The Application of Behavioural

Science to Public Health

ADPH Webinar

Prof Jim McManus Hertfordshire County Council Dr Angel Chater University of Bedfordshire Dr Tim Chadborn PHE Behavioural Insights Team Dr Amanda Bunten PHE Behavioural Insights Team Michelle Constable Hertfordshire County Council

Objectives

Gain an overview of behavioural science.

Understand relevance and applicability of behavioural science in

public health.

Gain awareness of the Behavioural Science Strategy development

and relevance to ADsPH.

2

Timings

Time Description Presenter

11.00 Introductions and welcome Prof Jim McManus

11.05 Setting the scene Dr Tim Chadborn

11.10 Current directions in behaviour change theory Dr Angel Chater

11.20 Examples of the application of behavioural science Dr Amanda Bunten

11.30 Embedding behavioural science in Public Health Michelle Constable

11.40 Overview of the Behavioural and Social Science Strategy Dr Tim Chadborn

11.45 Respond to questions submitted All

12.00 Close Prof Jim McManus

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What are the

facilitators and

barriers to the

uptake of weight

management

services?

How can we

design the

built/ lived

environment

to influence

health-related

behaviours?

Typical questions from policy teams

What are the drivers

of the provision of

brief advice to

patients by healthcare

professionals?

4

Draws on insights from psychological research; primarily

behavioural economics and health psychology

Can be applied at the individual, professional, community or

population level

Used upstream and downstream in prevention and treatment

Central role of robust evaluation to demonstrate effectiveness

Small changes can have widespread impact

Previous behaviour is best predictor of future behaviour

– not intentions or beliefs

Behavioural Science

5

6

Behavioural ‘Definitions’

Behaviour is anything a person does

in response to internal or external events.

(Hobbs, Campbell, Hildon & Michie, 2011)

Behaviour should be differentiated from its

determinants (self-efficacy, emotion) and its

outcomes (quality of life, cholesterol level).

Traditional Theories of Behaviour

• The Health Belief Model – Becker (1974) Importance of beliefs, perceived benefits &

barriers to action, self-efficacy, stimulus/ cue to action. Limitations: focused on

conscious decision making and ignores habits.

• Social Learning Theory, Social Cognitive Theory – Bandura (1977) Importance of

social environment, modelling and self efficacy Limitations: emphasis on conscious

decision making and reflective processes

• Theory of Reasoned Action / Theory of Planned Behaviour – Ajzen (1985)

Limitation: assume people act in a rational way at all times, not all behaviour is

planned.

• Stages of Change Model / Transtheoretical Model – Prochaska and DiClemente

(1997) Limitation: assumes behaviour change occurs in a linear fashion, progression

through a series of stages.

Limitations:

• Effectiveness of predicting behaviour change

• Intention-behaviour gap

• Not addressing automatic motivation, habits and impulsive behaviour.

Public Health England - Behavioural Insights Masterclass Public Health England - Behavioural Insights Masterclass 7

“..this review suggests that intentional

control of behaviour is a great deal

more limited than previous meta-

analyses of correlational studies have

indicated”

Changing Behaviours: The limitations of changing minds

“Changing behaviour by changing

minds is unscaleable, increases

inequalities, not very effective”

(Professor Theresa Marteau)

(Slide adapted from one by Theresa Marteau) 8

Resist Environments Change Environments

Change minds to…

(Slide adapted from one by Theresa Marteau)

Before After

Changing behaviours: Two (not mutually exclusive) approaches

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Two interacting systems

Dual Process Theory

Reflective

Slow

Effortful

Self-aware

Complete a tax form

17 x 24

Automatic

Fast

Effortless

Unconscious

Driving on an empty road

2 + 2

Kahneman, D. (2011). Thinking, fast and slow. Macmillan.

10

Health Psychology

Health Psychology and Behaviour Change

• The science of human behaviour and experience

• Aims to:

• Promote and maintain health

• Enhance the well-being of those affected by illness

• Improve the health care system and support health

policy formation

• Understanding how people think, feel and learn

can help us understand and predict how they will

act

If we can UNDERSTAND human behaviour, it

gives us insight into how to CHANGE human

behaviour

At the heart of behaviour [change] is the

person…

Bio-Psycho-Social Model

(Engel,1977,1980)

Strength of Health

Psychology lies in the

application of theoretically-

driven, evidence-based

science

Behavioural Science

12

Importance of Theory • Key questions to ask when developing interventions

(individual, community or population based levels):

1. What things should be considered when trying to

understand and change behaviour? • What bio-psycho-social factors might be important?

2. What factors might influence uptake/engagement? • What barriers/ facilitators might influence behaviour?

• Must move away from ‘common sense’ models of

behaviour change and draw on theory

Imagine you wanted to change physical activity behaviour

in an obese population to reduce diabetes and CVD risk…

What would you need to consider?? Hold that thought…

13

Now imagine a population of

Homer Simpsons!

Theory: COM-B

Capability

Motivation

Opportunity

Behaviour

Problem = Obesity

Target behaviour = Physical Activity

(Michie et al., 2011)

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Behaviour

Capability

Psychological capability

Physical capability

Motivation

Reflective motivation

Automatic motivation

Opportunity

Social opportunity

Physical opportunity

A more holistic model of

behaviour change – COM-B

Capability, motivation and opportunity all need to be present for a behaviour to occur

They all interact as part of a system

Motivation must be stronger towards the target behaviour than competing behaviours

(Michie et al., 2011)

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COM-B model

components

Definition

Psychological

capability

Knowledge, psychological skills (such as planning, attention,

strength and stamina) to engage in the necessary mental

processes (interpersonal skills, memory, attention, decision

processes).

Physical capability Physical skills, strength or stamina

Reflective motivation Active thought processes – attitudes and beliefs about what is

good or bad, the costs and benefits of doing something,

beliefs about consequences, goals, plans, and intentions.

Automatic motivation Less conscious thoughts processes that drive behaviour -

emotional reactions, desires (wants and needs), impulses,

drive states, habits, reinforcement, associative learning and

reflex responses.

Social opportunity Opportunity afforded by the social environment, social cues

and cultural norms, social acceptability and expectations.

Physical opportunity Opportunity afforded by the environment involving time,

resources, locations, cues.

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(Michie et al., 2011)

Behavioural Economics

Standard Economic Theory

• Consistently rational

(not emotional)

• Self-interested (not

altruistic)

• Utility maximisers

(the greatest amount

of value possible for

the budget)

• Takes the optimal

route to achieve

goals

• Subject to biases

• Subject to irrationalities

• Use heuristics (shortcuts) to

make decisions

• Context and time

dependent

(inconsistent)

• Emotional

‘Homo-economicus’ In reality

Behavioural Economics

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Heuristics Mental shortcuts or rules of

thumb to aid in problem solving

Cognitive Biases Systematic thinking errors that affect decisions and judgement

Anchoring

Availability

Loss Aversion

Status Quo

How can Behavioural Science be Utilised?

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Defaults We tend to ‘go with the flow’ of

a pre-set option

Salience Our attention is draw to what

is novel and appears relevant

to us

Substitution Easier to substitute a

behaviour than eliminate an

entrenched one

We are expecting you

at St Barts Hospital on

Sep 26 at 2.30. Not

attending costs NHS

£160 approx. Call

02077673200 if you

need to cancel or

rearrange.

What can it do for you?

Help to achieve local and national public health outcomes

Provide theoretically-driven, evidence-based programmes

Provide low cost ways of enhancing existing systems or

processes

Improve the effectiveness of delivery and outcomes of

training

Provide rigorous, scientifically led evaluations

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Analyse Advise Design Trial Train Behavioural

Analysis

Policy Interventions RCTs Masterclasses

Literature

review

Systematic

review

Programmes

Communication

Mode of

delivery

Programmes

Quasi-

experimental

studies

Evaluation

Qualitative

research

Workshops

Seminars

How can Behavioural Experts help?

Translation of evidence into practice

Building the Evidence

Health Checks

Increasing uptake of NHS Health

Checks

Health issue: Diabetes, CVD (heart attack and stroke), Kidney Disease and Dementia

Behavioural target: Increasing uptake of NHS Health Checks

Method: Altering the standard invitation letter and sending SMS messages

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Control Treatment

DH led trial

NHS Health Check

You will receive a letter

about your NHS Health

Check.

Your NHS Health Check

is due tomorrow at

13.30.

vs.

+

Primer

Reminder

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NHS Health Check: Results

18%

30%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Standard letter and no texts Revised letter and primer and promptmessages

Percentage uptake of NHS Health Checks

All reported results are statistically significant at p< 0.05 level. 27

Antimicrobial Resistance

Reducing inappropriate antibiotic

prescribing

Health issue: Antimicrobial resistance

Behavioural target: Reducing inappropriate prescription of antibiotics in primary care

Method: Letter sent to the top 20% GP prescribers

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AMR

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“The great majority

(80%) of practices in

INSERT NHS AREA

prescribe fewer

antibiotics per head

than yours.”

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Reduction of 3·3% in top 20% - equates to 0.83% across all GPs

Estimated 73,406 fewer antibiotic items dispensed

Cost of £4,335 - saving £92,356 in just prescription costs

Quality Premium allocated up to £23m to reduce prescriptions by 1%

2014 2015

Letter reduced prescriptions

Letter

Letter reduced prescriptions in control group

Rate of antibiotics dispensed per 1,000 weighted population for study period, with 95% CI

AMR: Results

Hallsworth, M., Chadborn, T., Sallis, A., Sanders, M., Berry, D., Greaves, F., Clements, L. and

Davies, S.C., 2016. Provision of social norm feedback to high prescribers of antibiotics in general

practice: a pragmatic national randomised controlled trial. The Lancet, 387(10029), pp.1743-1752

Food Environment

Encouraging Healthy Food and Drink

Purchasing

Health issue: High rates of obesity

Behavioural target: Make the Healthy choice the Easy Choice

Method: Product placement and pricing promotions on sales of food and drink within 3

NHS food environments

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Three studies of choice architecture

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Sales of water by 22 bottles a day

Proportion of total water sales by

12%

23% in confectionary sales

63% in water and 67% in

fruit sales

No effect on crisps 12%

Approx reduction of 14

kcals per drink

Embedding Behavioural Science

in Public Health

NICE Guidance

Public Health commissioning - lifestyle factors

NICE Guidance PH6, PH49 and LGB7

o Develop a local behaviour change policy and

strategy

o Commission interventions at population,

community, and individual levels

o Embed behaviour change all programmes from initial planning to

evaluation

34

National Developments

Health Psychology in Public Health Network

o Network launched in 2014 to build on the synergy between

health psychology and public health agendas.

Behavioural Sciences Strategy for Public Health

o Strategy for all public health organisations being developed by a

range of partners: ADPH, PHE, HPPHN, FPH, LGA, BPS

Campaign for Social Sciences – The Health of People

o Launched in 2017 - How the social sciences can improve

population health

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Local Opportunities Explore shared agendas

Different approaches to embedding behaviour change in

England

oJointly funded posts – Warwickshire

oEmploy a behaviour change specialist – Herts, Solihull

oFund a PhD

oInterns, MSc & PhD training placements, secondments

oDiscrete pieces of research for MSc or Doctoral

students

oCommission research, consultancy, training

oJoint funding bids

oAcademic evaluations

36

Interventions and Collaborations

37

Hertfordshire – Active Herts Joint Sport England funding bid – PH, CCGs,

Herts Sports Partnership

Systematic review (Howlett et al. 2016)

Evidence based intervention developed

Behaviour Change training for those delivering

interventions

Academic evaluation of behaviour change

constructs, level of activity, wellbeing and fidelity

Interventions and Collaborations cont.

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Hertfordshire Health Improvement Service

Stop Smoking Service delivering weight management

intervention

Health Psychologist input:

o Development of service spec.

and evaluation of bids ensure behaviour

change embedded in intervention

o Developing training plan including

behaviour change

(Dixon & Johnston 2011)

o Comprehensive evaluation framework

A Behavioural and

Social Sciences Strategy

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Proposal

• develop a framework strategy for maximising the contribution of behavioural science to the protection and improvement of the public’s health and wellbeing in England;

• with a particular focus on enhancing the effectiveness of public health interventions and reducing health inequalities through better application of behavioural science.

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Toward a behavioural sciences strategy for public health and wellbeing in

England

A prospectus for conversation and development

February 2017

Conversation Event – Fri 17th March 2017

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Potential objectives

1. Enhanced pre-service curricula

2. Strengthened in-service training

3. Guidance on approaches and frameworks

4. Inclusion in governance processes

5. Improving access to evidence

6. Capacity through networks and procurement

7. Community of evidence and practice

8. Advise on research priorities

Questions and Next Steps

Further learning opportunities Health Psychology in Public Health Network: http://www.hpphn.org.uk

Online training http://www.bct-taxonomy.com/

Teaching, training & events http://www.ucl.ac.uk/behaviour-change

Public Health England’s Behavioural Insights Masterclasses: Tim.Chadborn@phe.gov.uk

Behavioural Economics Seminars at the London School of Economics

http://www.lse.ac.uk/LSEHealthAndSocialCare/events/BehavioralEconomicsSeminars.aspx

Behavioural Economics Events http://be-events.org/

Campaign for Social Sciences: YouTube: The Health of People: Part 2

Recommended Reading

Chater, A. & Cook, E. (2014). Health Psychology. London: Pearson.

(Chapter 3, Intervention Design: Changing Health Behaviour.)

Kahneman, D. (2011). Thinking, fast and slow. Macmillan.