behaviour change as part of a public health strategy
DESCRIPTION
This presentation to a public health strategy workshop discussed how we could embed behaviour change at population level into our public health strategyTRANSCRIPT
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Health Improvement and Behaviour Change: changing professional behaviour to improve the public’s health
Jim McManus, CPsychol, CSci, AFBPsS, FFPH,
Director of Public Health, Hertfordshire
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The Challenge
The Challenge:
Creating conditions in which individuals and
communities have control over their health and lives
and participate fully in society.
New Levers:• Healthwatch – full engagement• Health and Wellbeing structures
– local democratic engagement• Public health transfer• Health scrutiny function• Duty to tackle health inequality• NHS Outcomes Framework• Public Health Outcomes
Framework• EDS
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So what’s the role for health improvement and behaviour change, then?
Health Improvement• Structural – policy level• Service – configuration of
services which meet need, are easy to access and
• Societal – social norms (e.g. The smoking ban)
• Interpersonal – coping with pressure to behave in way x
• Intrapersonal - the cognitive and motivational aspects of performing in a desired way
Behaviour change• Embed behaviour change
capability in our services to help people achieve goals
• Set achievable and realistic goals with people
• Motivate and continue support• Helps with maintenance of
desired behaviour• A key dimension of health
improvement
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Important Context
• Behaviour alone will not work, but policy intervention alone is usually not sufficient
• Need to work in the context of– Contributors to health outcomes– Lifecourse– Individual behaviour and issues
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This means
• Can rarely work at an individual level only, or societal level only
• A plan for intervention needs to understand the various dimensions of the issue
• Need to work on all aspects at once
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What does Lifecourse mean?
• From conception to grave, things influence our health all the time
– Lower birth weight – disease in later life– South Asian – genetic risk for diabetes– Readiness for school
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Smoking 10%
Diet/Exercise 10%
Alcohol use 5%Poor sexual health
5%
Health Behaviours
30%Education 10%
Employment 10%
Income 10%
Family/Social Support 5%Community Safety 5%
Socioeconomic Factors
40%Access to care
10%
Quality of care 10%
Clinical Care 20%
Environmental Quality 5%
Built Environment 5%
Built Environment
10%
Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Used in US to rank counties by health status
While this is from a US context it does have significant resonance with UK Evidence, though I would want to increase the contribution of housing to health outcomes from a UK perspective.
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Life course perspective• A way of looking at life not as disconnected stages, but as
an integrated continuum• Suggests that a complex interplay of
– biological, – behavioral, – psychological, – and social protective and risk factors contributes to health outcomes across the span of a person’s life.
• The life course perspective conceptualizes birth outcomes as the end product of not only the nine months of pregnancy, but the entire life course of the mother leading up to the pregnancy.
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The Lifecourse impact of health
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Example: Gaps in school readiness at 3 and 5 years by family income: UK
Ave
rage
per
cent
ile sc
ore
Waldfogel & Washbrook 2008
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So what does all that mean?
• Macro level – Marmot or Ottawa– Service configuration and commissioning
• Tactical level – access and design
• Individual Level – Assess and intervene appropriately using behavioural techniques
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• Best start in life – conception, weight, vaccs, imms
• Readiness for school• Good Housing• Resilient Childhood, Resilient Adulthood• Into employment and education• Lifestyle in working age• Self management in older age
Work for us all here!
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Increasing deprivation
Target health outcome
Amount of intervention needed to get everyone to target level
Current level of health outcome
High level of deprivation
Low level of health
Low level of deprivation
High level of health
www.hertsdirect.orgYears
0 1 5 10 15
Planning
Education
Vitamin Supplements
Air Pollution
Decent Homes
Jobs
Primary Care
20
CVD Events Self Care
Vitamin D and TBRickets
CVD EventsAcute Bronchitis Admissions
RespiratoryMental Health overcrowding educational attainment
Life Expectancy
Healthier space use Changing culture of activity
Life ExpectancyMental Health
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• A strong role for every agency• A need to rethink what the specialists bits of
public health have done and what they do in future – how do we embody this approach?
• A need to rethink how we transform all our agencies into public health agencies
• Everyone has a PH role
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The upshot of this unless we do something is that 2/3 of people will be in chronic ill health or disability before age 68, the new retirement age
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And Hertfordshire shows the same pattern!
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Why lifestyle alone will not eliminate health inequalities 1
• Lifestyle is not sufficient – environment, genetic, lifecourse influences
• It’s too late for some people – those who have disease already – while lifestyle will help manage disease and health they will need treatment
• It will be ten to fifteen years before lifestyle effects sustained population change. Meanwhile people will still need treatment
• Lifestyle is not enough for some people at high risk – other treatments are needed to
• Some risks are not amenable to lifestyle interventions for (e.g. immunosuppresion; infectious diseases which make up 16% of Birmingham’s deaths)
Healthy lifestyle is necessary but not sufficient of itself for significant Reduction of health inequalities
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So what are the big ticket issues?
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Big Ticket Issues• At Population Level
– Enable public health professionals to take whole system action
– Enable other professionals to do the same– Configure services with stronger behavioural
element• At personal level
– Put in place the skills to do behaviour change, even during brief interventions
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Smoking as an example• At Population Level
– Enable public health professionals to take whole system action
– Enable other professionals to do the same
– Configure services with stronger behavioural element
• At personal level– Put in place the skills to do
behaviour change, even during brief interventions
• Tobacco control partnership with key actions
• Behavioural support change and pathway
• Individuals have ability to do behaviour change
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In order to perform a given behaviourone or more of the following must be true:1. The person must have formed a strong positive intention
(or made a commitment) to perform the behaviour;
2. There are no environment constraints that make it impossible to perform the bahviour;
3. The person has the skills necessary to perform that behaviour;
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A simple model for behaviour change
1. AssessCritical Factors
Motivation
ReadinessAbility & Self-Efficacy
2. If they are truly ready thenset achievable goals which:a)Deal with barriersb)Sustain motivationc)Are likely to give them successd)Incremental benefit
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Audiences along a Behaviour Audiences along a Behaviour Continuum: Possible Communication Continuum: Possible Communication Strategies – Population or Individual?Strategies – Population or Individual?
Unaware
Aware, concerned,knowledgeable
Motivated toChange
Tries NewBehaviour
Sustains NewBehaviour
Raise awareness. Recommend a solution.
Identify perceived barriers and benefits tobehaviour change.
Provide logistical information.Use community groups to counsel and motivate.
Provide information on correct use.Encourage continued use by emphasisingbenefits.Reduce barriers through problem solving.Build skills through behavioural trials.Social support.
Remind them of benefits of new behaviour.Assure them of their ability to sustain newbehaviour.Social support.
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So what do professionals need to do?
1. When you design a service, identify the behavioural outcomes, identify the evidence of theory for those and identify how you will turn these into practice – a clear plan or protocol
2. When you develop service providers apply this and test
3. At service delivery level, understand and apply a model of behaviour change which works
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For another time – intervention mapping
Bartholomew, K.L., Parcel, G. S., Kok, G., and Gottlieb, N.H. (2006). Planning Health Promotion Programs: An Intervention Mapping Approach (2nd ed). Jossey-Bass: San Francisco.
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Some Reading
• Engaging and Retaining Clients in Healthy Behaviour Change, Roy Sugarman (2011)
• Health Behavior Change, Pip Mason (2010)• Health Psychology, Jane Ogden (2012)• Formulation and Treatment in Clinical Health
Psychology Ana V. Nikcevic, Andrzej R. Kuczmierczyk and Michael Bruch (6 Jul 2006)
