This presentation to a public health strategy workshop discussed how we could embed behaviour change at population level into our public health strategy

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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%
Socioeconomi
c 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
Averagepercentilescore
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

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Years
0 1 5 10 15
Planning
Education
Vitamin
Supplements
Air Pollution
Decent
Homes
Jobs
Primary
Care
20
CVD
Events
Self Care
Vitamin D and TB
Rickets
CVD Events
Acute Bronchitis Admissions
Respiratory
Mental 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 behaviour
one 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. Assess
Critical
Factors
Motivation
ReadinessAbility &
Self-
Efficacy
2. If they are truly ready then
set achievable goals which:
a)Deal with barriers
b)Sustain motivation
c)Are likely to give them
success
d)Incremental benefit

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Audiences along a BehaviourAudiences along a Behaviour
Continuum: Possible CommunicationContinuum: Possible Communication
Strategies – Population or Individual?Strategies – Population or Individual?
Unaware
Aware, concerned,
knowledgeable
Motivated to
Change
Tries New
Behaviour
Sustains New
Behaviour
Raise awareness.
Recommend a solution.
Identify perceived barriers and benefits to
behaviour change.
Provide logistical information.
Use community groups to counsel and motivate.
Provide information on correct use.
Encourage continued use by emphasising
benefits.
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 new
behaviour.
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)

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Thank you!
Jim.McManus@hertfordshire.gov.uk