetable
Physical
inactivity
Illicit drugs
Unsafe sex
Iron deficiency
0
5
10
15
Percentage of healthy years of life lost due to behavioural
factors in wealthy nations (World Health Organization,
2002)
Focusing on the behaviours that cause illness is
part of a broader change in the Government’s
approach, set out in the Public Health White
Paper published in November 2010, which will
fundamentally change our ‘National Sickness
Service’ to one that is more focused on preventing
ill-health. The creation of a strong, local base for
the promotion and commissioning of public health
should also create the conditions for innovation
and experimentation, pushing forward our
understanding about what works, while opening
the door to new delivery partners.
In short, we need to think about new and costeffective ways of encouraging healthy behaviour,
by addressing the causes of ill-health rather than
seeking to cure the consequences of them.
Of course, there is a role for central government
too, not least in getting the overall framework
right. Government also has a role in ensuring
there is transparent health data and that, where
relevant, government works with national
businesses and other organisations to ensure that
we all live up to our responsibilities in supporting
healthy lifestyles – the Public Health Responsibility
Deal is an example of this. Government may also
have a role in supporting further research and the
spreading of best practice, discussed briefly in the
concluding section of this document.
In a world where general practitioners, public
health professionals and local communities
increasingly hold the budgets and power, we hope
that some of the ideas contained here will spark
interest well beyond Whitehall.
7
8
1. Smoking
More than a quarter of all deaths
are smoking related1
There are currently 8.5 million adult smokers in
the UK.2 Smoking creates both psychological and
physiological addiction, and though it is widely
known that smoking is bad for you, smokers
still tend to underestimate the risks to them
personally.3 All of these factors are important in
understanding why it is so hard to quit.
We know that 65 per cent of smokers want to
quit and the majority have unsuccessfully tried to
give up in the last five years.4 Increasing the success
rate and frequency of smokers’ quit attempts is a
top public health priority.
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There is an extensive evidence base for current
tobacco control policy. Within this, there is
evidence that people can respond to incentives
to make a quit attempt and stick with it during
the incentivised period.4 This is particularly true
if the incentives are relatively large. For example,
smokers in the USA who were given $750 over
the course of a year were three times more likely
than the control group to quit smoking. 5
But evidence on incentives is very mixed and
they have their downsides. We know that oneoff incentives may condition us to maintain our
behaviour only if we continue to be rewarded.
The danger with time-limited trials is that after the
incentives have stopped, the individual may begin
smoking again. We also know that individuals will
often respond more strongly to losing something
they value than to being given a reward of
equivalent value, and that incentives tend to be
more effective at forming permanent habits if they
reward us only sometimes.6
Another approach to encouraging positive
behaviours is to use commitment devices.7 The
evidence from a range of studies suggests that
people are more likely to respond in a positive
way when they have entered into some kind of
commitment with another individual or group,
which could be in the form of a ceremony or
signing a pledge in the presence of someone the
individual in question trusts.
M I N D S PAC E
Building on this research, the Behavioural Insights
Team has been examining a range of ways in which
individuals might be encouraged to stop smoking
by using loss aversion and commitment devices.
Individuals who commit to quitting smoking in a
way that they stand to lose something should they
fail to achieve their objective, and who are not
rewarded too frequently, are more likely to
be successful. So, for example, quitters could
be asked to sign a contract where they lose
or keep rewards based on whether they pass
regular smoking tests that prove they have not
smoked. Successful ongoing commitment could
be encouraged by introducing a regular lottery for
people to win prizes.
Thanks to a new collaboration between
Boots, the Behavioural Insights Team
and the Department of Health, Boots UK
has committed to developing a smoking
cessation trial that could launch in early
2011, seeking to encourage people to
make more successful quit attempts. This
trial will be designed using insights from
behavioural science and medicine, and
will build on the NHS-commissioned stop
smoking services already provided in their
stores. The Behavioural Insights Team
will work in 2011 to extend these trials to
other areas, should they prove successful.
Ego, Incentives, Commitment
and Salience
Evidence shows that smokers, despite knowing
the damaging effects of smoking, tend to
underestimate its negative impact on their
own health.8 This reflects a widespread
‘attributional bias’ that leads to most people
overestimating the chances that good things
will happen to them (such as winning the
lottery) and underestimating the chances that
bad things will happen. Such psychological
defences make us feel better (ego), but they
can also inhibit us from changing our behaviour.
It has also been found that when our behaviour
and beliefs are in conflict – known as ‘cognitive
dissonance’ – it is very often our beliefs that we
change rather than our behaviour. Hence if we
are undertaking a behaviour that we believe
is dangerous, such as smoking, rather than
correct the ‘dissonance’ by quitting, we instead
adjust our beliefs about the danger.
In terms of successful programmes to
encourage quitting, several effects are likely
to be involved. First, small incentives can
sometimes work better than medium to
large incentives since these create a helpful
dissonance – emphasising that the quitter
is motivated not by the incentive itself, but
by the intrinsic value of giving up smoking.
Second, commitments where we promise
to ourselves and others – particularly involving
other people we care about – are known
to be a powerful force in behaviour change.
Third, the form of the incentives matters too:
lotteries are a way of multiplying the impact
of small financial incentives, and intermittent
rewards can be more effective at maintaining
change. Finally, there is a strong case for
shaping the incentives around the profile of
nicotine addiction and withdrawal, increasing
the salience and profile of support and
rewards in the critical period two or three days
into the programme, when the negative effects
of withdrawal are especially pronounced.
9
10 Applying behavioural insight to health
2. Organ donation
Every day three people on the organ
transplant waiting list die1
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donation in England. While good progress has
been made, with an increase in donor numbers of
over 20 per cent since 2008, the Government is
determined to explore all avenues for increasing
donor rates still further.1
There are more than 10,000 people on the
waiting list for an organ transplant and every day
three people on the waiting list die. Currently only
27 per cent of us are on the NHS Organ Donor
Register, despite the fact that surveys consistently
show that 65 per cent of us would be willing to
donate an organ and 90 per cent of us are in
favour of organ donation.2
One such avenue is that of ‘prompted choice’,
whereby a person is required to make a choice
about if they would like to be an organ donor
when completing, for example, a driving licence
application form. Prompted choice has already
been successfully applied to organ donation
registration in several US states. Since 2008,
Illinois has required that all driving licence
applicants actively decide whether to register as
a donor or not. The percentage of donors signed
up to the register has increased from 38 per cent
to 60 per cent as a result. At the start of the year,
Texas also implemented such a system and donor
registration rates have already doubled. Most
recently California announced in October that
it would introduce prompted choice to driving
licence applications.3
England currently has an ‘opt-in’ system, whereby
active consent is required to become an organ
donor, instead of an ‘opt-out’ system, whereby
consent is presumed. A review by the Organ
Donation Taskforce in 2008 concluded that,
although presumed consent may have the
potential to increase donor rates, itt would
also have the potential to undermine
ne the
concept of donation as a gift and erode trust
in NHS professionals. The Government
ment has
therefore concentrated on the Taskforce’s
skforce’s
recommendations to improve the
infrastructure supporting organ
d
ar
c
r
o
don
r
n
S
NH
a
Org
o
Don
ist
g
e
R
er
Applying behavioural insight to health 11
M I N D S PAC E
Salience and Defaults
Given the large percentage point difference
between the number of individuals currently
registered as organ donors in England and those
who say that they would be willing to become
donors, the Behavioural Insights Team considers
that offering a prompted choice is likely to
significantly increase the number of organ
donor registrations.
Thanks to a collaboration between the
Behavioural Insights Team, Department
of Health, NHS Blood and Transplant,
Department for Transport and Driver
and Vehicle Licensing Agency (DVLA),
we can announce that a system of
prompted choice will be trialled in
England in 2011. This will be introduced
to the DVLA online application form
for renewing and applying for driving
licences and if this approach proves to
be as effective as evidence in the USA
suggests, it can be extended to other
registration routes.
There are many things that we mean to do
but never get around to. A major reason for
this is that we live for today at the expense
of tomorrow. This is known as ‘hyperbolic
discounting’ and it refers to how people
discount the future heavily compared with
the present. So even though it may appear
that there is little effort involved in signing the
Organ Donor Register, this effort is immediate
(salience), whereas the gain is distant. Hence
our good intentions never come to pass (see
also Section 8 on physical activity).
Prompted choice has been found to be a highly
successful approach to addressing the issue of
discounting the future in a number of areas,
and is based on the insights around the power
of defaults. Changing the default options
for pensions to a system of prompted choice
has led to around 70 per cent of employees
deciding to save more, versus around 40 per
cent who opt into a pension scheme. This is
lower than the 90 per cent who stay in an optout pension scheme – an even simpler default
– but has the advantage of making the choice
a conscious one. Another recent high-profile
use of prompted choice resulted from the long
legal battle between the EU and Microsoft,
with the resolution being that instead of new
PC users being automatically directed to using
one particular browser, users are required to
make a choice from a menu of five options.
3. Teenage pregnancy
Britain has the highest rate of teenage
pregnancy in Western Europe1
Evidence shows that being pregnant young can lead
to adverse effects in young people’s lives – including
low self-esteem, depression, poor relationships,
reduced educational achievement and increased
risk of social deprivation and adopting risky
behaviours.2,3,4,5,6
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Teens and Toddlers is a UK charity which tackles
teenage pregnancy in an unusual way. Teenagers
take part in a 20-week programme where
they mentor a toddler. Each week they spend
time supervising and playing with a toddler at a
nursery, experiencing first hand the demands and
responsibilities of parenthood. This is then followed
by sessions run by trained support workers who
teach them about child development, parenting
skills, sexuality and relationships. These sessions
also provide a forum for the teenagers to discuss
their experiences with each other.
Teens and Toddlers found that over a six-year
period, the pregnancy rate of those who had
participated in the programme was 2.7 per cent,
in contrast to the national teenage average of
4.1 per cent. This lower rate was achieved in spite
of the higher-risk teenagers that the programme
targeted.7 The Department for Education believes
that this is a promising initiative, and as a result
is supporting a randomised controlled trial to
provide a robust assessment of the impact on
teenage pregnancy rates.
The widespread practice by many schools when it
comes to preventing teenage pregnancy is to bring
in young teenage mothers to discourage pupils
from following their lead. In many cases this will be
ineffective or even counter-productive. In contrast,
the Teens and Toddlers approach actively brings
home the enormity of the responsibility of bringing
up a child, fosters emotional development and has
been shown to change young people’s behaviour.
The Teens and Toddlers charity co-funds
each of these initiatives, and so far it has
been taken up by 26 local authorities, with
over 6,000 teenagers taking part. Thanks
to the reforms set out in the Public Health
White Paper, power will be devolved to
local authority public health professionals
– giving them the freedom to innovate.
This means that it will become much
easier for local authorities to partner
with charities like Teens and Toddlers,
paving the way for this kind of innovative
approach to become more widespread.
M I N D S PAC E
Norm, Messenger and Ego
Our behaviour is strongly influenced by
what we see other people doing – called the
‘declarative’ or ‘descriptive’ social norm. For
example, experiments have found that the
proportion of people dropping a leaflet on the
ground rose from 10 per cent to 40 per cent as
the number of similar pieces of litter already on
the ground rose from one to eight or more.8 In
short, we are heavily influenced by what other
people are doing. These effects help to explain
why sending a teenage mother into schools to
discourage teenage parenthood is problematic
(messenger). The challenge is made greater
by what psychologists call the ‘Romeo and
Juliet’ effect – the tendency, especially strong
in young people, to actively react against
being told what to do (ego). The elegance
of approaches such as Teens and Toddlers
is that they avoid the traps of reinforcing the
wrong social norm or telling young people
what to do, and instead catalyse the emotional
development of the young person, while at the
same time reducing teenage pregnancy.
4. Alcohol
Alcohol-related illness costs the NHS
around £2.7 billion a year1
Alcohol costs the NHS around £2.7 billion a
year and the cost of alcohol-related crime may
be as high as £7.2 billion.1 As a nation, we drink
345 million litres of alcohol a year.2 A review of
undergraduate drinking found that 52 per cent
of male and 43 per cent of female students
reported drinking above recommended levels.
In comparison, figures for 16–24-year-olds in
the general population are 37 per cent and
33 per cent respectively.3
mixed, demonstrating the need to identify the
specific behavioural influences involved.7
In order to test the efficacy of initiatives
aimed at reducing alcohol consumption,
the Welsh Assembly Government and
the charity Drinkaware are working
together to develop and run a year-long
pilot advertising campaign. This campaign
will communicate accurate drinking levels
to all university students in Wales. The
pilot will start at the beginning of the next
academic year.
M I N D S PAC E
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We know that people are influenced by what they
think other people are doing, even if the reality is
different.4 In the case of binge drinking, evidence
has shown that students consistently overestimate
how much alcohol their peers drink. 5 Recent
trends suggest that excessive drinking patterns
which begin during student years continue into
adulthood, and so reducing alcohol consumption
at this age is critical.
Several university campuses in the
USA have used social norm campaigns
in an effort to reduce heavy drinking.
In 1994, the University of Arizona set
out to correct the false perception
of how much students’ peers drank.
Using posters, flyers and word of
mouth, they communicated the real
levels of drinking among students and
as a result reduced the pressure to
drink. Between 1995 and 1998, the
campus experienced significant
decreases in the rate of heavy
drinking among undergraduate
students.6 However, evidence
from other trials has been more
Norms and Salience
Work on alcohol shows the effects of social
norms in action (specifically those called
‘descriptive norms’). We generally do what we
see or think others are doing, but an important
twist is that our estimate of what other people
are doing is often distorted. More specifically,
we use various mental shortcuts or ‘heuristics’
to judge the frequency of a behaviour, and
these shortcuts can sometimes mislead us.
For example, we may estimate how frequent
an event is by how readily we can call to
mind an example (the ‘availability heuristic’).
Hence we are prone to thinking that flying is
dangerous because we can easily call to mind
an example of a plane crashing (salience).8
Similarly, one can see why students might
overestimate the level of drinking among their
fellow students. The loud noise of a small
number of fellow students heading home
drunk in the early hours is hard to ignore
(salience), but the silent majority are much
less visible. The availability heuristic leads
us into thinking far more students drink to
excess than actually do, and this can influence
our behaviour.
5. Diet and weight
Six out of ten adults are overweight,
costing the UK economy around
£7 billion a year1
Six out of ten adults in the UK are overweight.1
This costs the NHS around £4 billion a year
and, because being overweight is associated
with increased morbidity and more certified
sick days, the total economic cost is £7 billion a
year.1 Overweight and obesity levels for children
also remain disturbing, with nearly a quarter of
all 4-year-olds and nearly a third of 10-year-olds
overweight or obese.2
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The quality of our diet reflects levels of obesity.
Most people know that they should eat more fruit
and vegetables but in England 65 per cent of adults
eat fewer than five portions of fruit and vegetables
a day,3 even though nutritional experts suggest
that fruit and vegetables should make up about
a third of the food we eat each day.4
A pilot experiment conducted by Collin Payne of
New Mexico State University College of Business
found that a simple line of yellow tape together
with a sign placed across a shopping trolley could
prompt shoppers to choose to buy more fruit
and vegetables. The tape and sign designated one
part of the trolley for fruit and vegetables and the
other for all other purchases. By visually prompting
people in this way, there was a large increase in
the amount of fruit and vegetables purchased,
without a decrease in profitability for the retailer. 5
Evidence suggests that making the trolley even
more visually engaging by including an appealing
picture of fresh fruit and vegetables is likely to
make this even more effective.
Visual prompts are already widely used
by supermarkets and food manufacturers.
But there is the potential for visual
prompts to be introduced in more ways
that help people make healthier food
choices. Examples include experimenting
with the design of trolleys and considering
the order or height of healthier options on
supermarket shelves. A recent example
of this is the collaboration between Asda
and the Department of Health’s Change
for Life campaign, whereby social norm
messages were advertised on trolleys.6
In the future, the Behavioural Insights
Team will be reaching out to partners in
the private, public and voluntary sectors
to examine where trials of this kind might
be most effective.
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LazyTown is an Icelandic TV and live show which
is watched by children all over the world. Its
healthy superhero Sportacus motivates children
to eat healthily and be active. In Iceland, several
LazyTown initiatives have been run in partnership
with the Government and private sector. For
instance, children between 4 and 7 years old
were sent an ‘Energy Contract’ that they signed
with their parents, in which they were rewarded
for eating healthily, going to bed early and being
active. In one supermarket chain, all the fruit
and vegetables were branded ‘Sports Candy’ –
LazyTown’s name for fruit and vegetables – leading
to a 22 per cent increase in sales.7 Since LazyTown
became mainstream in 1996, Iceland’s child obesity
levels have started falling – one of the few places in
the world to show such a trend (see graph).8
There is much that local authorities,
supermarket chains and those with a
role in public health might learn from
the Icelandic initiatives. In order to test
whether these will have a similar impact
in the UK, the Behavioural Insights Team
and the Department of Health have now
established a partnership with LazyTown.
This national initiative will be developed
using behavioural science insights and
will involve partnering with nurseries up
and down the country. Coordinated at a
national level, local health professionals
will also have a crucial role in delivering
this initiative, and this relationship will be
indicative of the devolved principles of the
newly created Public Health England. The
Behavioural Insights Team will continue to
play a role in helping to facilitate new and
innovative initiatives of this kind.
Obesity among 9-year-old children in Iceland
Obesity levels (%)
25
LazyTown has been
mainstream in Iceland
since 1996
20
15
10
5
0
1930
1940
1950
LazyTown presentation to Cabinet Office, 2010
1960
1970
1980
1990
2000
2010
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Advocates have argued for a number of years
for clearer labelling of the calorific and nutritional
content of foods. Indeed, Secretary of State for
Health Andrew Lansley has said he wants to go
further on getting restaurants, takeaways, fast food
outlets and others to provide calorie information.
In ways like this, people can be empowered to
make a healthier choice through the provision
of relevant information.
Research from behavioural science suggests that the
key to communicating information effectively is to
do it in relevant and engaging ways. Soon-to-be
published research suggests that well-designed
labels can reduce the calorific levels of a snack
chosen by around 20 per cent, especially when
done so in relevant and engaging ways.9
However, critics rightly point out that even the
most ‘unhealthy’ of items can be perfectly healthy
when part of a balanced diet. This suggests a
strong case for giving consumers a more holistic
account of their diet against which they can make
choices. Bringing together ideas of transparency,
behavioural economics and the capabilities
of today’s technology and store cards, many
potentially powerful possibilities exist.
The Department of Health’s Public
Responsibility Deal team is currently
working to secure voluntary agreements
from the food industry to commit to outof-home food labelling in 2011. Evidence
suggests that consumer behaviour might
also be positively stimulated by food
retailers in other ways, such as offering
customers three-month summaries of
the nutritional profile of the food that
they buy, set against a healthy average.
M I N D S PAC E
Priming, Salience and Affect
The ideas in this section illustrate a number
of behavioural effects. Several illustrate the
power of priming and salience – such as
priming shoppers to think about buying healthy
food. People show a strong tendency to
anchor to an object or a number that we are
primed with, such as how much fruit to eat.
For example, if people are asked: “How many
countries are there in Africa? Is it, for example,
x?” their answer is strongly anchored to the
arbitrary number that is mentioned, even
when they are specifically told that this is not
the right answer. These ‘anchoring’ effects are
particularly relevant in relation to the yellow
tape on the supermarket trolley, but also to
the well-known campaign to eat ‘5 a day’ for
fruit and vegetables.10
Finally, we might note that diet is an area
where short-term emotional responses tend
to overpower longer-term, more ‘rational’
thinking (affect). In a study, where workers
were offered a prize next week of fruit or
chocolate, 74 per cent chose fruit. But when
the delivery van arrived on the day and said
they had ‘lost’ the form and again asked what
the person wanted, around 70 per cent
claimed to have chosen chocolate. In other
words, there are various opportunities for
products and services that allow people to
pre-commit to healthier options.11
6. Diabetes
M I N D S PAC E
Incentives and Salience
2,940 diabetic children in the UK are
admitted to hospital every year as a
result of failing to keep their blood
sugar levels under control1
From 1996–2005 the proportion of people with
diabetes in Britain rose from 2.8 per cent to 4.3
per cent.2 Of those, just over 21,000 under-17s
have type 1 diabetes.3 Managing diabetes requires
regular monitoring of blood sugar levels and this
consistent, regular monitoring can prove especially
challenging for children and their parents.
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A collaboration between Bayer Healthcare and
Nintendo DS has led to the development of
a Didget device which gives points to diabetic
children in return for them consistently consenting
to regular pin-prick blood-sugar tests. These
points can be used on Nintendo games or in
the Didget web community, where children can
compare their performance against others. This
device shows how using fun, innovative products
can have very practical effects on people’s health
and wellbeing.4
Developers of other non-health
technologies may also have cost-effective
ideas that local authorities and GP
commissioning consortia may wish to trial
or, if appropriate, prescribe.
As is often the case, blood testing for diabetes
juxtaposes short-term pain – literally in this
case – for a long-term gain (incentives).
This is a problem that most adults struggle
with, but which children may find even more
difficult. One option is to try to make the
long-term gain (or avoidance of loss) clearer,
but an alternative is simply to create an
immediate gain (salience). In this case, the
Nintendo game introduces an element of fun
even before the discomfort of the test, so the
pain is being discounted too. Of course, the
game itself helps to distract attention from
the discomfort of the test, and since the game
continues after the test, the pain looms smaller
in the memory. This relates to what are called
‘primacy and recency effects’ – we remember
most clearly the first and the last part of
an experience. 5
7. Food hygiene
There are over a million cases of food
poisoning a year in the UK, costing the
NHS and business £1.5 billion a year1
Of the million plus cases of food poisoning a
year in the UK, 20,000 people are hospitalised
and 500 die. Food Standards Agency research
has found that people primarily judge hygiene
standards of food outlets on the appearance of an
establishment (68 per cent), appearance of staff
(44 per cent), cleanliness of toilets (33 per cent)
and word of mouth (22 per cent).
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Up until now, people have had to make
judgements on the hygiene of restaurants and
food outlets based on appearance and hearsay
alone. This is now set to change, with the recent
launch of the National Food Hygiene Rating
Scheme by the Food Standards Agency, in
partnership with local authorities. The aim of
this scheme is to empower customers to make
more informed decisions
when it comes to the
hygiene standards of food
premises.
This national scheme,
building on a number of
local authority-led pilots,
will enable people to view
simply summarised hygiene
information online and on
stickers voluntarily posted
on the entrance door or
window of restaurants and
food outlets. The ratings
range from 5 (very good)
to 0 (urgent improvement
necessary). Evaluation of the pilot schemes found
that 7 in every 10 customers are unlikely to enter a
restaurant rated below the midpoint in the scale.2
Schemes similar to this one have already worked
successfully in both Denmark and California. In
Denmark, there was an increase in good hygiene
scores from 70 per cent to 86 per cent since the
scheme launched in 2002,3 and in California there
was a 13 per cent drop in food-borne disease
hospitalisations.4
The National Food Hygiene Rating
Scheme was launched in November 2010
and the Behavioural Insights Team will be
working with the Food Standards Agency
to make the information generated by
the scheme as widespread and accessible
as possible. One option is to encourage
respected restaurant reviewers and
organisations such as Time Out, Top
Table and the Good Food Guide to rank
restaurants on their hygiene standards
as well as the quality of food, service and
atmosphere – which will be possible for
the first time due to the availability of this
information.
M I N D S PAC E
Salience
Evidence suggests that when information is
made public and salient, such as the hygiene
standards of a restaurant, this exposure will
motivate that restaurant to improve their
standards. Exposing potential customers to
this kind of hygiene information, particularly
when they are booking and made aware of
this information in advance before they are in
a hungry, or ‘hot’, state, can dramatically change
their choices and in so doing strongly drive
hygiene improvements without the need for
further regulation.
8. Physical activity
If people who engage in low levels
of physical activity were more active,
we could save more than £900 million
a year1
If recommended levels of activity were met, 1 in
10 premature deaths could be prevented.2 Over
the last century, the number of people employed
in inactive professional or managerial roles has
more than doubled, while the proportion of
people employed in active, skilled or unskilled
jobs has decreased by two-thirds. A key challenge
for improving physical fitness is tackling our
increasingly inactive lifestyles at work and play:
sitting on public transport rather than walking,
using escalators rather than stairs, playing video
games and watching television rather than playing
sports.3 Most people are aware of the health
benefits of taking the stairs instead of the escalator,
but when faced with the choice, we usually take
the easy option – particularly when others are
doing the same.
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Volkswagen has been working in Sweden to
develop the ‘Fun Theory’ campaign, which
predicts that by making things fun, we can
change our behaviour for the better.
Volkswagen launched a competition
asking people to submit their ideas
for green and other pro-social
innovations. Over 700 ideas from more than
200 countries were submitted, all of which
were judged by a panel of Swedish experts in
behavioural science and the environment.
The piano stairs was one of the most popular
ideas. For one day in a Stockholm metro station,
Volkswagen installed motion-sensor piano keys so
that musical tunes were played as people climbed
the stairs. A before-and-after study showed that
66 per cent more people than normal took the
stairs rather than the escalator. Making the stairs
eye-catching and fun to climb had a motivating
effect. In addition, once more people started
taking the stairs, others tended to follow.4,5,6
This was just a one-day trial and so we do
not know the long-term effects of such an
intervention. However, trials such as this
do demonstrate that there are creative
ways to encourage people to choose the
more active option. These insights can be
applied to many areas beyond tube and
railway stations – for example, architects
and town planners play a key role in
designing more active environments,
whether through the layout of parks or
the positioning of stairs (relative to lifts)
in a building.
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As detailed in the recent Public Health White
Paper, when it comes to running, Nike has been
turning its attention to motivational tools. They
have recently launched the Nike+ GPS iPhone
app, which allows you to track your run, receiving
live updates as you go. The app also informs
the user how fast they are running and delivers
motivational messages from famous athletes such
as Paula Radcliffe and Lance Armstrong.
‘The Grid’ is another innovative initiative that turns
running into a game.7 Phone boxes in London
have been branded, identifying themselves as
visual markers for people to run from one to the
next, typing in their personal ID number as they
go. It is a competition to be the fastest to find
all the phone boxes, and scores are uploaded
automatically to the Grid website where runners
can compare their scores against those of others.
Nike has put both of these tools to good use when
it comes to its youth running projects in the UK.
Partnering with Charlie Dark – a teacher, writer
and DJ – they organise weekly running groups
(called ‘Run Dem Crew Youngers’) 8 where they
combine creative workshops with runs. Charlie
uses the Nike+ app on his iPhone to give regular
feedback to the young people, and they have used
the Grid game to create a competition between
11 running groups across the country.
There is potential for these kinds of
tools and ideas to be used at a local level,
perhaps creating group running clubs
set up in partnership with public health
professionals, community organisations
and local sports clubs.
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As highlighted in the Public Health White
Paper, Transport for London’s and Intelligent
Health’s ‘Step2Get’ initiative combines swipe
card technology, online gaming and rewards to
incentivise pupils to walk to school. So far it has
been piloted in two London secondary schools,
where pupils were given a card to swipe machines
placed on lamp-posts along a route to school. The
more miles they walked, the more points they
earned, which could then be redeemed for rewards
that included cinema tickets and Topshop vouchers.
They could then track their progress online and also
compare it with that of other classes.
A third of all pupils signed up to Step2Get, and this
not only increased the number of children walking
to school by 18 per cent, but resulted in more of
them getting to class on time. Also, as a result of
the visibility of the lamp-post swipe machines and
seeing others walking to school, a new social norm
was created.
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Whereas children used to go out to play, more of
their time is now spent on inactive pursuits such as
watching television and playing computer games.
Computer games are here to stay, with average
weekly gaming time averaging 12.2 hours a week.
However, recent technological developments
have led to game consoles such as the Nintendo
Wii requiring players to use body movements to
control on-screen action – thus increasing the
opportunities for physical activity.
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Next year, this initiative is going transatlantic and
approximately 30,000 pupils from London and
New York will be competing with each other
to walk the most miles. The winning city of the
‘International Walk to School Challenge’ will be
announced during the 2012 Olympic Games.9
Could local authorities and schools work
with providers such as Intelligent Health
to expand a scheme like this beyond
London? The health and related cost
savings have been shown to be significant
– notably the reduction in rush-hour
congestion. Whether you use lamp-posts
or phone boxes as your markers, these
prove useful devices for motivating people
to be more active.
Studies by Liverpool John Moores University found
that, compared with video gaming, active gaming
on the Wii significantly increased total body and
upper limb movement in adolescent boys and
girls. This was a result of participants being on
their feet and using wireless handheld remotes
to play the games, with the associated increases
in energy expenditure and heart rate significantly
greater than sedentary gaming. The studies found
that, when using the Wii console, the participants’
energy expenditure increased 156 per cent above
resting. Based on the average gaming week of 12.2
hours, this translates to a potential 1,830 calories
burned per week when using the Wii.10,11
With more motion-controlled gaming consoles
entering the market (such as Kinect for Xbox 360
or Move for PlayStation 3) and the huge popularity
of the games played on these platforms (Wii
Sports Resort was the second most popular video
game in the world in 2009), the potential to shift
to more physically active gaming is significant.12
With this knowledge, parents can
be empowered to make healthier
choices when it comes to which
computer consoles and games they
buy for their children.
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The introduction of bike hire schemes in major
cities across the world offers a fascinating test of
conventional versus behavioural economics. In
conventional economics, it would be expected
that introducing a large number of relatively cheap
and easy-to-hire bikes would make it less likely that
people would buy a bike themselves. In contrast,
behavioural economics suggests that the effect
would go the other way – that seeing more people
cycle would create a new social norm and visual
prompt, encouraging more people to want to
cycle. The answer? Bike retailers have reported
significant increases in bike sales since the advent
of London’s bike hire scheme.
This is an interesting lesson for other cities
considering taking up similar schemes.
Also, if the cycling stations and bikes
themselves act as such a positive visible
cue, perhaps their presence could be
made even more prominent in
future schemes.
M I N D S PAC E
Norms, Affect and Salience
There is ongoing academic debate about the
exact causal relationship between exercise,
diet and weight, and specifically around how
much exercise is a cause or effect on changes
in weight. We certainly know that individual
differences in weight are strongly and causally
linked to levels of movement, but there has
also been growing study of how obesity
(and exercise) appears to spread through
social networks (norms), as most famously
illustrated by the long-term, cross-generational
Framingham Health Study in the USA.13
Like other lifestyle habits, exercise is strongly
affected by our tendency to discount future
gains, such as being fit and feeling good, relative
to short-term pains. The Harvard economist,
David Laibson, often uses the specific example
of exercise to illustrate our deeply ingrained
tendency to procrastinate. Exercising today
involves immediate sweat and effort, with
the benefits being realised in the long term –
we are therefore less inclined to exercise as
much as we should. By contrast, the idea of
exercising tomorrow looks very attractive.
Hence we intend, quite sincerely, always to
exercise tomorrow.14
The examples in this section seek to turn this
problem around, such as through adding an
immediate pleasure up front with the fun of
the piano stairs (affect and salience), or by
changing the social norm around exercise with
the city bike hire scheme.15
9. Social care
Social care for the elderly costs
government more than £16 billion
each year1
as demand increases – there will be a projected
1.6 million more adults in England over the
age of 18 with a care need by 2026 (a 30 per
cent increase).4
The UK population is expected to increase to
67 million by 2020.2 The number of those aged
over 85 will increase by 50 per cent by 2020.2
Increases in life expectancy will mean greater
numbers of people with greater health and care
needs. Demand for informal care from family,
friends and community members is projected to
rise by 40 per cent by 2022, particularly affecting
those without children and those who do not have
relatives living close by.3
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Despite the significant contribution of informal
care to support friends and family, we know that
there is sizeable unmet need for social care in the
current system. This unmet need will grow rapidly
Enabling people to help one another, by unlocking
currently under-utilised time and skills, will be crucial
to ensuring that older people can live a happy and
independent lifestyle for as long as possible.
The ‘Fureai Kippu’ scheme has been developed
in Japan over the past 15 years, and is a powerful
example of an alternative approach to social care.
The unit of care (the ‘Fureai Kippu’) is an hour
of time earned for individuals who help older
people with any aspects of their care that the
national healthcare system does not cover: for
Growth of the number of Fureai Kippu branches
May 2003
2001
1998
1996
1992
0
100
200
300
400
Source: Lietaer B (2004) Complementary currencies in Japan today: Their history,
originality and relevance. International Journal of Community Currency Research 8:1–23.
example help with shopping or food preparation,
or with the daily bath (a ritual in Japan). These
Fureai Kippu can be saved for the individual’s own
use in the future, or transferred to someone of
their choice, typically a parent or family member
who lives elsewhere in the country and who
needs similar help. There are now more than 400
Fureai Kippu branches in Japan, involving tens of
thousands of active participants. 5
Because the elderly participating in this scheme
now have a support system at their own home,
the time when they have to be moved to
expensive retirement homes can be significantly
postponed, and the period they are spending
in hospitals after a medical problem can also be
much shorter. All this reduces the costs to society
of elderly care, while improving the subjective
quality of life of the elderly themselves.6,7
Drawing on these insights, the
Behavioural Insights Team, together
with the Department of Health, the
Department for Work and Pensions
and the Department for Communities
and Local Government, is working
with the Royal Borough of Windsor and
Maidenhead – one of the four Big Society
‘vanguard communities’ announced by the
Prime Minister in July 2010 – to develop
a reciprocal time-credit scheme to help
catalyse more peer-to-peer provision of
social care. The Royal Borough will be
designing and testing the feasibility of a
local ‘CareBank’ model, which enables all
residents to gain time-credits in return
for voluntary activity in support of older
people. The project will be co-designed
with the local community to develop
exchange mechanisms and incentive
schemes that maximise opportunities
for everybody to participate as both
givers and receivers. If successful, it is
hoped that localities in other parts of the
country would develop their own social
care time-credit and, with an effective
nation-wide exchange platform, people
could start to trade credits across
different localities.
M I N D S PAC E
Commitment
A series of studies has shown the remarkable
relationship between social connection or
isolation and ill-health. In longitudinal studies,
social isolation has been found to be associated
with two- to five-fold increases in age-adjusted
mortality rates, particularly in men.8 Social
isolation has also been found to decrease
survival rates after the onset of a condition,
reduce post-operative survival rates, and even
– under experimental conditions – increase
susceptibility to specific viruses, such as the
common cold.9
The causal pathways for these effects are
increasingly well understood. They include
not only the direct effects of caring support
– making sure that we are fed and warm –
but also demonstrable positive effects on
the immune system that seem to result from
confiding in others.10
The care credit scheme described rests
heavily on the power of reciprocity and
commitment – our desire to help others
who have helped us.
Conclusion
There is no reason why we cannot succeed in
tackling today’s rising tide of chronic lifestylerelated diseases. Some trends are already
encouraging, such as the overall falls in smoking
rates (though there are still rises in some key
groups). Other trends are more worrying, such
as rising levels of children who are overweight.
In most cases, success will not come from a single
‘silver bullet’. Instead it will come from a combined
approach between many partners – local
communities, professionals, businesses and
citizens themselves.
A key objective of the coming years will be to
try out behavioural approaches – to experiment
at local level – to find the most effective ways of
adjusting our lifestyles in ways that keep or put
citizens in the driving seat and make it easy to live
a happy and healthy life. The current state of our
knowledge – about both health and behavioural
science – gives us many powerful clues about what
is likely to work, but there is a great deal that we
do not know. In such cases, we must ensure we
test new approaches in a robust way – preferably
with randomised control trials and before and
after measures – supported with evaluations
that will help other areas learn the lessons. In
recognition of this need, a new Policy Research
Unit on Behaviour and Health was announced in
the recent Public Health White Paper.
It is clear to us from our work with the Department
of Health, health professionals and businesses that
there is a great deal of energy and enthusiasm
for the new health agenda. If we can combine
the insights from behavioural science with this
enthusiasm and professional expertise, the benefits
are likely to be very substantial indeed – fewer lives
lost, better value for money and better health.
Designing in experimentation
Though behavioural science gives us a good starting point for how communities and citizens can
improve health, there is a strong case for trying and testing variations in approach.
When you use many well-known websites or browsers, the page you are directed to is often one
of two or more versions, varying slightly in wording or position. This enables the site’s designers to
see whether any of the variations work significantly better. This approach, sometimes known as A-B
testing, enables a constant process of innovation and learning, but is very rarely used in the public
sector. Public health professionals can learn much from these types of careful experimentation, such
as which kinds of link or information from a public website lead to more attempts to quit smoking or
joining the organ donation register.
The same applies for other kinds of approaches to encourage healthy behaviour. Even within the
examples presented in this paper, there are many possible variations in approach. For example, there
are many different combinations of the schemes to help smokers quit, to encourage more active
lifestyles, or to improve diets. The fact is we generally cannot know in advance which combination will
work best. But we can easily find out. We – local communities, citizens, public health professionals –
can try out alternative combinations. What we must do is ensure that such trials are framed in a robust
way – preferably with randomised control trials and before and after measures – supported with
evaluations that will help other areas learn the lessons, and with transparency of results so that others
can study and learn from what happened.
References and useful links
8&20.;/52%.&(
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See also NHS Choices, Smokefree: http://smokefree.nhs.uk/
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Donation Taskforce. London: Department of Health.
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Donation in the UK: An Independent Report from the Organ Donation Taskforce.
London: Department of Health.
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cadaveric organ donation: A cross-country study. Journal of Health Economics
25(4): 599–620.
See also NHS Blood and Transplant: www.uktransplant.org.uk
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relationships between depression and academic achievement. International Journal
of Behavioral Development 31(4): 328–339.
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Harden A, Brunton G, Fletcher A and Oakley A (2009) Teenage pregnancy and
social disadvantage: Systematic review integrating controlled trials and qualitative
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factors associated with early sexual intercourse of young adolescents. Children and
Youth Services Review 31(12): 1272–1282.
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Journal of Sociology 112: 1811–1847.
6
Thornberry TP (1987) Toward an interactional theory of delinquency. Criminology
25: 863–891.
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Programme. London: Children Our Ultimate Investment UK.
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Cialdini RB, Reno RR and Kallgren CA (1990) A focus theory of normative conduct:
Recycling the concept of norms to reduce littering in public places. Journal of
Personality and Social Psychology 58(6): 1015–1026.
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!#5.+.#(
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Department of Health (2010) Healthy Lives, Healthy People: Our Strategy for Public
Health in England. London: Department of Health.
2.
Rickards L, Fox K, Roberts C et al. (2004) Living in Britain: Results from the 2002
General Household Survey. London: Office for National Statistics.
3.
Gill JS (2002) Reported levels of alcohol consumption and binge drinking within the
UK undergraduate student population over the last 25 years. Alcohol and Alcoholism
37(2): 109–120.
4.
Thaler RH and Sunstein CR (2008) Nudge: Improving Decisions about Health,
5.
Bellis MA, Hughes K, Cook PA and Morleo M (2009) Off Measure: How We
Underestimate the Amount We Drink. London: Alcohol Concern.
6.
Johannessen K and Glider P (2003) The University of Arizona’s Campus Health
social norms media campaign. In Perkins HW (ed.) The Social Norms Approach
to Preventing School and College Age Substance Abuse: A Handbook for Educators,
Counselors, and Clinicians. San Francisco: Jossey-Bass.
7.
Moreira T, Smith LA and Foxcroft DR (2009) Social norms interventions to reduce
alcohol misuse in university or college students. Cochrane Database of Systematic
Reviews 3: CD006748.
8.
Tversky A and Kahneman D (1973) Availability: A heuristic for judging frequency
and probability. Cognitive Psychology 5(2): 207–232.
See also DrinkAware: www.drinkaware.co.uk
=%*2(,&;(C*%'+2(
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Government Office for Science (2007) Foresight – Tackling Obesities: Future Choices –
Modelling Future Trends in Obesity and the Impact on Health, second edition.
London: Department for Innovation, Universities and Skills.
2.
National Statistics and NHS Information Centre (2009) National Child Measurement
Programme: England, 2008/09 School Year. London: NHS Information Centre.
3.
Bates B, Lennox A and Swan G (2010) National Diet and Nutrition Survey. Headline
Results from Year 1 of the Rolling Programme (2008–09). London: Food Standards
Agency and Department of Health.
4.
Lock K, Pomerleau J, Causer L et al. (2005) The global burden of disease
attributable to low consumption of fruit and vegetables: Implications for the global
strategy on diet. Bulletin of the World Health Organization 83: 100–108.
5.
Payne C (2010) Personal communication. New Mexico State University College of
Business.
6.
Change4Life: www.nhs.uk/change4life
7.
LazyTown: www.lazytown.biz
8.
LazyTown presentation to Cabinet Office, 2010.
9.
Loewenstein G et al: forthcoming.
10. Thaler RH and Sunstein CR (2008) Nudge: Improving Decisions about Health,
11. Read D and van Leeuwen B (1998) Predicting hunger: The effects of appetite
and delay on choice. Organizational Behavior and Human Decision Processes
76(2): 189–205.
=%,)*2*1(
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Edge JA, Jakes RW, Roy Y et al. (2006) The UK case-control study of
cerebral oedema complicating diabetic ketoacidosis in children. Diabetologia
49(9): 2002–2009.
2.
Masso Gonzalez EL, Johansson S, Wallander M-A and Garcia Rodrigues LA (2009)
Trends in the prevalence and incidence of diabetes in the UK: 1996–2005. Journal of
Epidemiology and Community Health 63(4): 332–336.
3.
Diabetes UK (2010) Diabetes in the UK 2010: Key Statistics on Diabetes. London:
Diabetes UK.
4.
Bayer Didget: www.bayerdidget.co.uk
5.
Deese J and Kaufman RA (1957) Serial effects in recall of unorganized and
sequentially organized verbal material. Journal of Experimental Psychology
54(3): 180–187.
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1.
Food Standards Agency (2009) Annual Report of the Chief Scientist 2008. London:
Food Standards Agency.
2.
Food Standards Agency National Food Hygiene Rating Scheme: www.food.gov.uk/
news/newsarchive/2010/nov/fhrslaunch
3.
Data from the Danish Ministry of Food, Agriculture and Fisheries.
4.
Simon PA, Leslie P, Run G et al. (2005) Impact of restaurant hygiene grade cards on
foodborne-disease hospitalizations in Los Angeles County. Journal of Environmental
Health 67(7): 32–36.
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Britton A and McPherson K (2000) Monitoring the Progress of the 2010 Target for
Coronary Heart Disease Mortality: Estimated Consequences on CHD Incidence and
Mortality from Changing Prevalence of Risk Factors. London: National Heart Forum.
2.
World Health Organization (European Region) data: www.euro.who.int
3.
Department of Health (2009) Be Active, Be Healthy: A Plan to Get the Nation Moving.
London: Department of Health.
4.
www.rolighetsteorin.se
5.
www.youtube.com/watch?v=ivg56TX9kWI
6.
www.thefuntheory.com
7.
Nike Grid: www.nikegrid.com
8.
Nike Run Dem Crew Youngers: www.rundemcrew.com/rdc-youngers/
9.
Step2Get and International Walk to School Challenge: www.intelligenthealth.co.uk
10. Graves L, Stratton G, Ridgers ND and Cable NT (2007) Energy expenditure
in adolescents playing new generation computer games. British Journal of Sports
Medicine 42(7): 592–594.
11. Graves L, Ridgers ND and Stratton G (2008) The contribution of upper limb and
total body movement to adolescents’ energy expenditure whilst playing Nintendo
Wii. European Journal of Applied Physiology 104(4): 617–623.
12. NPD Group, GfK Chart-Track Ltd and Enterbrain Inc (2010) The Top Global
Markets Report.
13. Christakis NA and Fowler JH (2007) The spread of obesity in a large social network
over 32 years. New England Journal of Medicine 357(4): 370–379.
14. Laibson D (1998) Self control and saving for retirement. Brookings Papers on
Economic Activity 1: 91–172.
See also London Cycle Hire: www.tfl.gov.uk/barclayscyclehire
@.5%,#(5,0*(
1.
Featherstone H and Whitham L (2010) Careless: Funding Long-term Care for
the Elderly. London: Policy Exchange.
2.
Office for National Statistics (2007) 2006 Based Projections.
3.
Botsman R and Rogers R (2010) What’s Mine is Yours: The Rise of Collaborative
Consumption. New York: HarperCollins.
4.
Department for Communities and Local Government (2010) Local Authority
Resource Account.
5.
Lietaer B (2004) Complementary currencies in Japan today: History, originality and
relevance. International Journal of Community Currency Research 8: 1–23.
6.
Cacioppo JT and Patrick W (2008) Loneliness: Human Nature and the Need for
Social Connection. New York: Norton and Co.
7.
Halpern D (2010) The Hidden Wealth of Nations. Cambridge: Polity Press.
8.
Berkman L (1983) The assessment of social networks and social support in the
elderly. Journal of the American Geriatrics Society 31(12): 743–749.
9.
Cohen S, Doyle W, Skoner D et al. (1997) Social ties and susceptibility to the
common cold. Journal of the American Medical Association 277 (24): 1940–1944.
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disruption, and immune function. Psychosomatic Medicine 49(1): 13–34.
This is a discussion paper. Its purpose is to encourage
public debate.
Published by the Cabinet Office Behavioural Insights Team
Publication date: December 2010
© Crown copyright 2010
Behavioural Insights Team
Issue Date: October 2007
Behaviour change at
population, community
and individual levels
NICE public health guidance 6
1
NICE public health guidance 6
‘Behaviour change at population, community and individual levels'
Ordering information
You can download the following documents from www.nice.org.uk/PH006
• The NICE guidance (this document) which includes all the
recommendations and details of how they were developed.
• A quick reference guide for professionals and the public.
• Supporting documents, including an evidence review and an economic
analysis.
For printed copies of the quick reference guide, phone the NHS Response
Line on 0870 1555 455 and quote N1230.
This guidance represents the views of the Institute and was arrived at after
careful consideration of the evidence available. Those working in the NHS,
local authorities, the wider public, voluntary and community sectors and the
private sector should take it into account when carrying out their professional,
managerial or voluntary duties.
National Institute for Health and Clinical Excellence
MidCity Place
71 High Holborn
London
WC1V 6NA
www.nice.org.uk
© National Institute for Health and Clinical Excellence, 2007. All rights reserved. This material
may be freely reproduced for educational and not-for-profit purposes. No reproduction by or
for commercial organisations, or for commercial purposes, is allowed without the express
written permission of the Institute.
2
Introduction
The Department of Health asked the National Institute for Health and Clinical
Excellence (NICE or the Institute) to produce public health guidance on the
most appropriate generic and specific interventions to support attitude and
behaviour change at population and community levels.
This guidance provides a set of generic principles that can be used as the
basis for planning, delivering and evaluating public health activities aimed at
changing health-related behaviours. The guidance should be read in
conjunction with other topic-specific public health guidance issued by NICE. It
does not replace any of this guidance.
Future NICE guidance that aims to change people’s behaviour will be based
on the principles outlined in this guidance.
The guidance is for NHS and non-NHS professionals and others who have a
direct or indirect role in, and responsibility for, helping people change their
health-related knowledge, attitudes and behaviour. This includes national
policy makers in health and related sectors (including those with a
responsibility for planning or commissioning media, marketing or other
campaigns), and commissioners, providers and practitioners in the NHS, local
government, the community and voluntary sectors. It is also relevant for the
research community (including those who oversee research funding), social
and behavioural scientists, and health economists working in the area of
health-related knowledge, attitude and behaviour change.
The Programme Development Group (PDG) has considered a range of
evidence, key theories, economic data, stakeholder comments and the results
of fieldwork in developing these recommendations.
Details of membership of the PDG are given in appendix A. The methods
used to develop the guidance are summarised in appendix B. Supporting
documents used in the preparation of this document are listed in appendix E.
Full details of the evidence collated, including fieldwork data and activities and
3
stakeholder comments, are available on the NICE website, along with a list of
the stakeholders involved and the Institute’s supporting process and methods
manuals. The website address is: www.nice.org.uk
This guidance was developed using the NICE public health programme
process.
4
Contents
1
Public health need and practice................................................................6
2
Considerations..........................................................................................8
3
Recommendations..................................................................................19
4
Implementation .......................................................................................27
5
Recommendations for research..............................................................28
6
Updating the recommendations ..............................................................31
7
Related NICE guidance ..........................................................................32
8
References .............................................................................................32
9
Glossary..................................................................................................35
Appendix A: membership of the Programme Development Group, the NICE
Project Team and external contractors ..........................................................37
Appendix B: summary of the methods used to develop this guidance ...........41
Appendix C: the evidence ..............................................................................50
Appendix D: gaps in the evidence..................................................................55
Appendix E: supporting documents ...............................................................56
5
1 Public health need and practice
There is overwhelming evidence that changing people’s health-related
behaviour can have a major impact on some of the largest causes of mortality
and morbidity. The Wanless report (Wanless 2004) outlined a position in the
future in which levels of public engagement with health are high, and the use
of preventive and primary care services are optimised, helping people to stay
healthy. This ‘fully engaged’ scenario, identified in the report as the best
option for future organisation and delivery of NHS services, requires changes
in behaviours and their social, economic and environmental context to be at
the heart of all disease prevention strategies.
Behaviour plays an important role in people’s health (for example, smoking,
poor diet, lack of exercise and sexual risk-taking can cause a large number of
diseases). In addition, the evidence shows that different patterns of behaviour
are deeply embedded in people’s social and material circumstances, and their
cultural context.
Interventions to change behaviour have enormous potential to alter current
patterns of disease. A genetic predisposition to disease is difficult to alter.
Social circumstances can also be difficult to change, at least in the short to
medium term. By comparison, people’s behaviour – as individuals and
collectively – may be easier to change. However, many attempts to do this
have been unsuccessful, or only partially successful. Often, this has been
because they fail to take account of the theories and principles of successful
planning, delivery and evaluation. At present, there is no strategic approach to
behaviour change across government, the NHS or other sectors, and many
different models, methods and theories are being used in an uncoordinated
way.
Identifying effective approaches and strategies that benefit the population as a
whole will enable public health practitioners, volunteers and researchers to
operate more effectively, and achieve more health benefits with the available
resources.
6
Health inequalities
Social and economic position is directly linked to health. In the UK, there is a
health inequalities gradient, with the least advantaged experiencing the worst
health. Social and economic conditions can prevent people from changing
their behaviour to improve their health, and can also reinforce behaviours that
damage it.
Health inequalities are the result of a set of complex interactions, including:
•
the long-term effects of a disadvantaged social position
•
differences in access to information, services and resources
•
differences in exposure to risk
•
lack of control over one’s own life circumstances
•
a health system that may reinforce social and economic inequalities.
These factors all affect people’s ability to withstand the stressors – biological,
social, psychological and economic – that can trigger ill health. They also
affect the capacity to change behaviour.
Changing behaviour
Actions to bring about behaviour change may be delivered at individual,
household, community or population levels using a variety of means or
techniques. The outcomes do not necessarily occur at the same level as the
intervention itself. For example, population-level interventions may affect
individuals, and community- and family-level interventions may affect whole
populations.
Significant events or transition points in people’s lives present an important
opportunity for intervening at some or all of the levels, because it is then that
people often review their own behaviour and contact services. Typical
transition points include: leaving school, entering the workforce, becoming a
parent, becoming unemployed, retirement and bereavement.
7
This guidance provides a systematic, coherent and evidence-based approach,
considering generic principles for changing people’s health-related
knowledge, attitudes and behaviour, at individual, community and population
levels.
Strategies for reaching and working with disadvantaged groups are
considered and the health equity implications assessed.
2 Considerations
The PDG took account of a number of factors and issues in making the
recommendations.
Key theories
2.1
The PDG was influenced by a number of different theories, concepts
and accounts of behaviour and behaviour change, drawn from the
social and behavioural sciences. These include: resilience, coping,
self-efficacy, planned behaviour, structure and agency, ‘habitus’ and
social capital. (Ajzen 1991, 2001; Antonovsky 1985, 1987; Bandura
1997; Bourdieu 1977, 1986; Conner and Sparks 2005; Giddens 1979,
1982, 1984; Lazarus 1976, 1985; Lazarus and Folkman 1984;
Morgan and Swann 2004; Putnam 2000.) (For more details see
appendix A.)
2.2
The PDG discussed efforts to use policy and legislation to change
behaviour (although relatively little formal evidence on legislation was
identified). Such measures tend to work through a combination of
awareness-raising, compulsion and enforcement, providing legislative
or environmental ‘structure’ to the decisions people make about their
behaviour. It was noted that legislation can appear to be a simple and
powerful tool, and the evidence suggests that introducing legislation,
in conjunction with other interventions, can be effective at the
individual, community and population levels. However, it also
suggests that it can be subject to contingencies and side effects,
8
including criminalisation, compensating or displaced behaviour, and
lack of public support (Gostin 2000; Haw et al. 2006; WHO 2005).
2.3
The PDG observed that people’s health behaviours may change,
depending on their social and material circumstances and their time
of life. It was also noted that many other factors (such as place of
birth, parental income, education and employment opportunities, or
the impact of prejudice and discrimination) can have both direct and
indirect effects on health, and on people’s ability to change, leading
to a cumulative effect over the life course (Graham and Power 2004;
Kuh et al. 1997). The PDG considered the concept of the life course
and evidence was sought on the potential benefits of intervening at
key life stages or transition points. Explicit, formal evidence (at the
level searched) was scarce.
2.4
The PDG further noted that the knowledge and evidence from
different disciplines are very different in the concepts they use, the
assumptions they make about cause and explanation, and
(sometimes) the methods that they favour. Consequently, combining
knowledge and evidence from different levels – such as the social
and the individual – is extremely difficult. To ensure that as broad a
range as possible of knowledge and evidence was taken into
account, the PDG adopted a pluralistic approach that acknowledged
the value of different forms of evidence and research methods.
2.5
The psychological literature is extensive and provides a number of
general models of health behaviour and behaviour change. However,
the research literature evaluating the relevance and use of these
models is inconsistent. For example, it includes multiple adaptations
of particular models, poor study designs and studies that fail to take
account of all the confounding factors. Having considered some of
the more commonly used models of health behaviour, the PDG
concluded that the evidence did not support any particular model
(although some have more evidence of effectiveness than others).
For this reason, it believes training should focus on generic
9
competencies and skills, rather than on specific models. These
include the ability to:
•
critically evaluate the evidence for different approaches to
behaviour change
•
design valid and reliable interventions and programmes, that take
account of the social, environmental and economic context of
behaviours
•
Identify and use clear and appropriate outcome measures to
assess changes in behaviour
•
employ a range of behaviour change methods and approaches,
according to the best available evidence
•
regularly review the allocation of resources to interventions and
programmes in light of current evidence.
Definitions
2.6
For the purposes of this guidance, human behaviour is defined as:
’the product of individual or collective human actions, seen within and
influenced by their structural, social and economic context’. These
actions produce observable social, cultural and economic patterns
which limit – or enable – what individuals can do. The
recommendations in this guidance span the individual, social and
group processes involved in human behaviour.
2.7
The PDG considered the psychological models showing relationships
between knowledge, attitudes and behaviour, according to the
various definitions outlined in the identified literature. The PDG noted
that for some actions the links between intentions and behaviour can
be described precisely. However, simple models do not capture more
complex or population-level dynamics.
2.8
Although the evidence on psychological models was found to be
limited, a number of concepts drawn from the psychological literature
are helpful when planning work on behaviour change with individuals.
10
When used in conjunction with recommendations here on planning
and social context, these concepts could be used to structure and
inform interventions. They include:
•
outcome expectancies (helping people to develop accurate
knowledge about the health consequences of their behaviours)
•
personal relevance (emphasising the personal salience of health
behaviours)
•
positive attitude (promoting positive feelings towards the
outcomes of behaviour change)
•
self-efficacy (enhancing people’s belief in their ability to change)
•
descriptive norms (promoting the visibility of positive health
behaviours in people’s reference groups – that is, the groups they
compare themselves to, or aspire to)
•
subjective norms (enhancing social approval for positive health
behaviours in significant others and reference groups)
•
personal and moral norms (promoting personal and moral
commitments to behaviour change)
•
intention formation and concrete plans (helping people to form
plans and goals for changing behaviours, over time and in
specific contexts)
•
behavioural contracts (asking people to share their plans and
goals with others)
•
relapse prevention (helping people develop skills to cope with
difficult situations and conflicting goals).
2.9
Coordinated attempts to promote or support behaviour change can
take a number of forms. These activities can also be delivered at a
number of levels, ranging from local, one to one interactions with
individuals to national campaigns. Many terms are used to describe
these activities and sometimes these are used interchangeably (see
glossary). Broadly, interventions can be divided into four main
categories:
11
•
policy – such as legislation, workplace policies or voluntary
agreements with industry
•
education or communication – such as one to one advice, group
teaching or media campaigns
•
technologies – such as the use of seat belts, breathalysers or
child proof containers for toxic products
•
resources – such as leisure centre entry, free condoms or free
nicotine replacement therapy.
2.10 This guidance adopts the NICE definitions for public health
interventions and programmes, unless another specific term has
been used in the literature (such as ‘campaign’ to refer to a media
initiative). See ‘The public health guidance development process: an
overview for stakeholders including public health practitioners, policy
makers and the public’ (details in appendix E).
2.11 Whether an intervention or programme is delivered to individuals, in
community or family settings, or at population level, the effects are
rarely restricted to one level. For example, a brief primary care
intervention aimed at reducing alcohol consumption among
individuals could have an impact:
• on the individual’s behaviour (for example, level of alcohol
consumption, individual health outcomes, or incidence of
domestic violence)
• on the local community (for example, local alcohol sales, alcoholrelated crime or accident and emergency [A&E] events)
• at population level (for example, national alcohol sales and
consumption, national statistics on alcohol-related crime and A&E
events, or demographic patterns of liver cirrhosis).
Planning and design
2.12 The PDG noted that it is important to specify three things with respect
to any intervention that aims to change behaviour. First, be as
12
specific as possible about its content. Second, spell out what is done,
to whom, in what social and economic context, and in what way.
Third, make it clear which underlying theories will help make explicit
the key causal links between actions and outcomes (Davidson et al.
2003; Pawson 2006; Weiss 1995). The PDG noted that the evidence
is often very weak in these respects.
2.13 It is important for those planning health improvement interventions to
be clear about the behaviours that need to be changed, any relevant
contextual changes that also need to be made, and the level at which
the intervention will be delivered (individual, community or
population). The following questions should be used as a guide:
• Whose health are you seeking to improve (target population/s)?
• What behaviour are you seeking to change (behavioural target)?
• What contextual factors need to be taken into account (what are
the barriers to and opportunities for change and what are the
strengths/potential of the people you are working with)?
• How will you know if you have succeeded in changing behaviour
(what are your intended outcomes and outcome measures)?
• Which social factors may directly affect the behaviour, and can
they be tackled?
• What assumptions have been made about the theoretical links
between the intervention and outcome?
2.14 A range of resources provide access to good quality, up-to-date
evidence on the effectiveness of interventions and programmes
aimed at changing behaviour. These include: NICE public health
guidance, research and review databases (for example, the
Database of Abstracts of Reviews of Effectiveness, the Cochrane
Library, Medline, and the Social Science Citation Index), and current
texts on behaviour change (for example, Conner and Norman 2005).
13
When drawing up plans to change people’s behaviour, enough time
needs to be set aside to consult these resources to establish which
interventions and programmes will be most appropriate.
2.15 Time and resources should be set aside for evaluation. The size and
nature of the intervention, its aims and objectives and the underlying
theory of change used should determine the form of evaluation (see
below).
2.16 Attempts to change behaviour have not always led to universal
improvements in the population’s health. For example, different
groups (measured by age, socioeconomic position, ethnicity or
gender) react differently to incentives and disincentives, or ‘fear’
messages. Effective interventions target specific groups and are
tailored to meet their needs. This is particularly important where
health equity is one of the goals. Service user views may be helpful
when planning interventions.
2.17 The cultural acceptability and value of different forms of behaviour
varies according to age, ethnicity, gender and socioeconomic
position. It is important not to stereotype or stigmatise groups or
individuals because of these variations. This can be avoided by
working closely with communities over time, by tackling prejudice and
discrimination in professional practice, and by using needs
assessments to gather local and cultural information to ensure
interventions are tailored appropriately.
2.18 Changing behaviour may not be a priority for the individuals being
targeted. People do not necessarily make their own long-term health
a priority and may want to focus on other, more immediate needs and
goals (for example, relieving stress, or complying with peer pressure).
2.19 Some damaging and, therefore, apparently negative health
behaviours may provide positive psychological, social or physical
benefits for individuals in certain social and cultural contexts. For
example, smoking cigarettes may provide ‘time out’ for people in
14
difficult circumstances. Effective interventions take account of the
social, cultural and economic acceptability of the intervention and the
target group’s attitudes toward the behaviour. They recognise
diversity in the values people use to guide their lives and behaviour.
2.20 Interventions may have unintended and negative consequences.
When planning an intervention, it is often helpful to conduct a
prospective health and equity impact assessment.
2.21 No single method can be universally applied to influence all
behaviour and all people. Universal interventions do not invariably
have uniform effects, and may be more effective among some
population groups, or in some settings, than others.
2.22 An intervention aimed at changing one behaviour may inadvertently
lead to other changes. For example, someone who gives up smoking
may start eating more food to compensate, leading to other health
risks.
2.23 Motivated individuals actively seeking to make changes in their
behaviour require a different approach from those who are
unmotivated. The latter may need more information about the
benefits of change, as well a realistic plan of action. Equally, different
methods may be required at different times and to reach different
people. This guidance identifies the broad principles.
2.24 Enabling individuals and communities to develop more control (or
enhancing their perception of control) over their lives can act as a
buffer against the effects of disadvantage, facilitating positive
behaviour change.
2.25 A range of cognitive, social and environmental resources can help to
boost the resilience of people living in difficult circumstances. These
resources can help promote their health and protect them against
illness and other negative outcomes. They include a positive attitude
to health (leading to positive, health-related behaviours), coping skills
15
and ‘social capital’, the relationships of trust and reciprocity built up
through, for example, friendship, family and faith networks.
2.26 Action taken earlier, rather than later, in an individual’s life can
sometimes be more effective at preventing health-damaging
behaviours. Consequently, interventions that focus on children and
young people (and usually, their carers too) are important. However,
interventions with other population groups can be highly effective and
cost effective. An example is action to prevent falls among older
people.
2.27 All interventions need to be developed and evaluated in stages, using
an established approach such as the Medical Research Council’s
framework for the development and evaluation of complex
interventions (Campbell et al. 2000; see also Campbell et al. 2007;
Flay 1986; Nutbeam 1998). Such an approach will help ensure
interventions are based on the best available evidence of feasibility,
acceptability, safety, effectiveness, efficiency or equity.
Delivery
2.28 As well as focusing on individual factors, it is important that policy
makers and commissioners take steps to address the social,
environmental, economic and legislative factors that affect people’s
ability to change their behaviour.
2.29 A large number of mechanisms could be used to influence behaviour
but the amount of evidence varies. Generally, there is far more
evidence on activities aimed at individuals than on policies and other
activities aimed at tackling the wider determinants of health. The
evidence on efficacy and equity is also variable. The PDG could not
review all the possibilities, but noted that the following mechanisms
were successful in some circumstances:
•
legislation and taxation
•
mass media campaigns
16
•
social marketing
•
community programmes
•
point of sale promotions.
2.30 Population-level interventions have the greatest potential, however, if
supported by government and implemented effectively. (Legislation
making it compulsory to wear seatbelts in the front seats of cars is an
example of a highly effective, population-level intervention.)
2.31 Epidemiological theory suggests that even small degrees of change,
over time, can result in significant improvements in population-level
health (Rose 1985). Population-level interventions could be an
effective and cost-effective way of changing behaviour.
2.32 The PDG noted that a wide range of policies and the actions of a
range of government and non-governmental organisations impact
directly and indirectly on health. (Relevant policies and actions
include those related to taxation, the licensing laws and the benefits
system.) This could be explicitly acknowledged by carrying out
routine health impact assessments on how a policy, law or system
affects people’s health-related behaviour. It could also be
acknowledged through partnership and cross-government working.
2.33 The level of skills, knowledge and the competencies required by
those providing health-related interventions will differ, according to
their specific role. However, some are central to most public health
activity. These include: knowledge of the full range of difference
approaches to behaviour change, competence in planning and
evaluation, understanding the principles of non-discriminatory
practice; and the ability to use evidence from research and practice.
2.34 The PDG noted that the capacity of the public health workforce
requires assessment. An education and training strategy to support
the development needs of those involved in helping to change
people’s behaviour (within both NHS and non-NHS settings) could
improve effectiveness. National training standards to reflect the skills
17
and competencies described in the recommendations would support
their implementation.
Evaluation
2.35 The distinction between monitoring and evaluation is important.
Monitoring involves routinely collecting information on a day to day
basis and using shared information resources and statistics to keep
local and national health activity under surveillance. It is part of
quality and safety assurance. Evaluation, on the other hand, is the
formal assessment of the process and impact of a programme or
intervention. Where an intervention is employed that has already
been rigorously evaluated (for example, in NICE public health
guidance) and demonstrated to be effective in equivalent conditions,
then monitoring, rather than a full evaluation, is likely to be sufficient.
2.36 Complex public health interventions can be systematically evaluated,
based on the relevant theory and evidence, if they use a wellplanned, ‘staged’ approach to evaluation.
2.37 Formal outcome and process evaluation can be challenging, but it is
an important way of assessing efforts to change behaviour. An
effective evaluation is based on clearly defined outcome measures –
at individual, community and population levels, as appropriate.
Qualitative research looking at the experience, meaning and value of
changes to individuals may also be appropriate. Methods and
outcome measures are identified during the planning phase. In
addition, effective interventions specify their ‘programme theory’ (or
reason why particular actions are expected to have particular
outcomes). They also use a framework of ‘action – reason –
outcome’ to guide evaluation (Campbell et al. 2000; Campbell et al.
2007; Flay 1986; Nutbeam 1998; Pawson 2006; Weiss 1995).
18
3 Recommendations
This document is the Institute’s formal guidance on generic principles that
should be used as the basis of initiatives to support attitude and behaviour
change. When developing the principles the PDG (see appendix A)
considered the evidence of effectiveness (including cost effectiveness),
relevant theory, fieldwork data and comments from stakeholders. Full details
are available on the Institute’s website at: www.nice.org.uk/PH006.
The reviews that informed this guidance are listed in appendix B. The
evidence reviews, supporting evidence statements and economic appraisal
are available on the Institute’s website at: www.nice.org.uk/PH006.
Key theories, concepts, and other evidence that informed this guidance are
listed in appendix C.
On the basis of the evidence considered, the PDG believes that where
interventions and programmes are applied appropriately, according to the
principles outlined in this guidance and in conjunction with other topic-specific
NICE guidance, then they are likely be cost effective. In some circumstances,
they will save money.
For the research recommendations and other gaps in the evidence see
section 5 and appendix D, respectively.
The guidance highlights the need to:
• Plan carefully interventions and programmes aimed at changing behaviour,
taking into account the local and national context and working in
partnership with recipients. Interventions and programmes should be based
on a sound knowledge of community needs and should build upon the
existing skills and resources within a community.
• Equip practitioners with the necessary competencies and skills to support
behaviour change, using evidence-based tools. (Education providers
should ensure courses for practitioners are based on theoretically informed,
evidence-based best practice.)
19
• Evaluate all behaviour change interventions and programmes, either locally
or as part of a larger project. Wherever possible, evaluation should include
an economic component.
Planning
Principle 1: planning interventions and programmes
Target audience
Policy makers, commissioners, service providers, practitioners and others
whose work impacts on, or who wish to change, people’s health-related
behaviour.
Recommended action
• Work in partnership with individuals, communities, organisations and
populations to plan interventions and programmes to change health-related
behaviour. The plan should:
− be based on a needs assessment or knowledge of the target
audience
− take account of the circumstances in which people live,
especially the socioeconomic and cultural context
− aim to develop – and build on – people’s strengths or ‘assets’
(that is, their skills, talents and capacity)
− set out how the target population, community or group will be
involved in the development, evaluation and implementation
of the intervention or programme
− specify the theoretical link between the intervention or
programme and its outcome
− set out which specific behaviours are to be targeted (for
example, increasing levels of physical activity) and why
− clearly justify any models that have been used to design and
deliver an intervention or programme
20
− assess potential barriers to change (for example, lack of
access to affordable opportunities for physical activity,
domestic responsibilities, or lack of information or resources)
and how these might be addressed
− set out which interventions or programmes will be delivered
and for how long
− describe the content of each intervention or programme
− set out which processes and outcomes (at individual,
community or population level) will be measured, and how
− include provision for evaluation.
• Prioritise interventions and programmes that:
− are based on the best available evidence of efficacy and cost
effectiveness
− can be tailored to tackle the individual beliefs, attitudes,
intentions, skills and knowledge associated with the target
behaviours
− are developed in collaboration with the target population,
community or group and take account of lay wisdom about
barriers and change (where possible)
− are consistent with other local or national interventions and
programmes (where they are based on the best available
evidence)
− use key life stages or times when people are more likely to be
open to change (such as pregnancy, starting or leaving school
and entering or leaving the workforce)
− include provision for evaluation.
• Disinvest in interventions or programmes if there is good evidence to
suggest they are not effective.
• Where there is poor or no evidence of effectiveness (or the evidence is
mixed) ensure that interventions and programmes are properly evaluated
whenever they are used.
21
• Help to develop social approval for health-enhancing behaviours, in local
communities and whole populations.
Principle 2: assessing social context
Target audience
NHS and non-NHS policy makers and commissioners planning behaviour
change interventions or programmes for communities or populations,
especially disadvantaged or excluded groups.
Recommended action
• Identify and attempt to remove social, financial and environmental barriers
that prevent people from making positive changes in their lives, for
example, by tackling local poverty, employment or education issues.
• Consider in detail the social and environmental context and how it could
impact on the effectiveness of the intervention or programme.
• Support structural improvements to help people who find it difficult to
change, or who are not motivated. These improvements could include
changes to the physical environment or to service delivery, access and
provision.
Principle 3: education and training
Target audience
Policy makers, commissioners, trainers, service providers, curriculum
developers and practitioners.
Recommended action
•
Provide training and support for those involved in changing people’s
health-related behaviour so that they can develop the full range of
competencies required. These competencies include the ability to:
22
− identify and assess evidence on behaviour change
− understand the evidence on the psychological, social,
economic and cultural determinants of behaviour
− interpret relevant data on local or national needs and
characteristics
− design, implement and evaluate interventions and
programmes
− work in partnership with members of the target population(s)
and those with local knowledge.
• Appropriate national organisations (for example, the Faculty of Public
Health, the British Psychological Society, the Chartered Institute of
Environmental Health and the Nursing and Midwifery Council) should
consider developing standards for these competencies and skills. The
standards should take into account the different roles and responsibilities of
practitioners working both within and outside the NHS.
• Ensure fair and equitable access to education and training, to enable
practitioners and volunteers who help people to change their health-related
behaviour to develop their skills and competencies.
• Review current education and training practice in this area, and disinvest in
approaches that lack supporting evidence.
Delivery
Principle 4: individual-level interventions and programmes
Target audience
Commissioners, service providers and practitioners working with individuals.
Recommended action
•
Select interventions that motivate and support people to:
23
− understand the short, medium and longer-term consequences
of their health-related behaviours, for themselves and others
− feel positive about the benefits of health-enhancing
behaviours and changing their behaviour
− plan their changes in terms of easy steps over time
− recognise how their social contexts and relationships may
affect their behaviour, and identify and plan for situations that
might undermine the changes they are trying to make
− plan explicit ‘if–then’ coping strategies to prevent relapse
− make a personal commitment to adopt health-enhancing
behaviours by setting (and recording) goals to undertake
clearly defined behaviours, in particular contexts, over a
specified time
− share their behaviour change goals with others.
Principle 5: community-level interventions and programmes
Target audience
NHS and non-NHS policy makers and commissioners planning behaviour
change interventions and programmes for communities or subgroups in the
population.
Recommended action
• Invest in interventions and programmes that identify and build on the
strengths of individuals and communities and the relationships within
communities. These include interventions and programmes to:
− promote and develop positive parental skills and enhance
relationships between children and their carers
− improve self-efficacy
− develop and maintain supportive social networks and
nurturing relationships (for example, extended kinship
networks and other ties)
24
− support organisations and institutions that offer opportunities
for local people to take part in the planning and delivery of
services
− support organisations and institutions that promote
participation in leisure and voluntary activities
− promote resilience and build skills, by promoting positive
social networks and helping to develop relationships
− promote access to the financial and material resources
needed to facilitate behaviour change.
Principle 6: population-level interventions and programmes
Target audience
National policy makers, commissioners and others whose work impacts on
population-level health-related behaviour.
Recommended action
• Deliver population-level policies, interventions and programmes tailored to
change specific, health-related behaviours. These should be based on
information gathered about the context, needs and behaviours of the target
population(s). They could include:
− fiscal and legislative interventions
− national and local advertising and mass media campaigns (for
example, information campaigns, promotion of positive role
models and general promotion of health-enhancing
behaviours)
− point of sale promotions and interventions (for example,
working in partnership with private sector organisations to
offer information, price reductions or other promotions).
• Ensure population-level interventions and programmes aiming to change
behaviour are consistent with those delivered to individuals and
communities.
25
• Ensure interventions and programmes are based on the best available
evidence of effectiveness and cost effectiveness.
• Ensure the risks, costs and benefits have been assessed for all target
groups.
Evaluation
Principle 7: evaluating effectiveness
Target audience
Researchers, policy makers, commissioners, service providers and
practitioners whose work impacts on, or who wish to change, people’s healthrelated behaviour.
Recommended action
•
Ensure funding applications and project plans for new interventions and
programmes include specific provision for evaluation and monitoring.
•
Ensure that, wherever possible, the following elements of behaviour
change interventions and programmes are evaluated using appropriate
process or outcome measures:
− effectiveness
− acceptability
− feasibility
− equity
− safety.
Principle 8: assessing cost effectiveness
Target audience
Policy makers, research funders, researchers and health economists.
26
Recommended action
•
Collect data for cost-effectiveness analysis, including quality of life
measures. Where practicable, estimate the cost savings (if any) when
researching or evaluating behaviour change interventions and
programmes. This is particularly pertinent for research:
− on mid- to long-term behaviour change
− comparing the effectiveness and efficiency of interventions
and programmes delivered to different population groups (for
example, low- versus high-income groups, men versus
women, young versus older people)
− comparing the cost effectiveness of primary prevention versus
clinical treatment for behaviour-related diseases.
4 Implementation
NICE guidance can help:
• NHS organisations meet DH standards for public health as set out in the
seventh domain of ‘Standards for better health’ (updated in 2006).
Performance against these standards is assessed by the Healthcare
Commission, and forms part of the annual health check score awarded to
local healthcare organisations.
• NHS organisations and local authorities (including social care and
children’s services) meet the requirements of the government’s ‘National
standards, local action, health and social care standards and planning
framework 2005–2008’.
• National and local organisations within the public sector meet government
indicators and targets to improve health and reduce health inequalities.
• Local authorities fulfil their remit to promote the economic, social and
environmental wellbeing of communities.
27
• Local NHS organisations, local authorities and other local public sector
partners benefit from any identified cost savings, disinvestment
opportunities or opportunities for re-directing resources.
• Provide a focus for children’s trusts, health and wellbeing partnerships and
other multi-sector partnerships working on health within a local strategic
partnership.
NICE has developed tools to help organisations implement this guidance. The
tools will be available on our website (www.nice.org.uk/PH006).
• Slides highlighting key messages for local discussion.
• Costing statement.
5 Recommendations for research
The PDG has made the following recommendations to plug the most
important gaps in the evidence.
Recommendation 1
Who should take action?
Research councils, national and local research commissioners and funders,
research workers and journal editors.
What action should they take?
• Include as standard in research reports:
− a description of what was delivered, over what period, to
whom and in what setting
− information on the impact on health
− clear definitions of the ‘health outcomes’ measured
− a report of differences in access, recruitment, and (where
relevant data are available) uptake, according to socio-
28
economic and cultural variables such as social class,
education, gender, income or ethnicity
− a description and rationale of the research methods and forms
of interpretation used, and where relevant the reliability and
validity of the measures of behaviour change adopted.
• Ensure research studies on behaviour change always:
− identify and account for the different components of change
among different social groups
− pay attention to minority ethnic and religious groups
− include social variables wherever possible (for example,
social class or education) in every study
− consider the impact of age and gender on the effectiveness of
interventions and programmes.
• Promote the inclusion of process as well as outcome data.
• Encourage those in charge of randomised controlled trials on health-related
behaviour change to register with a trial register.
Recommendation 2
Research commissioners and funders.
• Encourage research that takes into account the social and cultural contexts
in which people adapt or change their behaviour and the factors that
encourage or inhibit change. These include:
− the role of support networks, neighbourhood resources and
community action
− the relationships that help protect and build people’s
resilience
29
− the way people adapt positively to adverse socio-structural
conditions
− social processes that strengthen the mutual support provided
by families and other forms of households
− the clustering of health behaviours
− the material circumstances in which people live, including
income levels, environmental characteristics of
neighbourhoods and work-related factors.
• Use embedded process evaluations that include the perspectives of
recipients.
• When studying the mechanisms of adaptation and change, use mixed
method ethnographic research, longitudinal studies and qualitative
approaches, as well as multivariate and interactive statistical models.
• Support development of new methods for collating and synthesising a
range of evidence on effectiveness. These methods should meet the
highest scientific standards.
Recommendation 3
Policy makers, research commissioners and local service providers.
• Collect baseline data at the outset of interventions or policy changes and
allow for an adequate length of time for evaluation.
• Develop evaluative approaches which can accommodate the complexities
inherent in community and population-level interventions or programmes,
including multiple and confounding factors.
30
• Develop methods for synthesising and interpreting results across studies
conducted in different localities, policy environments and population
groups.
• Formulate rigorous and transparent methods for assessing external validity
and for translating evidence into practice.
Recommendation 4
Policy makers, research funders and health economists.
As a matter of urgency, commission research on the cost-effectiveness of
behaviour change interventions. This should cover:
• interventions over the mid to long term
• interventions aimed at specific population groups (for example, low-income
groups, men versus women, young people versus older people)
• primary prevention versus clinical treatment for behaviour-related disease.
More detail on the evidence gaps identified during the development of this
guidance is provided in appendix D.
6 Updating the recommendations
NICE public health guidance is updated as needed so that recommendations
take into account important new information. We check for new evidence 2
and 4 years after publication, to decide whether all or part of the guidance
should be updated. If important new evidence is published at other times, we
may decide to update some recommendations at that time.
31
7 Related NICE guidance
Much of NICE guidance, both published and in development, is concerned
with changing people’s knowledge, attitudes and behaviours to prevent and
tackle disease and illness. For more details go to: www.nice.org.uk/guidance
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Wanless D (2004) Securing good health for the whole population: final report.
London: HM Treasury.
Weiss CH (1995) Nothing as practical as good theory: exploring theory-based
evaluation for comprehensive community initiatives for children and families.
In Connell JP, Kubisch A, Schorr LB et al. editors. New approaches to
evaluating community initiatives: concepts, methods and context. Washington
DC: Aspen Institute.
WHO (2005) Seventh futures forum on unpopular decisions in public health.
Regional office for Europe [online]. Available from:
www.euro.who.int/InformationSources/Publications/Catalogue/20050608_1
34
9 Glossary
Assets
Assets are the skills, talents and capacity that individuals, associations and
organisations can share to improve the life of a community. An assets
approach focuses on the strengths rather than the weaknesses (or
deficiencies) found in groups or communities.
Communities
For the purposes of this guidance, communities are defined as social or family
groups linked by networks, geographical location or another common factor.
Determinants of health
The wide range of personal, social, economic and environmental factors
which determine the health status of people or communities. These include
health behaviours and lifestyles, income, education, employment, working
conditions, access to health services, housing and living conditions and the
wider general material and social environment.
Health inequalities
The gap or gradient in health, usually measured by mortality and morbidity,
between population groups identified by social characteristics, including
different social classes, ethnic groups, wealth and income groups, genders,
educational groups, housing and geographical areas.
Interventions
Clearly circumscribed actions that help promote or maintain a healthy lifestyle.
Life course
The life course is a term used in social epidemiology to describe the
accumulation of material, social and biological advantages and disadvantages
during a lifetime.
Population
The aggregate of individuals defined by membership of a social, geographic,
35
political or economic unit (for example, members of a state, a region, a city or
a cultural group).
Programmes
Multi-agency, multi-packages and/or a series of related policies, services and
interventions or other actions focused on broad strategic issues. They can
involve a suite of activities that may be topic, setting or population based –
and may involve changes to organisational infrastructures.
Promoting and supporting behaviour change
A number of terms are used to describe attempts to promote or support
behaviour change and sometimes these are used interchangeably. They
include: initiative, scheme, action, activity, campaign, policy, strategy,
procedure, programme, intervention and project.
Resilience
The ability to withstand or even respond positively to stressors, crises or
difficulties.
Self-efficacy
Self-efficacy is a person’s estimate or personal judgment of his or her own
ability to succeed in reaching a specific goal.
Social capital
Social capital is commonly defined as those features of a society, such as
networks, social trust and cohesion, that facilitate cooperation among people
for mutual benefit.
Socioeconomic status
A person’s position in society, as determined by criteria such as income, level
of education achieved, occupation and value of property owned.
Transition points
Points of change during a lifetime or the life course (for a definition of life
course, see above). Examples include: leaving school, entering or leaving a
significant relationship, starting work, becoming a parent or retiring from work.
36
Appendix A: membership of the Programme
Development Group, the NICE Project Team and
external contractors
The Programme Development Group (PDG)
PDG membership is multidisciplinary. It comprises researchers, practitioners,
stakeholder representatives and members of the public as follows.
Professor Charles Abraham Professor of Psychology, Department of
Psychology, University of Sussex
(CHAIR) Professor Mildred Blaxter Hon. Professor of Medical Sociology,
Department of Social Medicine, Bristol University
Dr Vicky Cattell Senior Research Fellow, Centre for Psychiatry, Queen Mary,
University of London
Ms Vimla Dodd Community Member
Professor Christine Godfrey Professor of Health Economics, Department of
Health Sciences and Centre for Health Economics, University of York
Dr Karen Jochelson Fellow, Health Policy, King's Fund
Ms Miranda Lewis Senior Research Fellow, Institute for Public Policy
Research
Mr Terence Lewis Community Member
Professor Miranda Mugford Professor of Health Economics, School of
Medicine and Health Policy and Practice, University of East Anglia
Professor Ray Pawson Professor of Social Research Methodology and
Research Director, School of Sociology and Social Policy, University of Leeds
Professor Jennie Popay Professor of Sociology and Public Health, Institute
for Health Research, University of Lancaster
Professor Wendy Stainton Rogers Professor of Health Psychology, Faculty
of Health and Social Care, The Open University
Professor Stephen Sutton Professor of Behavioural Science, Institute of
Public Health, University of Cambridge
37
Professor Martin White Professor of Public Health, Institute of Health and
Society, Newcastle University
Ms Ann Williams Community Member
Dr David Woodhead Development Manager Public Health, The Healthcare
Commission
Expert cooptees to the PDG
Professor Roisin Pill Emeritus Professor, University of Wales College of
Medicine
Professor Robert West Professor of Health Psychology and Director of
Tobacco Studies, Cancer Research UK Health Behaviour Unit, University
College London
NICE Project Team
Professor Mike Kelly
Director of CPHE
Jane Huntley
Associate Director of CPHE
Dr Catherine Swann
Technical Lead
Chris Carmona
Analyst
Dr Lesley Owen
Analyst
Clare Wohlgemuth
Analyst
Dr Alastair Fischer
Health Economics Adviser
38
External contractors
External reviewers: effectiveness reviews
Review 1: ‘A review of the effectiveness of interventions, approaches and
models at individual, community and population level that are aimed at
changing health outcomes through changing knowledge, attitudes or
behaviour’, carried out by the Cancer Care Research Centre, University of
Stirling. The principal authors were: Ruth Jepson, Fiona Harris, Steve
MacGillivray (University of Abertay), Nora Kearney and Neneh Rowa-Dewar.
Review 2: ‘Review of the effectiveness of road-safety and pro-environmental
interventions’, carried out by the Institute for Social Marketing, University of
Stirling. The principal authors were: Martine Stead, Laura McDermott, Paul
Broughton, Kathryn Angus and Gerard Hastings.
Review 3: ‘Resilience, coping and salutogenic approaches to maintaining and
generating health: a review’, carried out by the Cardiff Institute of Society
Health and Ethics (CISHE), Cardiff University. The principal authors were:
Emily Harrop, Samia Addis, Eva Elliott and Gareth Williams.
Review 4: ‘A review of the use of the health belief model (HBM), the theory of
reasoned action (TRA), the theory of planned behaviour (TPB), and the transtheoretical model (TTM) to study and predict health-related behaviour
change’, carried out by The School of Pharmacy, University of London. The
principal authors were: Professor David Taylor, Professor Michael Bury, Dr
Natasha Campling, Dr Sarah Carter, Dr Sara Garfied, Dr Jenny Newbould and
Dr Tim Rennie.
Review 5: ‘The influence of social and cultural context on the effectiveness of
health behaviour change interventions in relation to diet, exercise and
smoking cessation’ carried out by The School of Pharmacy, University of
London. The principal authors were: Professor David Taylor, Professor
Michael Bury, Dr Natasha Campling, Dr Sarah Carter, Dr Sara Garfied, Dr
Jenny Newbould and Dr Tim Rennie.
39
Review 6: ‘Social Marketing: a review’, carried out by the Institute for Social
Marketing, University of Stirling. The principal authors were: Martine Stead,
Laura McDermott, Kathryn Angus and Gerard Hastings.
External reviewer: expert report
‘Evidence for the effect on inequalities in health of interventions designed to
change behaviour’. The author was Professor Mildred Blaxter (Chair
of the PDG).
External reviewers: economic appraisal
Economic analysis: ‘The cost-effectiveness of behaviour change interventions
designed to reduce coronary heart disease: A thorough review of existing
literature’; and ‘The cost-effectiveness of population level interventions to
lower cholesterol and prevent coronary heart disease: extrapolation and
modelling results on promoting healthy eating habits from Norway to the UK’.
This is the final phase two report for a project entitled ’Health economic
analysis of prevention and intervention approaches to reducing incidence of
coronary heart disease’. This was carried out by the Health Economics
Research Group, Brunel University. The authors were: Julia Fox-Rushby,
Gethin Griffith, Elli Vitsou and Martin Buxton.
Fieldwork
The fieldwork was carried out by Dr Foster Intelligence.
40
Appendix B: summary of the methods used to develop
this guidance
Introduction
The reports of the reviews and economic appraisal include full details of the
methods used to select the evidence (including search strategies), assess its
quality and summarise it.
The minutes of the PDG meetings provide further detail about the Group’s
interpretation of the evidence and development of the recommendations.
All supporting documents are listed in appendix E and are available from the
NICE website at: www.nice.org.uk/PH006
41
The guidance development process
The stages of the guidance development process are outlined in the box
below:
1. Draft scope
2. Stakeholder meeting
3. Stakeholder comments
4. Final scope and responses published on website
5. Reviews and cost-effectiveness modelling
6. Synopsis report of the evidence (executive summaries and evidence tables)
circulated to stakeholders for comment
7. Comments and additional material submitted by stakeholders
8. Review of additional material submitted by stakeholders (screened against
inclusion criteria used in reviews)
9. Synopsis, full reviews, supplementary reviews and economic modelling
submitted to the PDG
10.The PDG produces draft recommendations
11. Draft recommendations published on website for comment by
stakeholders and for field testing
12. The PDG amends recommendations
13. Responses to comments published on website
14. Final guidance published on website
Key questions
The key questions were established as part of the scope. Initially they formed
the starting point for the reviews of evidence and facilitated the development
of recommendations by the PDG. The overarching question was: What are
the most appropriate generic and specific interventions to support attitude and
behaviour change at population and community levels? The subsidiary
questions were:
1.
What is the aim/objective of the intervention?
2.
How does the content of the intervention influence effectiveness?
42
3.
How does the way that the intervention is carried out influence
effectiveness?
4.
Does effectiveness depend on the job title/position of the deliverer
(leader)? What are the significant features of an effective deliverer
(leader)?
5.
Does the site/setting of delivery of the intervention influence
effectiveness?
6.
Does the intensity (or length) of the intervention influence
effectiveness/duration of effect?
7.
Does the effectiveness of the intervention vary with different
characteristics within the target population such as age, sex, class and
ethnicity?
8.
How much does the intervention cost (in terms of money, people and
time)? What evidence is there on cost effectiveness?
9.
Implementation: what are the barriers to implementing effective
interventions?
These questions were refined further in relation to the topic of each review
(see reviews for further details).
Reviewing the evidence of effectiveness
Six reviews of the evidence, one cost-effectiveness review and one economic
modelling report were conducted. In addition, a number of important
theoretical and methodological principles were taken into account.
The empirical evidence about behaviour change is very varied and
methodologically diverse. Areas of focus can include one or more of the
following:
•
the individual, including the psychological processes affecting individuals
•
social factors
43
•
large-scale policy and legislative arrangements
•
empirical investigations and observations
•
propositional and modelling approaches.
Identifying the evidence
It is not always appropriate – or even possible – to carry out controlled trials or
gather experimental evidence for public health interventions, including those
covering legislation or policy. The search process initially followed standard
NICE processes. However, as relatively little evidence on behaviour change
addresses effectiveness or cost effectiveness, the review of the literature was
extended to cover theoretical, descriptive and empirical studies of a type not
normally reviewed for NICE guidance.
The goal of the primary studies varied and included efficacy, effectiveness,
the theoretical elegance of models, implementation and programme
evaluation. Some studies included all or some of these elements. The
economic modelling for this guidance reflected the state of the literature.
There are few evidenced-based reviews on the effect of behaviour change
interventions on social and health inequalities. There is evidence that the
uptake of interventions or response to health education messages differs by
social circumstances, and this has historically, widened the health inequalities
gap. Evidence about interventions intended to narrow the health inequalities
gap had to be drawn from the outcomes and methods described in other sorts
of literature.
Databases were searched to identify the evidence relevant for each review.
Since very different types of evidence were being gathered for each review,
no common core set of databases was searched.
Further details of the databases, search terms and strategies used are
included in the individual review reports.
44
Selection criteria
Inclusion and exclusion criteria for each review varied and details for each
review can be found at www.nice.org.uk/PH006.
Summary of reviews
• Review 1 included systematic reviews and meta-analyses which focused
on public health, health promotion or primary care-led interventions which
contained an educational or behavioural component.
• Review 2 (part one) included reviews of intervention studies that evaluated
the effectiveness of road safety interventions. Part two included reviews of
intervention studies that evaluated the effectiveness of ’pro-environmental
behaviour’.
• Review 3 (part one) included reviews that provided an overview of
conceptual, theoretical or research issues in relation to resilience, coping
and salutogenesis. It also included reviews of interventions explicitly linked
to one of these theories. Part two included reviews of empirical evidence on
positive adaptation in conditions of socio-structural adversity.
• Review 4 included reviews of four behaviour change models.
• Review 5 included reviews of empirical data on the effectiveness of
interventions designed to change knowledge, attitude, intention and
behaviour with respect to smoking, physical activity and healthy eating.
Specific attention was focused on whether or not effectiveness was
influenced by the individual’s position in the life course, the intervention’s
mode of delivery or the social and cultural context.
• Review 6 included reports on the strategies used by marketeers to
influence low-income consumers and any evidence of effectiveness.
Quality appraisal
Papers included in the reviews and additional empirical and theoretical data
were assessed where appropriate for methodological rigour and quality using
45
the NICE methodology checklist. This is set out in the NICE technical manual
‘Methods for development of NICE public health guidance’ (see appendix E).
Each study or paper was described by study type and graded (++, +, -) to
reflect the risk of potential bias arising from its design and execution.
Study type
• Meta-analyses, systematic reviews of randomised controlled trials (RCTs)
or RCTs (including cluster RCTs).
• Systematic reviews of, or individual, non-randomised controlled trials, casecontrol studies, cohort studies, controlled before-and-after (CBA) studies,
interrupted time series (ITS) studies, correlation studies.
• Non-analytical studies (for example, case reports, case series).
• Expert opinion, formal consensus, theoretical articles.
Study quality
++
All or most of the checklist criteria have been fulfilled. Where they have
not been fulfilled the conclusions are thought very unlikely to alter.
+
Some of the checklist criteria have been fulfilled. Those criteria that
have not been fulfilled or not adequately described are thought unlikely
to alter the conclusions.
-
Few or no checklist criteria have been fulfilled. The conclusions of the
study are thought likely or very likely to alter.
The studies or papers were also assessed for their applicability to the UK
where this was possible and the evidence statements were graded as follows:
A
Relevant – review makes direct reference to a UK population.
B
Probably relevant – review from outside UK but most likely equally
applicable to UK settings.
46
C
Possibly relevant – review from outside UK and needs interpreting with
caution for a UK setting.
D
Not relevant – review is from outside UK and is not relevant to a UK
setting.
Summarising the evidence and making evidence statements
The review data were summarised in evidence tables (see full reviews). The
findings from the reviews were synthesised and used as the basis for a
number of evidence statements relating to each key question. The evidence
statements reflect the strength (quantity, type and quality) of evidence and its
applicability to the populations and settings in the scope.
Economic appraisal
The economic appraisal consisted of a review of economic evaluations and a
model of cost effectiveness.
Review of economic evaluations
A systematic search of Medline, Embase, NHS EED, OHE HEED, NCCHTA,
CEA Registry (Harvard University) was undertaken in June 2006, using a
specified set of search terms, as well as inclusion and exclusion criteria.
Following a review of 4122 abstracts and 225 papers, 26 papers were
retained for full review, using a standard set of piloted questions. The data
extracted included: background, population characteristics, interventions and
alternatives, main features and findings and three sets of quality review
criteria.
Cost-effectiveness analysis
An economic model was constructed to incorporate data from the reviews of
effectiveness and cost effectiveness. The results are reported in: ‘The costeffectiveness of population level interventions to lower cholesterol and prevent
coronary heart disease: extrapolation and modelling results on promoting
47
healthy eating habits from Norway to the UK’. They are both available on the
NICE website at: www.nice.org.uk/PH006
Fieldwork
Fieldwork was carried out to evaluate the relevance and usefulness of NICE
guidance and the feasibility of implementation. It was conducted with policy
makers, commissioners, service providers and practitioners whose work
involves changing people’s health behaviour. They included those working in
local and national government, the NHS and in charitable organisations.
The fieldwork comprised:
• Qualitative interviews carried out by Dr Foster Intelligence with 97
individuals, either in small groups or individually, across 30 sites.
Participants included: representatives from the DH, other government
departments and arm’s length bodies; directors of public health in PCTs
and strategic health authorities; public health advisers, health promotion
staff and NHS practitioners (including GPs, practice nurses, community
midwives, health visitors and health advisers); community-based school
nurses; health trainers; and commissioners, service providers and
practitioners working in local and national charities.
The fieldwork was conducted in London, Greater Manchester and the West
Midlands to ensure there was ample geographical coverage. Grid analysis
was used to determine common ground and differences of opinion.
The main issues arising from the fieldwork are set out in appendix C under
‘Fieldwork findings’. The full fieldwork report is available on the NICE website:
www.nice.org.uk/PH006
How the PDG formulated the recommendations
At its meetings held between July 2006 and February 2007, the PDG
considered the evidence of effectiveness and cost effectiveness and
theoretical and methodological evidence. Initially, discussions focused on the
48
evidence outlined in the reviews (see appendix B). The PDG also considered
evidence on cost effectiveness, evidence from fieldwork, additional review
material and a range of theoretical and methodological approaches (see
appendix C).
In addition, at its meeting in May 2007 it considered comments from
stakeholders and the results from fieldwork to determine:
• whether there was sufficient evidence (in terms of quantity, quality and
applicability) to form a judgement
• whether, on balance, the evidence demonstrates that the intervention is
effective or ineffective, or whether it is equivocal
• where there is an effect, the typical size of effect.
The PDG developed draft recommendations through informal consensus,
based on the theoretical ideas that informed its view of behaviour, and the
degree to which the available effectiveness evidence could support these
ideas.
The draft guidance, including the recommendations, was released for
consultation in April 2007. The guidance was signed off by the NICE
Guidance Executive in September 2007.
49
Appendix C: the evidence
This appendix sets out a summary of the key behaviour change theories
(empirical, theoretical and methodological) and other, additional evidence
used to inform the recommendations. It also sets out a brief summary of
findings from the economic appraisal and the fieldwork.
The reviews, economic appraisal and fieldwork report are available on the
NICE website (www.nice.org.uk/PH006).
Key theories
The reviews were unable to capture all material related to behaviour change.
This is because the evidence is broad, the methods used are diverse and the
assumptions made about science, knowledge and explanation vary
considerably. Some evidence focuses on particular components of human
actions, much is theoretical, and some consists of models of human behaviour
(see also appendix B). The PDG has also, therefore, drawn on a range of
theoretical and methodological evidence. This evidence is briefly outlined
below.
Resilience and coping: Antonovsky (1985, 1987) and Lazarus (1976,
1985; Lazarus and Folkman 1984)
Antonovsky argued that there are ‘health-giving’ or ‘health-generating’ factors
in many situations. These ‘salutogenic’ factors can help people withstand or
respond positively to stressors, crises or difficulties. They help to protect
against vulnerability and disease and may help maintain good mental and
physical health. Lazarus argued that people develop habitual ways of coping
with life. However, although they may be highly effective from the individual’s
point of view, some coping mechanisms (like smoking or excessive alcohol
consumption) may damage their health and the health of others. Behaviour
change and readiness to change behaviour takes place in this context.
50
‘Habitus’: Bourdieu (1977)
Bourdieu argued that many of the things that people do and believe are so
familiar and habitual that they go largely unnoticed (because they are part of
their ‘habitus’). This makes changing them very difficult.
Social capital (Bourdieu 1986; Putnam 2000; Morgan and Swann 2004)
Social capital is commonly defined as those features of a society, such as
networks, social trust and cohesion, which facilitate cooperation among
people for mutual benefit. It was of interest because of the way these factors
might influence health behaviours and people’s ability to change.
Society: Giddens (1979, 1982, 1984)
Giddens argued that society was the product of interaction between individual
human behaviour and the social structure. He argued that the human actions
or agency produce societal patterns. The patterns repeat themselves to such
a degree that structures emerge. Although those structures change,
sometimes gradually, sometimes rapidly, individuals are aware of them and
orient their actions in line with them (and are constrained by them).
The Theory of Planned Behaviour: (Ajzen 1991) and Bandura’s construct
of self-efficacy (1997)
The Theory of Planned Behaviour (TPB) is the most widely applied model of
beliefs, attitudes and intentions that precede action (Ajzen 2001; Conner and
Sparks 2005). TPB proposes that intention is the main determinant of action
and is predicted by attitude, subjective norms and perceived behavioural
control (PBC). PBC is a person’s perception of whether or not they can control
their actions and is closely related to Bandura’s construct of self-efficacy
(1997). Both PBC and self-efficacy are likely to bolster intentions and sustain
action because people are more likely to attempt actions that are controllable
and easy to perform.
51
Additional evidence
The PDG drew on other sources for a general understanding of wider public
health issues. These included:
The former Health Development Agency's evidence base at:
www.nice.org.uk/page.aspx?o=hda.publications
Conner M, Norman P (2005) editors. Predicting health behaviour: research
and practice with social cognition models. Maidenhead: Open University
Press.
Cost-effectiveness evidence
The health economic analysis compared and contrasted the costeffectiveness of behaviour change interventions aimed at reducing coronary
heart disease (CHD) and delivered across the life course. Two phases were
completed. The first involved a review of the cost-effectiveness of
interventions designed to promote healthier lifestyles and to reduce the risk of
developing CHD. In the second phase, a model was developed to determine
the cost effectiveness of a population-based behaviour change intervention.
Phase one: comparing the cost-effectiveness of behaviour change
strategies to reduce the risk of CHD
Many interventions aimed at tackling multiple risk factors fell into the ‘likely to
be very cost effective’ category (£0–£20,000/per cost per quality adjusted life
year [QALY]). These included a mix of population-level and individual
interventions for adults over the age of 30.
Interventions aimed at changing the behaviour of adults with specific CHD risk
factors (such as smoking, poor diet and low levels of physical activity) fell into
the ‘likely to be very cost effective’ category. Two non-advisory interventions
(labelling of foods containing trans-fatty acid and a population-based
programme promoting a healthier diet) also fell into the ‘likely to be very cost
effective’ group.
52
Significant gaps in the evidence were noted. There was little evidence on the
cost-effectiveness of using behaviour change interventions with specified subgroups (for example, 19–30 year olds, low-income groups, pregnant women,
and particular ethnic or disadvantaged groups). The quality of evidence was
also a cause for concern. For example, there was a lack of reliable data from
which to extrapolate the long-term health outcomes. In addition, only a limited
number of economic evaluations had been conducted alongside RCTs of
behaviour change interventions to reduce CHD.
Phase two: modelling
In the second phase, a deterministic Markov chain simulation model was
developed of a population-wide intervention to lower cholesterol and prevent
CHD. The intervention was carried out in Norway in 1990. It included a mass
media campaign and information delivered to a range of sectors including
academia, the agricultural sector and schools. The model extrapolated the
results to England and Wales in the first decade of 2000.
In the base case, an incremental cost-effectiveness ratio (ICER) of £87 per
QALY (£116 per life year) was estimated. However, it was noted that the
health benefits were underestimated, as this model only reported those
related to CHD. Sensitivity analysis estimated that the intervention would be
highly cost effective in a wide range of situations.
Fieldwork findings
Fieldwork aimed to test the relevance, usefulness and the feasibility of
implementing the recommendations, and the findings were considered by the
PDG in developing the final recommendations. The fieldwork was conducted
with commissioners, service providers and practitioners involved in a wide
range of services and activities relevant to health-related behaviour change.
For details, see ‘Fieldwork on generic and specific interventions to support
attitude and behaviour change at population and community levels’ at
www.nice.org.uk/PH006.
53
Fieldwork participants were fairly positive about the recommendations and
their potential to support attitude and behaviour change at the individual,
community and population levels.
The recommendations were seen to reinforce aspects of a range of
government policies and initiatives, including providing support to achieve
certain public service agreement (PSA) targets (for example, to reduce
teenage pregnancies and to reduce health inequalities).
While participants did not view the recommendations as offering a new
approach, the principles they are based on have not been implemented
universally. They indicated that wider and more systematic implementation
would be achieved if there was:
• clarity about how the recommendations apply to people in different roles
• more information about how to implement some of the recommendations
• further information on how compliance with the recommendations will be
determined.
54
Appendix D: gaps in the evidence
The PDG identified a number of gaps in the evidence related to behaviour
change interventions and programmes, based on an assessment of the
evidence. These gaps are set out below.
1.
Evidence about the cost-effectiveness of behaviour change
evaluations is lacking, in particular, in relation to specific sub-groups
(for example, 19–30 year olds, low-income groups and particular
ethnic and disadvantaged groups).
2.
Evaluations of behaviour change interventions frequently fail to make
a satisfactory link to health outcomes. Clear, consistent outcome
measures need developing.
3.
Evaluations of interventions based on specific psychological models
tend not to relate the outcome measures to the model. As a result, it is
difficult to assess the appropriateness of using the model as a means
of describing behaviour change.
4.
Few studies explicitly address the comparative effect that behaviour
change interventions can have on health inequalities, particularly in
relation to cultural differences.
5.
There is a need for more information on the links between knowledge,
attitudes and behaviour. Conflation between them should be avoided.
6.
There is a lack of reliable data from which to extrapolate the long-term
health outcomes of behaviour change interventions.
The Group made five recommendations for research. These are listed in
section 5.
55
Appendix E: supporting documents
Supporting documents are available from the NICE website
(www.nice.org.uk/PH006). These include the following.
• Reviews of effectiveness
− Review 1: ‘A review of the effectiveness of interventions,
approaches and models at individual, community and
population level that are aimed at changing health outcomes
through changing knowledge, attitudes or behaviour’
− Review 2: ‘Review of the effectiveness of road-safety and proenvironmental interventions’
− Review 3: ‘Resilience, coping and salutogenic approaches to
maintaining and generating health: a review’
− Review 4: ‘A review of the use of the health belief model
(HBM), the theory of reasoned action (TRA), the theory of
planned behaviour (TPB), and the trans-theoretical model
(TTM) to study and predict health-related behaviour change’
− Review 5:‘The influence of social and cultural context on the
effectiveness of health behaviour change interventions in
relation to diet, exercise and smoking cessation’
− Review 6: ‘Social Marketing: a review’.
• Expert report
− ‘Evidence for the effect on inequalities in health of
interventions designed to change behaviour’.
• Evidence briefings and other reviews and toolkits published by the former
Health Development Agency (available on the NICE website at
www.nice.org.uk/page.aspx?o=hda.publications)
56
• Economic analysis:
− ‘The cost-effectiveness of behaviour change interventions
designed to reduce coronary heart disease: a thorough review
of existing literature’
− ‘The cost-effectiveness of population level interventions to
lower cholesterol and prevent coronary heart disease:
extrapolation and modelling results on promoting healthy
eating habits from Norway to the UK’.
• A quick reference guide (QRG) for professionals whose remit includes
public health and for interested members of the public. This is also
available from the NHS Response Line (0870 1555 455 – quote reference
number N1230).
For information on how NICE public health guidance is developed, see:
• ‘Methods for development of NICE public health guidance’ available from:
www.nice.org.uk/phmethods
• ‘The public health guidance development process: an overview for
stakeholders including public health practitioners, policy makers and the
public’ available from: www.nice.org.uk/phprocess
57
Changing Health Related Behaviour:
What is the Role of Behavioural Science in Improving Public Health?
Falko Sniehotta, PhD
Reader in Health Psychology
Where and how to intervene
Individual interventions
Societal interventions
• reduce motivation to engage in unhealthy behaviours
• increase motivation to engage in healthy behaviours
• motivation into action and sustain healthy behaviours (behavioural skills)
• enhance self‐regulation
• attitudes and culture
• incentive structures
• restrict or enhance opportunities Dynamic process of interaction between societal and individual level. E.g. walking/cycling: motivation + opportunities
‘Behaviour change at population, community and individual levels’: NICE review 2007
Three models of intervention development and implementation
1. RE‐AIM (Glasgow et al., 2001)
2. Precede–Proceed Model (Green & Kreuter, 1992)
3. MRC Guidance for the development and evaluation of complex interventions for health (Craig et al., 2008)
RE‐AIM: A model of sustainable implementation of effective, generalisable, evidence‐based interventions.
Reach ‐ How do we reach the targeted population with the intervention?
Efficacy ‐ How do we know our intervention is effective?
Adoption ‐ How do we develop organizational support to deliver our intervention?
Implementation ‐ How do we ensure the intervention is delivered properly?
Maintenance ‐ How do we incorporate the intervention so that it is delivered over the long term?
Glasgow et al. (2001) The RE-AIM Framework for Evaluating Interventions: What Can It Tell Us
about Approaches to Chronic Illness Management? Pt Educ Couns 2001;44:119-127.
Green and Kreuter's (2005) Precede–Proceed model of health program planning
Green, L.W., Kreuter, M. W. (1992). CDC's Planned Approach to Community Health as an application of
PRECEDE and an inspiration for PROCEED. Journal of Health Education 23: 140-147
Development and Evaluation of complex interventions – the ‘new’ MRC model
Craig et al., 2008; BMJ
Structure of the evidence base
for behaviour Interventions
change interventions Behavioural determinants e.g. cognitive, social, motivational & environmental
Behaviour
e.g., exercise; physical activity
Physiological & biochemical variables e.g. neurological & muscular processes
Health outcomes
health, mobility and quality of life
Hardeman, et al. (2005) A causal modelling approach to the development of theory‐based behaviour change
programmes for trial evaluation. Health Education Research, 20(6):676‐687
Determinants of health
Structure of the evidence base
for behaviour Interventions
change interventions Behavioural determinants e.g. cognitive, social, motivational & environmental
Behaviour
Health outcomes
Effects of behavioural interventions on health
Interventions
Good evidence from systematic reviews of RCTs for effectiveness of behavioural interventions on all outcome levels
Key challenges:
• Considerable heterogeneity of effect sizes
• Small to medium effects
• Lack of sustainability Behavioural determinants e.g. cognitive, social, motivational & environmental
Behaviour
Health outcomes
What is a complex intervention?
• Number of interacting components
• Number and difficulty of behaviours involved
• Number of groups or organisational levels targeted
• Number and variability of outcomes
• Degree of flexibility or tailoring permitted
Features of Behaviour Change interventions
1. Behaviour change techniques (BCTs), e.g., prompt goal setting or self‐monitoring of behaviour
2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc
3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention
4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training.
Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)
Behaviour change techniques: reliable taxonomy
Involves detailed planning of what the person will do
to change physical activity and healthy eating behaviours
including, at least, a very specific definition of the
behaviour e.g., frequency (such as how many times a
day/week), intensity
(e.g., speed) or duration (e.g., for
15. General encouragement
how long for). In addition, at least one of the following
16. Contingent rewards
contexts i.e., where, when, how or with whom must be
specified. This 17. Teach to use cues could include identification of sub-goals or
preparatory behaviours
and/or specific contexts in which
18. Follow up prompts
the behaviour will be performed.
1. General information 2. Information on consequences
3. Information about approval
4. Prompt intention formation 5. Specific goal setting 6. Graded tasks
7. Barrier identification
8. Behavioral contract
9. Review goals
10. Provide instruction
11. Model/ demonstrate 12. Prompt practice
13. Prompt monitoring 14. Provide feedback
19. Social comparison
20. Social support/ change
21. Role model
22. Prompt self talk
23. Relapse prevention
24. Stress management
The
person is asked to keep a
25. Motivational interviewing
record
of specified behaviour/s.
26. Time management
This
could e.g. take the form of a
diary or completing a
questionnaire about their
behaviour.
CALO-RE taxonomy for
diet and PA
1.
2.
3.
4.
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6.
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16.
17.
18.
18.
19.
20.
Provide information on consequences of behaviour in 21.
general
22.
Provide information on consequences of behaviour for 23.
the
24.
Individual
25.
Provide information about others' approval
26.
Provide normative information about others' 27.
behaviour
28.
Goal setting (behaviour)
29.
Goal setting (outcome)
Action planning
30.
Barrier identification/Problem solving
31.
Set graded tasks
32.
Prompt review of behavioural goals
33.
Prompt review of outcome goals
34.
Reinforcing effort or progress towards behaviour
35.
Provide rewards contingent on successful behaviour 36.
Shaping
37.
Prompting generalisation of a target behaviour
38.
Prompt self‐monitoring of behaviour
39.
Prompt self‐monitoring of behavioural outcome
40.
Prompting focus on past success
Provide feedback on performance
Provide instruction
Model/ Demonstrate the behaviour
Teach to use prompts/ cues
Environmental restructuring
Agree behavioural contract
Prompt practice
Use of follow up prompts
Facilitate social comparison
Plan social support/ social change
Prompt identification as role model/ position advocate
Prompt anticipated regret
Fear Arousal
Prompt Self talk
Prompt use of imagery
Relapse prevention/ Coping planning
Stress management
Emotional control training
Motivational interviewing
Time management
General communication skills training
Provide non‐specific social support
Michie, Ashford, Sniehotta, Dombrowski, Bishop & French (in press – Psychology & Health)
4.
5.
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Goal: set behavioural goal
Standard: decide target standard of behaviour (specified and observable)
Monitoring: record specified behaviour (person has access to recorded data ofbehavioural performance e.g. from
diary)
Record antecedents and consequences of behaviour (social and environmental situations and events, emotions,
cognitions)
Feedback: of monitored (inc. self-monitored) behaviour
Comparison: provide comparative data (cf. standard, person’s own past behaviour, others’ behaviour)
Social comparison: provide opportunities for social comparison e.g. contests and group learning
Discrepancy assessment: highlight nature of discrepancy (direction, amount) between standard, own or others’
behaviour (goes beyond simple self-monitoring)
Contract: of agreed performance of target behaviour with at least one other, written and signed
Planning: identify component parts of behaviour and make plan to execute each one or consider when and/or
where a behaviour will be performed, i.e. schedule behaviours (not including coping planning—see 11
Coping planning: identify and plan ways of overcoming barriers (note, this must include identification of specific
barriers e.g. “problem-solving how to fit into weekly schedule” would not count)
Goal review: assess extent to which the goal/target behaviour is achieved, identify the factors influencing this and
amend goal if appropriate
Discriminative (learned) cue: environmental stimulus that has been repeatedly associated with contingent reward
for specified behaviour
Prompt: stimulus that elicits behaviour (inc. telephone calls or postal reminders designed to prompt the
behaviour)
Reward: contingent valued consequence, i.e. if and only if behaviour is performed (inc. social approval, exc.
general non-contingent encouragement or approval)
Punishment: contingent aversive consequence, i.e. if and only if behaviour is not performed
Omission: contingent removal of valued consequence, i.e. if and only if behaviour is not performed
Negative reinforcement: contingent removal of aversive consequence, i.e. if and only if behaviour is performed
Threat: offer future punishment or removal of reward contingent on performance
Fear arousal: induce aversive emotional state associated with the behaviour
Anticipated regret: induce expectations of future regret about non-performance of behaviour
Graded tasks: set easy tasks to perform, making them increasingly difficult until target behaviour performed
Instruction: teach new behaviour required for performance of target behaviour (not as part of graded hierarchy or
as part of modelling) e.g. give clear instructions
Shaping: build up behaviour by initially reinforcing behaviour closest to required behaviour and systematically
altering behaviour required to achieve contingent reinforcement
Chaining: build up behaviour by starting with final component; gradually add components earlier in sequence
Behavioural rehearsal: perform behaviour (repeatedly)
Mental rehearsal: imagine performing the behaviour repeatedly
Habit formation: perform same behaviour in same context
Role play: perform behaviour in simulated situation
Behavioural experiments: testing hypotheses about the behaviour, its causes and consequences, by collecting
and interpreting data
Modelling: observe the behaviour of others
Vicarious reinforcement: observe the consequences of others’ behaviour
Self talk: planned self-statements (aloud or silent) to implement behaviour change techniques
Imagery: use planned images (visual, motor, sensory) to implement behaviour change techniques (inc. mental
rehearsal)
Cognitive restructuring: changing cognitions about causes and consequences of behaviour
Relapse prevention: identify situations that increase the likelihood of the behaviour not being performed and
apply coping strategies to those situations
Behavioural information: provide information about antecedents or consequences of the behaviour, or
connections between them, or behaviour change techniques
Personalised message: tailor techniques or messages from others to individual’s resources and context (includes
stages of change-based information; doesn’t include personal plans and feedback)
Verbal persuasion/persuasive communication: credible source presents arguments in favour of the behaviour.
Note, there must be evidence of presentation of arguments; general pro-behaviour communication does not
count.
Social support (instrumental): others perform component tasks of behaviour or tasks that would compete with
behaviour e.g. offering childcare
Social support (emotional): others listen, provide empathy and give generalised positive feedback
55.
56.
57.
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114.
115.
116.
Anti-depression skills training
Biofeedback
Differential reinforcement
Escape
Extinction
Flooding
Group contingencies
Implosive therapy
Avoidance
Counter-conditioning
Distraction
Exposure
Fading; thinning
Flooding in imagination
Habit reversal
Negative punishment
Non-contingent delivery of
reinforcing stimuli
Overcorrection
Peer-administered contingencies
Problem identification
Rational emotive therapy
Reinforcer sampling
Response cost
Response priming
Satiation
Screening
Social skills training
Stress inoculation program
Symbolic desensitisation
Thought stopping
Time out
Token economy
Activity scheduling
Adventitious
reinforcement/superstitious
conditioning
Altering antecedent chains
Anger control training
Assertion training
Buddy system
Clarification (supportive therapy)
Classical conditioning
Community reinforcement
Covert conditioning
Covert sensitisation
Deflection techniques
Discrimination training
Emetic therapy
Encounter (existential analysis)
Fishbowl
Fogging
Functional communication training
Functional family therapy
Identification (psychoanalysis)
Instigation
Interpretation (psychoanalysis)
Least-to-most prompting
Lottery
Most to least prompt sequences
Motivational techniques
Multiple exemplar training
(generalisation)
Natural maintaining contingencies
(generalisation)
Negotiation training
Paradoxical instructions
118.
119.
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126.
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130.
131.
132.
133.
134.
135.
136.
137.
Positive reinforcement
Positive scanning
Premackian reinforcers
Rate reduction
Reassurance (supportive
therapy)
Recapitulation
Reframing
Reinforcer displacement
Response priming
Restitution
Rule release
Self-exploration
Self-help
Small group exercises
Stimulus generalisation
Stimulus narrowing
Systematic rational
conditioning
Thinning
Turtle technique
Vicarious punishment
Michie et al., (2008)
Applied Psychology: An
International Review
1.
2.
3.
Identifying Effective Change Techniques in Interventions Designed to Promote Physical Activity and Healthy Eating
• Systematic review and meta‐analysis
• 84 interventions
• average of 6 techniques
• small effect d = 0.37 (95% CI 0.29 to 0.54, N = 28,838)
• self‐monitoring – associated with effectiveness (14.6% variance explained). – Interventions including this technique had a medium effect size of d = 0.57. – Interventions combining self‐monitoring with at least one other technique derived from control theory were more than twice as effective as the other interventions with d = 0.60 d = 0.26 respectively
Michie S, et al (in press) Identifying Effective Techniques in Interventions: A meta‐analysis and meta‐regression Health Psychology
Modes of delivery
•
•
•
•
•
•
•
•
Face to face vs. telephone vs. online
Group vs. single intervention
Nurse delivered vs. GP delivered Home based vs. hospital based
Use of materials Duration, intensity, frequency, lengths etc. Training of facilitator
Etc
Why theory? What does theory do?
• Enables cumulative science
• Provides a shared language
• Summarises known evidence
• Explains observations
• Allows prediction
• Enables intervention
• Problem of ‘implicit’ theory
‘a theory is a set of statements that organizes, predicts and explains
observations; it tells you how phenomena relate to each other, and what
you can expect under still unknown conditions’
Bem, S and Looren de Jong, H (1997) Theoretical issues in Psychology, Sage publications: London. p. 15
How does Theory help in developing and delivering interventions?
• Identify targets (e.g., cognitive or social determinants of behaviour)
• Suggest behaviour change techniques • Suggest sequences or combinations of techniques and determinants
• Allows for tailoring of interventions (e.g., stage theories such as the ‘TTM’ /’stages of change model’  Evidence very weak!
• Provides a ‘cover story’ for intervention content
Choosing a theoretical approach many theories of behaviour
• 33 theories and 128 constructs generated
• In four overlapping areas: – motivation
– action
– organisation
– behaviour change
• Simplified into 11 domains of theoretical constructs
• Interview questions associated with each domain
Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D. and Walker, A. (2005) Making psychological theory useful for implementing evidence based practice: a consensus approach, Quality and Safety in Health Care, 14, 26‐33. Motivation theories
explain why people want to do things
• Theory of Planned Behaviour
• Theory of Reasoned Action
• Protection Motivation Theory
• Health Belief Model)
• Social Cognitive Theory
• Locus of control theories
• Social Learning Theory
• Social Comparison Theory
• Cognitive Adaptation Theory
• Social Identity Theory
• Elaboration Likelihood Model
• Goal Theories
• Intrinsic Motivation Theories
• Self‐determination theory
• Attribution Theory
• Decision making theories eg. social judgment theory, “fast and frugal” model, systematic vs. heuristic decision making
• Fear arousal theory
Action theories
explain why people do things
•
•
•
•
•
•
•
•
•
•
•
Learning theory
Operant theory
Modelling
Self‐regulation theory
Implementation theory/automotive model
Goal theory
Volitional control theory
Social cognitive theory
Cognitive Behaviour therapy
Transtheoretical model
Social identity theory
Organisation theories
explain how groups and organisations influence what people feel and do
•
•
•
•
•
•
•
•
Effort‐reward imbalance
Demand‐control model
Diffusion theory
Group theory eg. group minority theory
Decision making theory
Goal theory
Social influence
Person situation contingency models
Simplifying theory: domains of behavioural determinants 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Knowledge
Skills
Role and identity
•Self-efficacy
Beliefs about capabilities •Control – of behaviour,
and material and social
Beliefs about consequences
environment
Motivation and goals
•Perceived competence
Memory, attention and decision processes•Self-confidence
•Empowerment
Environmental context and resources
•Self-esteem
Social influences •Perceived behavioural
Emotion
control
•Optimism/pessimism
Plans
Michie, S., Johnston, M., Abraham, C, Parker, Lawton, R, Walker, A (2005) Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality in Health Care, 14, 26‐33.
Buildings blocks of behaviour change
Self-regulation
• Self-monitoring
• Awareness of standards
• Means and skills
Planning
• Action Planning
• Coping Planning
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Environment & Social influence
Self-regulation
• Self-monitoring
Planning
• Action Planning
• Coping Planning
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Self-regulation
Implemental
phase
• Self-monitoring
Planning
• Action Planning
• Coping Planning
Decisional
phase
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Self-regulation
Implemental
phase
• Self-monitoring
• Having means and skills
How can I
change?
Planning
• Action Planning
• Coping Planning
Decisional
phase
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Would I like
to change?
The problem with behaviour change
•
Attempts to change people’s behaviour are often geared towards: –
Raising Knowledge (lecturing) •
–
Providing Advice (instructing) •
–
“Did you know that…”
“Why don’t you…”
Motivating (scaring) •
“If you don’t … then …”
Persuasive communications and targeted cognitions: UK safer sex leaflets
1. disease severity
2. knowledge/info
3. susceptibility
4. self-efficacy
1
2
3
4
5
6
7
5. others’ attitudes
6. attitudes to
behaviour
7. intention to
change
Impact on behaviour (correlation)
Average number of messages in UK
health
Abraham, C., Krahé, B., Dominic,
R., leaflets
& Fritsche, I. (2002). Does research into the social cognitive antecedents of action contribute to
health promotion? A content analysis of safer-sex promotion leaflets. British Journal of Health Psychology, 7, 227-246.
Health Risks
• Stroke
• Cancer of mouth, throat, oesophagus
• Cancer of larynx
• Coronary heart disease
• COPD
• Asthma exacerbations
• Lung Cancer
• Pancreatic Cancer
• Peptic ulcer
• Bladder Cancer
• Osteoporosis
• Cervical Cancer
• Peripheral artery disease
Other effects of smoking
• Yellowing of teeth/fingers
• Hair, skin, breath and clothes smell of tobacco
• Skin around eyes and mouth wrinkled
• Reduced fertility
• Increase risk LBW baby
• Increased risk spontaneous abortion
• Increased risk premature labour
• Cost (20 cigs/day costs £1000 per year)
The benefits of quitting
Within hours.......
8 hours
Nicotine and carbon monoxide levels halved,
Blood oxygen levels return to normal
24 hours
Carbon monoxide eliminated from the body
48 hours
Nicotine eliminated from the body,
Taste buds start to recover
Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk
Within months .......
1 month
Appearance improves – skin loses greyish pallor, less wrinkled Regeneration of respiratory cilia starts
Withdrawal symptoms have stopped
3‐9 months
Coughing and wheezing decline Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk
Within years .......
5 years
The excess risk of a heart attack reduces by half
10 years
The risk of lung cancer halved Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking. http://www.ash.org.uk
The Sums
Certain short term consequences are
often more
important for decision
Smoking is bad for you
making than uncertain long term
+
consequences
Giving up smoking is good for you
=
¼ of people smoke?
Designing interventions
• Start from an analysis of the nature of the behaviour to be changed
• Use a systematic approach to selecting from the range of interventions and policies available
– Need a framework that meets criteria of • comprehensive coverage,
• coherence (categories mutually exclusive and same level of specificity) and • linked to a model of behaviour
– Systematic review identified 18 existing frameworks, none met all these criteria
Michie, van Straalen & West 2010
The Behaviour Change Wheel
Service
prov
Behaviour source
Pe
rsu
asi
on
Modelling
Tra
inin
n
o
i
g
t
a
Educ
Ca
pa
bil
it
Physical
In
tiv
n
e
c
i
i on
t
a
s
Environmental/
social planning
Policy type
G
ui
de
lin
e
s
ision
L
l
e
g
ca
is
l
a
Fis
tion
Coercio
n
E
ion
n
ict
re viro
str
s
t
ru nm
Re
c
tu en
ir n tal
g
Re
Motivation
Intervention type
n
io
t
la
u
g
Reflective
y
Psychological
Non reflective
Social
Physical
it y
n
u
ort
p
Op
Enable
ment/
resourc
es
on/
i
t
a
c
i
un
Comm ing
t
marke
Intervention types
Education
Imparting knowledge e.g. on health risks
Persuasion
Incentivisation
Using communication to induce belief or knowledge Creating expectation of reward Coercion
Creating expectation of punishment or cost Training
Imparting skills Restriction Reducing availability
Environmental Changing the physical context
restructuring Modelling Providing an example for people to aspire to Enablement/ resources Increasing means/reducing barriers Policy types
Communication/ marketing
Guidelines Fiscal
Regulation
Using print, electronic, telephonic or broadcast media
Creating documents that recommend or mandate practice
Using the tax system
Legislation
Establishing rules or principles of behaviour or practice
Making or changing laws
Environmental/ social planning Service provision
Designing and/or controlling the physical or social environment
Delivering a service
The Behaviour Change Wheel
Service
prov
Behaviour source
Pe
rsu
asi
on
Modelling
Tra
inin
n
o
i
g
t
a
Educ
Ca
pa
bil
it
Physical
In
tiv
n
e
c
i
i on
t
a
s
Environmental/
social planning
Policy type
G
ui
de
lin
e
s
ision
L
l
e
g
ca
is
l
a
Fis
tion
Coercio
n
E
ion
n
ict
re viro
str
s
t
ru nm
Re
c
tu en
ir n tal
g
Re
Motivation
Intervention type
n
io
t
la
u
g
Reflective
y
Psychological
Non reflective
Social
Physical
it y
n
u
ort
p
Op
Enable
ment/
resourc
es
on/
i
t
a
c
i
un
Comm ing
t
marke
“He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast”
Leonardo Da Vinci, 1452‐1519
[email protected]
Spare slides
Matrix based approach
Theory /
Mediators
Modes of
Delivery
Behaviour Change
Techniques
Theories of How to change behaviour
• Self‐Regulation • Operant Learning
• Social Cognitive 3 theories which not only explain behaviour, but
• explain how to change behaviour
• have evidence of changing behaviour
Social Cognitive Theory (Bandura)
CHANGE BEHAVIOUR by changing self-efficacy by:
Mastery experience
Verbal persuasion
Vicarious experience
Physiological attributions
Bandura, A (1977 Self-efficacy: toward a unifying theory of behavioral change. Psychological Review 84, 191-215
Operant Learning Theory (Skinner)
CHANGE BEHAVIOUR by changing antecedents and/or consequences
A
B
Antecedents
Behaviour
e.g. environment
C
Consequences
e.g. reward/punishment
predicts reinforcement
http://www.bfskinner.org/Operant.asp
Behaviour change techniques from OLT
Techniques directly related to OLT
•
•
•
•
•
•
Positive reinforcement
Reward
Punishment
Extinction Negative reinforcement
Vicarious reinforcement
fundamentals of
reward/punishment
• Differential reinforcement
• Reinforcement of alternative behaviour
• Stimulus generalisation
• Stimulus narrowing
• Shaping • Chaining
• Thinning • Token economy
• Habit reversal
Action Control
Self‐regulation theory
CHANGE
BEHAVIOUR by
• Goal setting
• Self-Monitoring
GOAL
Compare
behaviour
with
standard
Act to
reduce
discrepancy
No gap goal met
• Comparison
• Effort to reduce
discrepancy
Discrepancy
noticed
Disengage
from goal
Carver C & Scheier M 1998 On the self-regulation of behaviour. New York, Cambridge University Press
Identifying Effective Change Techniques in Interventions Designed to Promote Physical Activity and Healthy Eating
• Systematic review and meta‐analysis
• 84 interventions
• average of 6 techniques
• small effect d = 0.37 (95% CI 0.29 to 0.54, N = 28,838)
• self‐monitoring – associated with effectiveness (14.6% variance explained). – Interventions including this technique had a medium effect size of d = 0.57. – Interventions combining self‐monitoring with at least one other technique derived from control theory were more than twice as effective as the other interventions with d = 0.60 d = 0.26 respectively
Michie S, et al (in press) Identifying Effective Techniques in Interventions: A meta‐analysis and meta‐regression Health Psychology
Intention‐Behaviour Gap Physical Exercise Following Cardiac Rehabilitation
I Intend to engage in vigorous exercise at least three
times a week for at least 30 min after my discharge.
Behaviour 4 months
following discharge
Exercise at least
3 x 30 minutes
Exercise less than
3 x 30 minutes
agree
not agree
Inclined Actors
Disinclined Actors
Inclined Abstainers
Disinclined Abstainers
53.2%
38.9%
0%
7.9%
Sniehotta, F. F., Scholz, U., & Schwarzer, R. (2006). Action plans and coping plans for physical exercise: A
longitudinal intervention study in cardiac rehabilitation. British Journal of Health Psychology, 11, 23–37.
Societal influences
Individual
psychology
Food Production
Individual
activity Activity
Food
Consumption
environment
Biology
Foresight, 2007
Bandura, A. (1986).
"Social Foundations of
Thought and Action: A
Social Cognitive
Theory." Englewood
Cliffs, NJ: PrenticeHall.
e.g. Personality, Identity
Beliefs and cognitions
PERSON
BEHAVIOR
e.g. Verbal Responses
Motor Responses
Social Interactions
ENVIRONMENT
e.g. Physical surroundings
Family and Friends
Other social influences
Behaviour change practice
Traditional
approach
Collaborative
approach
Health professional as
expert
Patient as expert in own life
Patient told what to do
Supporting patient finds own
solutions
Extrinsic motivators
Intrinsic motivators
Patient required to
facilitate change
Collaboration & assistance in
facilitating change
Ignores barriers to
change
Addresses barriers to change
Technique for
behaviour
change
Social/
Professional
role &
identity
Knowled
ge
Skills
Beliefs
about
capabiliti
es
Beliefs
about
consequenc
es
Motivati
on and
goals
Memory
,
attention
,
decision
processe
s
Goal/target
specified:
behaviour or
outcome
1
2 1
3 2 3
1
3 1
3 3 3 3
1 1
Monitoring
1
2
3 3 3
1 2 2
1 2 2
1 2 2
1 2 2
2 3 3
3 3 2 3
3 2 2 2
1 3 2 1
2 23
1
1
1 1
2 3 1 2
2
Self-monitoring
Environme
ntal context
and
resources
1
2
Social
influenc
es
Emoti
on
Action
planning
1
1 1
3 2 3 3
1 2
2
1 1 2
2
1 3
Contract
2 1
3 2
2 2 2
Rewards;
incentives (inc
Self-evaluation)
1 2 1
1
3 3 3
2 1
2 1 2
2 3 3 3
1 1 2
1
1 2
1 2 1
2 1 1
Graded task,
starting with easy
tasks
1
1
3 3 2
2 2 3
2
2 3 2 2
1 2
1
1
1 1
2 1*
Increasing skills:
problem solving,
decision making,
goal setting
1 2
3 3 3
3
2 2 3 2
1
2 3 2
1 2
1
2
3 1
Stress
management
1
1 2
1 1 1
1
1 2 1
1 2 1
1
3 3 2
1
1
Coping skills
1
2/3 3
1
2 2 2
1
1
1 1
1 1
3 2 2
1/2
Michie S, Johnston M, Francis JJ, Hardeman W, Eccles MP. (2008) Applied Psychology: An
Review. Special
an 2International
Review.
1
2 3 2Applied Psychology:
2 1
1
3 2
Rehearsal ofInternational
3 3 3Issue
l
t kill
3
3 1 1
The Behaviour System: Behaviour emerges from interactions between ….
Capability
Motivation
Psychological or physical ability to
enact the behaviour
Behaviour
Reflective and non-reflective
mechanisms that activate or inhibit
behaviour
Opportunity
Physical and social environment that
enables the behaviour
The Behaviour System: CMOB
Capability
Motivation
Opportunity
Capability, Motivation and Opportunity
must be present for a Behaviour to occur
Behaviour
The system is in dynamic
equilibrium and a change in
behaviour may require a
sustained change in one or more
of the other elements
system for choosing interventions and policies
Behaviour source
Policy type:
decisions
made by
authorities
concerning
interventions
Ca
pa
bil
it
Physical
Motivation
Intervention type:
activities
designed to
change
behaviours
Reflective
y
Psychological
Non reflective
Social
Physical
it y
n
u
ort
p
Op
Motivation
Reflective
Beliefs about what is good and bad,
conscious intentions and decisions as
per e.g. Theory of Planned Behaviour
Nonreflective
Emotional responses, desires and
habits resulting from associative
learning and physiological states
Reflective-Impulsive Model, Strack & Deutsch, 2004
PRIME Theory of Motivation, West, 2006

Wellbeing and Health Partnership – Executive Group

Transcription

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