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Developing and applying translational behavioural science to improve population health and reduce inequalities

In his keynote address at the 2018 Health Psychology in Public Health Annual Conference, Professor Falko Sniehotta (Newcastle University/Fuse) presented an excellent case for the need to apply translational behavioural science to public health.  Dr Angel Chater gets to grips with his key points.

Determinants of behaviour and health exist at many levels, from the socio-economic, environmental and cultural, through to community influence and individual factors (Dahlgren & Whitehead, 1991).  Conditions such as obesity have a complex web of causality, as exhibited in the Foresight Report (Butland et al., 2007), highlighting the importance of applying a holistic bio-psycho-social approach, as suggested in the 1970’s to challenge the traditional biomedical model of illness (Engel, 1977).  However, to date, the focus of intervention efforts is most often on the individual (Sniehotta et al., 2017).  While a change in individual ‘lifestyle’ factors, such as diet, exercise, smoking and alcohol are often the target of intervention design, there needs to be an acknowledgement that behavioural science is much more than just ‘lifestyle choice’.

There has been an increasing interest in ‘choice architecture’ and ‘nudging’ to facilitate behaviour (change), often by manipulating elements of the environment.  However, until recently there has been a limited approach to synthesize evidence in this area (Hollands et al., 2017).  Moreover, this approach often focuses on the automatic process of decision-making, while omitting the reflective considerations.  Public health agencies, policy makers and commissioners often work at a macro, population-based level, aiming to solve population-wide health issues en masse.  Choice architecture and behavioural economics have, therefore, been prominent in many of their approaches such as Public Health England’s EAST model, encouraging interventions to be Easy, Attractive, Social and Timely (Behavioural Insights Team, 2014).  The Behaviour Change Wheel (Michie, Van Stralen, & West 2011) in contrast, postulates a model that considers determinants of behaviour in terms of Capability (psychological and physical), Opportunity (social and physical) and Motivation (reflective and automatic), alongside ways in which to intervene, at an individual, micro and macro level (through COM-B, intervention functions and policy categories).  This approach, therefore, takes a more holistic view of intervention design than the aforementioned EAST model, yet they both are welcome over none at all. 

Behavioural science has a significant role to play within public health, incorporating a number of disciplines to understand the complex influences that may affect population health.  To navigate through inter-twining and often overlapping disciplines and the multitude of theoretical frameworks and approaches within, it is important to co-create interventions.  Such co-creation should involve not only those commissioning and delivering a service but also those who may receive the intervention and those able to support an effective design and evaluation. In doing so, it will reduce the risk of wasted resources or potential inequalities in engagement; two key features in the APEASE framework that suggests interventions should consider: Affordability, Practicability, Effectiveness, Acceptability, Side Effects and Equality (Michie, Atkins, & West, 2014).

Cross-collaboration with commissioners, designers, deliverers, receivers and evaluators of a service, also provides a prime opportunity to learn from this experience to shape future programmes.  While behavioural science has an important role to play in public health, so too does public health have a significant role to play in the understanding and use of behavioural science.  We need to create a two-way dialogue so that we can learn from one another, and translational work from academia to practice and visa versa is essential.

Sniehotta presented an overview of Fuse, which is a good example of how this can be achieved, and such collaborations should be encouraged.  Fuse is one of 5 UK Public Health Research Centres of Excellence that links public health researchers across five universities in north-east England.  For these cross-collaborations to work, it is essential not only to speak the same language, but also to share a mutual understanding of the pressures of each discipline.  Public health is under pressure to deal with real world problems, in a timely fashion with limited resource. Behavioural scientists based in academia are heavily influenced by the Research Excellence Framework (REF), an audited measure of research quality and the impact (changes that occur as a result of research) it has made (locally, nationally, internationally).  The greater the quality of the research and its impact, the more kudos and financial support the academic institution will receive over the next funding period (next assessment occurs in 2021 for the period January 2014 to December 2020).  Cross-collaboration will work best, if the needs of each discipline can be considered from the onset.  The REF is conducted by the Higher Education Funding Councils for England (HEFCE), Scotland (SFC), and Wales (HEFCW) and the Department for the Economy, Northern Ireland (DfE), and assesses the quality of publications and other research outputs, in addition to the volume of research income the universities have reached, the impact this has made and the research environment that has been developed to be a conduit for this work.  Often, to reach high quality, the work must be novel, internationally recognised, evidence-based and replicable, supported by funding and a positive research culture.

Fuse researchers, for which Sniehotta has an integral role, have been able to meet these standards, while also collaborating with public health, publishing over 390 peer reviewed papers between 2009-2014 with over 15,000 citations, showing a high level of dissemination from the work they are involved in.  Its core funding is from the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council (ESRC), the Medical Research Council (MRC) and the National Institute for Health Research (NIHR), achieving grants of over £210M.  Those affiliated to Fuse work with policy makers and practice partners in six research programmes: Early Life; Healthy Ageing; Behaviour Change; Complex Systems; Translational Research and Inequalities.  Part of the research environment includes the successful completion of PhDs, and Fuse has funded 45 students through this process, adding to the capacity to engage in population-based, translational research.

The challenge going forward is to find ways to link behavioural science and public health together for mutual benefit, however, this equally presents an opportunity.  Methods of knowledge exchange used by Fuse include embedding researchers within the public health domain; funded PhD studentships, secondments, involvement of academics in local public health strategies, reviews of funding proposals, support for programme development, joint funding applications and the development of the NIHR School of Public Health Research.  A rapid response and evaluation service was launched in 2013 which acts as a portal to broker across the five participating universities that Fuse is part of.  This includes an initial free conversation to explore needs, matching enquiries to relevant academics.  This has led to long-term working collaborations and has facilitated the flow of evidence into practice.  An approach that could be replicated elsewhere. 

Fuse has supported over 240 enquiries within a three-year period.  The majority of enquiries have been from local authority public health teams (26%) and the voluntary and community sector (25%); and range from rapid service evaluations (31%), developing interventions (20%) and signposting (18%).  The most common evidence needs are related to lifestyle interventions (27%), integrated health services (22%) and specific diseases (20%).  Public health research conducted by the Fuse team includes work that has led to the remission of Type 2 Diabetes (Lean et al., 2017); reducing smoking behaviour in pregnant women (the babyClear© programme: Morgan et al., 2015); and reducing salt intake in takeaway food outlets (Goffe et al., 2016).

In conclusion, we need to see the challenges ahead in terms of population health with a wider lens, ensuring we co-create the interventions we commission, design, deliver and evaluate.  We need to ensure multi-disciplinarity and reduce the risk of wasted resources and inequality of services.  To achieve this, we need to embrace, in Sniehotta’s words, a ‘translational revolution’ between behavioural science and public health.  The developing Behavioural Science and Public Health Network has a significant role to play in linking these disciplines together and supporting this agenda. 

References

Behavioural Insights Team. (2014). EAST: Four simple ways to apply behavioural insights. Behavioural Insight Team, Public Health England: London.

Butland, B., Jebb, S., Kopelman, P., McPherson, K., Thomas, S., Mardell, J., & Parry, V. (2007). Foresight. Tackling obesities: future choices. Project report. London

Dahlgren, G. & Whitehead, M. (1991). Policies and Strategies to Produce Social Equity in Health. Stockholm: Institute for Futures Studies.

Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136.

Goffe, L., Hillier-Brown, F., Doherty, A., Wrieden, W., Lake, A. A., Araujo-Soares, V., .... & Adams, J. (2016). Comparison of sodium content of meals served by independent takeaways using standard versus reduced holed salt shakers: cross-sectional study. International Journal of Behavioral Nutrition and Physical Activity, 13(1), 102.

Holland, G. J., Bignardi, G., Johnston, M., Kelly, M. P., Ogilve, D., Petticrew, M., … & Marteau, T. M. (2017). The TIPPME intervention typology for changing environments to change behaviour. Nature Human Behaviour, 1, 0140.

Lean, M. E., Leslie, W. S., Barnes, A. C., Brosnahan, N., Thom, G., McCombie, L., ... & Taylor, R. (2017). Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet, 391(10120), 541-545.

Michie, S., Atkins, L., & West, R. (2014). The Behaviour Change Wheel: A Guide to Designing Interventions. Great Britain: Silverback Publishing

Michie, S., Van Stralen, M. M. & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science, 6(1), 42.

Morgan, H., Hoddinott, P., Thomson, G., Crossland, N., Farrar, S., Yi, D., … & Campbell, M. (2015). Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design. Health Technology Assessment, 19(30).

Sniehotta, F. F., Araújo-Soares, V., Brown, J., Kelly, M. P., Michie, S. & West, R. (2017). Complex systems and individual-level approaches to population health:  a false dichotomy? The Lancet Public Health, 2(9).

Written by Angel Chater