The field of public health currently faces a variety of significant challenges including tackling obesity, reducing smoking, increasing physical activity, improving mental health, increasing uptake of screening and immunisation, reducing inappropriate antibiotic use in order to address antimicrobial resistance, and improving air quality. Progress on these challenges will rely on changing behaviours (individual, professional, and organisational) as well as understanding and changing systems. A systems approach is needed because the complexity of public health means that change often needs to happen at multiple levels simultaneously.
Traditionally, public health professionals have worked to change behaviour by informing and educating people (health education and health promotion), as well as making structural changes. In more recent years we have recognised that many of the behaviours targeted by information and education campaigns are more effectively changed by also addressing psycho-social and structural issues (e.g., food environments) and other wider determinants of health, These can shift systems towards healthier states, can create new healthier practices, and can encourage ‘making the healthier choice the easier choice’. The focus on the individual and the focus on the social and structural therefore need to be integrated.
The use of behavioural and social sciences in public health can be traced back a long way. For instance, Dr John Snow used geography to trace a cholera outbreak to a water pump in Soho in 1854 and Dr Joseph Goldberger drew on sociology when arguing that pellagra was caused by dietary deficiencies in 1914. More recently, evidence from the social sciences was influential in changing legislation, such as securing tobacco advertising bans and introducing mandatory wearing of seat belts, which has then affected cultural norms. However, to date, the behavioural and social sciences have often not been applied in a systematic way.
The behavioural and social sciences include a range of disciplines that study individual behaviour and social systems. ‘Behavioural insights’ and behaviour change methodologies have been gaining recognition over the last ten years. These approaches combine findings from fields such as cognitive psychology, behavioural economics, social psychology and health psychology to understand human behaviour and decision making. Behavioural insights can be used to develop and evaluate behaviour change interventions and the approach has now gained support from key leaders (11). To demonstrate leadership in this area, the Department of Health and Social Care (DHSC) launched ‘DHSC Collaborate’ in 2018. This stepwise initiative to further develop open policy making was established with an initial focus on behavioural science. Public Health England (PHE) has embedded the behavioural insights approach into recent strategies including ‘From evidence into action: opportunities to protect and improve the nation’s health’ (12) and ‘Strategic plan for the next four years: better outcomes by 2020’ (13). These state that the behavioural insights approach is a game changer for PHE and the wider system because it delivers high value for money and return on investment, and uses a systematic approach based on evidence and theory.
A range of developments is also happening at a local level. Since local authorities have become responsible for public health in England, the increasing use of behavioural and social science approaches is evident. The Local Government Association (LGA) produced two briefings for public health professionals on behaviour change in 2013 and 2016 including local examples of good practice (14, 15). In 2015/16, the LGA initiated a behavioural insights grant funding programme that was subsequently re-run in the next two years. The most recent wave was hugely oversubscribed, despite the requirement of matched funding. Across a number of areas, local authorities have been working to enhance capability for applying the behavioural and social sciences to public health practice. This has been achieved in a variety of ways including employment of a behaviour change lead (such as in Solihull and Croydon), setting up a behaviour change hub (Croydon), and collaboration between academic experts and councils (such as in Coventry and Warwickshire). As a result, behavioural science expertise has been applied to external funding applications, rapid literature reviews and service redesigns. It has also led to the embedding of behavioural science in specific interventions and the provision of ad-hoc advice across organisations. This work has also extended to the upskilling of frontline staff through a range of behaviour change and communication skills training courses, led by behavioural and social scientists. Competency frameworks have also been developed in some areas to ensure that staff gain the appropriate skills and that these skills are embedded into practice.
Although there have been many gains in terms of behavioural science being better taken up by local public health functions, there have been fewer initiatives for building similar capacity for other social sciences. Many local authorities do commission from, work with, and learn from psychologists, sociologists, geographers, and anthropologists working on public health, but there are fewer resources to provide guidance about where insights from these disciplines could have greatest impact, or how best to work with social scientists. There needs to be a step change in these areas following publication of this strategy.
There is an important role for Health Education England (HEE) in developing competencies, and identifying opportunities for training and capacity building. Some professions already include behavioural science in their core curriculum; professional bodies should encourage and build upon this.
This strategy for incorporating the behavioural and social sciences into public health builds on recent work by the Academy of Medical Sciences, the British Academy, and the Campaign for Social Science, which has highlighted some of the current and future needs across the public health system for the behavioural and social sciences. The roles of behavioural and social science in public health practice have gained momentum in recent years. Some of the key developments include:
- British Journal of Health Psychology special issue on links between public health and psychology (1998)
- European University Studies Monograph on Health Behaviour and Health Promotion in a Public Health Psychology by Thomas von Lengerke (16) (2001)
- American Psychological Association book on Integrating Behavioural and Social Sciences with public health (2001)(17)
- Secondment of two Health Psychologists to the government’s Division of Public Health (2003)
- National Consumer Council review of health-related campaigns and social marketing, ‘It’s Our Health!’ (2006)(18)
- NICE Guidance on behaviour change: general approaches (2007)(19)
- Funded places for Health Psychology training (stage 2) through the Scottish Health Boards and National Health Service (NHS) (2008).
- Evidence based public health: a review of the experience of NICE in developing public health guidance (20)
- Behavioural and Social Sciences Teaching in Medicine published “A Core Curriculum for Psychology in UK Undergraduate Medical Education” (2010)(21)
- House of Lords Science and Technology Select Committee on Behaviour Change (2011)
- Public Health England created with a specific Behavioural Insights function (2013)
- Behavioural Science in Public Health Network (BSPHN) founded (2013)
- Local Government Association briefing on ‘Changing Behaviours in Public Health’ (2013)(14)
- NICE Guidance on behaviour change: individual approaches (2014)(22)
- Behavioural Experiments in Health Network founded (2015)
- PHE and British Psychology Society’s Division of Health Psychology briefing on ‘Why Directors of Public Health need to know a Health Psychologist’ (2015)(23)
- Behavioural Experiments in Health Network (BEH-net) launched its international workshop, now in its fifth edition (2015)
- European Health Psychology Society monograph on Health Psychology (2016)
- Behavioural and Social Sciences Teaching in Medicine published “A Core Curriculum for Sociology in UK Undergraduate Medical Education” (2016)(24)
- Local Government Association’s briefing on ‘Behavioural insights and health’ (2016)(14)
- Academy of Medical Sciences launch “Health of the Public 2040” (2016)(25)
- National Academy of Social Sciences’s Campaign for Social Science launches “The Health of People: How the Social Sciences can improve population health” (2017)(26)
- London School of Economics launched the first Executive MSc course in “Behavioural Science for Health” (2017)
- Competencies developed and applied to lifestyle services in Hertfordshire (2017) and Solihull, based on the Dixon and Johnston behaviour change competency framework
- Behavioural Experiments in Health Network and three universities launch the first PhD Summer School in Behavioural and Experimental Health Economics (2018)
- Social science evidence used in development of NICE guidelines on topics such as Active Travel and Environmental Interventions