The document discusses the role of advanced nurse practitioners in behavior change and public health. It outlines models for behavior change and describes levers for influencing behavior at individual, social, and environmental levels. An example is given of an ANP who worked to reduce glass injuries from pub fights by implementing plastic drink containers. The summary concludes that ANPs can play a valuable role shaping health services and policy to improve outcomes at community and population levels through applying behavior change models and setting clear outcome measures.

1. Do Advanced Nurse Practitioners
have a wider role to play inhave a wider role to play in
behaviour change at community
d l i l l?and population level?
Gina Perigo
Health Outcomes Support ManagerHealth Outcomes Support Manager
Public Health,Liverpool PCT

2. Aim of this Session
• To discuss the levers for behaviour change and how theyg y
can impact on the individual, social, environment and
economic factors that impact on behaviour.
• To understand the behaviour change model and the
i limportance to set clear outcomes measures to assess
behaviour change
• To consider how the Advanced Nurse Practitioner can play
a wider role in influencing and shaping services to improvea wider role in influencing and shaping services to improve
public health

3. Health-related Behaviour Change
• Changing people’s health-related behaviour can
have major impact on some of the largest
causes of mortality and morbidity.
• Behaviour plays an important role in people’s
health. For example; smoking, poor diet, lack ofhealth. For example; smoking, poor diet, lack of
exercise and sexual risk taking can cause a
large number of diseases.large number of diseases.

4. Raising Rates and Rising Cost of:
• Obesity• Obesity
• Alcohol abuse
• Smoking related deaths
• Infectious diseases• Infectious diseases
• Drug abuseg
• Poor mental health
H lth I liti• Health Inequalities

5. Dahlgren and Whitehead (1991)

6. NHS White Paper sets out its vision:
f• to strengthen the role of local government
in improving healthp g
• ring fenced public health budgets
i th t th NHS h h l• recognises that the NHS has a huge role
to play in Public Health
• emphasis public health is everyone
businessbusiness

7. A New Approach to Public Health
“ P bli h lth i t d b f“ Public health is a movement, owned by everyone, for
everyone's benefit. A movement which unites those who
have been trying to prevent ill health with thosey g p
responsible for treating it….
…. to work hand and hand with colleagues across local
government and the NHS, to challenge and lead others; to
d li b f h i Tdeliver better outcomes for the nation; …. To support
communities and empower individuals …..”
Department of Health, A New Approach to Public Health, UK Faculty of Public Health Conference, 7th July 2010.

8. How can you as an Advanced Nurse
Practitioner develop your role in publicPractitioner develop your role in public
health and influence and shape services to
improve health outcomes at a community
and population level?and population level?

9. NICE GuidanceNICE Guidance
• Interventions to change behaviour have enormous potential to
alter current patterns of diseasealter current patterns of disease
• Often the theories and principles in relation to behaviourOften the theories and principles in relation to behaviour
change are not taken into account when planning, delivering
and evaluating health improvement initiatives
• NICE produced eight generic principles that can be used as
th b i f l i d li i d l ti blithe basis for planning, delivering and evaluating public
health activities aimed at changing health-related behaviour at
individual community and population levelsindividual, community and population levels
NICE public health guidance 6 2007 www nice org uk/PH006NICE public health guidance 6. 2007 www.nice.org.uk/PH006

10. Behaviour Change ModelBehaviour Change Model
• Provides a framework to ensure we are more effective and
systematic in identifying approaches and strategies in relationsystematic in identifying approaches and strategies in relation
to health-related population behaviour change
• It is based on North Karelia model
• It is underpinned by a mix of theory types
• Takes account of the individual, social, economic and
environmental factors which impact on behaviour change
• Makes the link between the intervention, its
outcomes and the impact on behaviouroutcomes and the impact on behaviour.

11. BEHAVIOURAL CHANGE PROCESS
INFORMATION
PERSUASION
MEDIA
MESSAGES
TRAINING FOR SKILLS
MESSAGES
TRAINING FOR SKILLS
COMMUNITY
SOCIAL SUPPORT SERVICES
&
ORGANISATIONS
ENVIRONMENTAL
MODIFICATION &
COMMUNITY SUPPORT

12. Choosing Appropriate Outcomes for
Health-Related Behaviour ChangeHealth Related Behaviour Change
Levers for change
Information Persuasion
Training for
Skills
Social Support
Community
Organisations
Environmental
Change
Outcome Measures
Raised
Awareness
Changed
Attitudes
Enhanced
practical skills
Enhanced
motivation
and success
Increased
support,
Removed
barriers,
Increased
Awareness
Increased
Knowledge
Attitudes
Increased
Motivation
Empowered
and increased
self-efficacy
via
professionals
peer, family
support
advocacy and
more favourable
social norms
opportunities
Increased
demand
Change policy
Impact on Behaviour
Less likely toLess likely to
happen or be
sustained by
simply
providing
Need to be
persuaded to
act on
information
Easier to
translate
intention into
action
More likely to change and sustain
if reinforced by social environment
providing
information
information action
© Liverpool PCT HOU Based on North Karelia Model, McAlister et al, 1982, American Journal for Public Health

13. Choosing Appropriate Outcomes for
Health-Related Behaviour Change
Levers for change
Health Related Behaviour Change
Information Persuasion
Training for
Skills
Social Support
Community
Organisations
Environmental
Change
Outcome Measures
Raised
Awareness
Changed
Attitudes
Enhanced
practical skills
Enhanced
motivation
and success
Increased
support,
Removed
barriers,
Increased
Awareness
Increased
Knowledge
Attitudes
Increased
Motivation
Empowered
and increased
self-efficacy
via
professionals
peer, family
support
advocacy and
more favourable
social norms
opportunities
Increased
demand
Change policy
Examples
Standardized Messages on Breastfeeding Peer Social inclusion Equality Bill 2010Standardized
messages Via
Social Marketing
Campaign, Health
Professionals
Leaflets, Posters,
W b it
Messages on
benefits for mum
and baby, provided
by Peers,
GPs, Midwives,
Health Visitors
Breastfeeding Peer
Support Service
Peer training
Breastfeeding
Information
provided to family
& friends will help
them support
breastfeeding
mums
Social inclusion
team
Stakeholder
engagement
N i hb h d
Equality Bill 2010
Local Workplace
Charter
Breastfeeding
Friendly Welcome
Scheme
Website,
Press coverage
Children Centre
teams
Management &
Unicef Audit
training for
professionals
mums
Peer to Peer
support
Relevant written
materials© Liverpool PCT HOU
Neighbourhood
teams
Local Business
Unicef Baby
Friendly Initiative
Directory of
Breastfeeding
Welcome Places

14. Example (personal communication)
• ANP working in A&E.
• Regularly deals with glass injuries from fights in pubs• Regularly deals with glass injuries from fights in pubs
& clubs.
Mainl facial & hand inj ries ith significant• Mainly facial & hand injuries with significant
consequences.
• Gives regular advice on drinking, safety etc (Brief
intervention)

15. • ANP Initiated meeting with:
– Police
– Licensing Authority
– Local Authority
– PCT
– Representatives from Licensed Premises
• Concept – To introduce plastic unbreakable
t i t t t d b d l b hcontainers to targeted pubs and clubs where younger
people drink(1) to reduce A&E attendances and
hospital admissionshospital admissions
1 L k t l A littl i ht l b di i th h lth i li ti f l bbi1. Luke et al: A little nightclub medicine: the healthcare implications of clubbing.
Emergency Medical Journal 2002;19:542-545

16. Series of meetings with held to discuss:
D t• Data
– (where offences happen, age groups, popular
pubs & clubs, time of drinking etc)
• How to implement a policy & what would thatHow to implement a policy & what would that
look like?
• Policy developed, signed off by all partners &y p , g y p
implemented.

17. Expected Outcomes:Expected Outcomes:
• Reduction in glass injuries
• Reduction in A&E attendancesReduction in A&E attendances
• Reduction in alcohol-related hospital admissions
However, would this policy influence & change behaviour?
Could the ANP taken even further steps to change behaviour?
For example:
• Alcohol Screening and brief intervention offered to all patients
in the A&E department, extend this to all patients in the
hospital (System & Scale)hospital (System & Scale)
• Put pressure on the key stakeholders to the tackle root cause -
binge drinking by implementing an alcohol harm reductiong g y g
programme

18. It is important when planning health improvement
interventions to:
1. Critically evaluate the evidence to the specific health
related behaviour you want to changerelated behaviour you want to change
2. Design valid and reliable interventions and programmes
th t t k t f th l f hthat take account of the levers for change
3 Apply social and behaviour change models and3. Apply social and behaviour change models and
concepts to each of the levers of change were
appropriate
4. Set clear outcome measures to assess the change in
behaviour

19. SummarySummary
• Encouraging healthier lifestyle is the job of all staffEncouraging healthier lifestyle is the job of all staff
working in the health service, not just those working
specifically on public health projects.
• All interactions between patients and health professional
presents an opportunity to deliver messages about
h l hi lif l d b h ihealthier lifestyles and behaviours.
• Advanced Nurse Practitioners can play a valuable role• Advanced Nurse Practitioners can play a valuable role
influencing and shaping services and local policy to
improve health outcomes at not only an individual level
but at a community and population levelbut at a community and population level.

20. Any questions?y
Gina Perigo
Health Outcomes Support Manager
P bli H lth D t tPublic Health Department
Liverpool Primary Care Trust
gina perigo@liverpoolpct nhs ukgina.perigo@liverpoolpct.nhs.uk
Tel: 0151 296 7839