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Improving People's Health: Applying behavioural and social sciences to improve population health and wellbeing in England

What are behavioural and social sciences? What key theories and frameworks do they offer public health practitioners?

  • Public Health England
  • Faculty of Public Health
  • Association of Directors of Public Health
  • Behavioural Science and Public Health Network
  • Local Goverment Association

The richness and diversity of behavioural and social scientific disciplines is impossible to encompass in a strategy document, and there are many more than we have chosen to represent in brief here. Those summarised in the sections below are chosen purposefully as examples of disciplines where there has been, or currently is, fruitful engagement with public health disciplines, and where there are insights which are valuable. It is not any indication or suggestion that those not included here are not valuable or important. Figure 3 shows how a larger, though still not comprehensive, list of disciplines can inform different aspects of public health, taking a systems approach with both upstream and downstream factors.

Figure 3. Conceptualising the contributions of behavioural and social science disciplines.

Although we set out illustrative examples of the contributions of different disciplines, our aim is to support the interdisciplinary application of the behavioural and social sciences. Indeed, it is sometimes difficult to say which discipline is responsible for a particular approach or framework, so our classification is necessarily somewhat imprecise. This simply highlights our broader point that exemplar applications of behavioural and social sciences do not follow disciplinary boundaries and that our application of behavioural and social science to public health needs to be transdisciplinary and issue-based.

In what follows, we focus on the contribution of behavioural and social sciences to understanding behaviour and behaviour change, but all of these disciplines can also contribute quantitive and qualitative methods for evaluation, in order to answer such questions as what is happening and why, what interventions work and why, and for whom.

A. Anthropology

Anthropology is the study of human cultures and societies. Anthropology has made important methodological contributions to public health, in particular through the use of ethnography (explained below) to better understand the spread of infection and adopting healthier practices. Anthropological approaches can also contribute to the translation of scientific knowledge into effective practice at the community level.

Key concepts and theories

The focus on cultures, societies and communities can be applied to digital projects (e.g., in the discovery phase, when research is done on whether users need the service that it is proposed to build and what other services exist).

Tools and frameworks

Ethnography: a form of qualitative inquiry used to gain insight into the lived experience of individuals and groups, where the researcher is embedded in the society or group that is being studied and observes behaviour in order to develop insights. ‘Focused ethnography’, which studies specific beliefs and practices of a particular group of people, has been adopted for work in health (56).

B. Economics

Behavioural economics

Behavioural economics takes into account theories, insights, and methods from economics, psychology, and other disciplines (sociology, anthropology, philosophy, but also biology, neuroscience, medicine) to improve the descriptive power of economic models of decision making. Traditional economics is based on a model of rational decision making. The behavioural economics approach builds on, and departs from, traditional economics by acknowledging that human decision making and behaviour are not always fully rational and optimal, and may be subject to biases and heuristics. It discovers and diagnoses biases through testing the assumptions of the rational choice model, and it implements psychological insights into standard economic models. Behavioural economics can contribute to public health by enhancing our understanding of how humans behave and make decisions (in contrast with how they should behave and make decisions), thus informing the design of effective policy interventions.

Key concepts and theories

Non-standard beliefs: while traditional economics assumes that people’s beliefs are formed in a rational manner based on all available evidence, behavioural economics allows that people may have systematically incorrect beliefs because of biases in the way beliefs are formed.

Non-standard preferences: traditional economics assumes that people are time-consistent (that they have the same preferences about future plans at different points in time), that they only care about their final outcomes, and that they are rationally self-interested; behavioural economics allows that people are time-inconsistent, that they care about whether an outcome is a gain or a loss and may be particularly averse to losses, and that they may also care about other people’s wellbeing.

Non-standard decision making and behaviour: traditional economics assumes that decisions are consistent and optimal, given a person’s preferences; behavioural economics allows, for instance, that people may use suboptimal heuristics, that they may have limited attention, that they may be affected by the framing of the decision, or that their choices may be affected by their emotional state.

Key frameworks and tools for public health practitioners

Nudge (57): we can change behaviour through ‘nudges’, altering the way choices are presented without restricting any options.

MINDSPACE (58): a framework to develop behaviourally informed interventions, including insights from psychology and behavioural economics.

EAST (59): a framework to support the application of behavioural insights to public policy, including insights from psychology and behavioural economics. 

What is Really ‘Behavioural’ in Behavioural Health Policy? (60): a conceptual framework for preference-based policies, information-based policies, incentives, nudges, regulation, taxation, and ‘behaviourally super-charged’ health policies.

Behavioural Insights in Healthcare (61): an quick scoping review, summarising the evidence of the application of nudge-type interventions in health care and considering opportunities for reducing inefficiency and waste in health care using nudge-type interventions.

The Behavioural Experiments in Health Economics checklist (62): an Oxford Research Encyclopaedia toolbox to navigate 10 key areas of potential challenge/debate about applying behavioural economics experiments to health.

Test, Learn, and Adapt (63): a guide to using Randomized Controlled Trials (RCTs) to evaluate policy interventions.

Public and health economics

Public and health economics have contributed to the design of public interventions and incentive frameworks in public and health-related sectors and organisations. In particular, public economics has proposed a fundamental tri-partition of public finance functions into (i) economic stabilization, (ii) income redistribution, and (iii) resource allocation. Economic stabilization is achieved through both fiscal and monetary policies. Income redistribution is achieved through taxation and provision of subsidies, public goods, and social services, including healthcare. Resource allocation is achieved through direct public provision of public goods and social services, and through regulation of private markets, including price regulation.

Building on the public economics framework, health economics has proposed a rationale for public intervention in the health and healthcare sectors in all the instances where those sectors are characterised by market failures, namely: public goods, externalities, asymmetric information, and monopoly. Health economics has contributed to informing the design and implementations of behavioural interventions embedded within health systems and to evaluating their macro-level impact, including also any unintended spillover effects across different stakeholders. Health economic modelling can further help to identify cost-effective interventions and potential return on investment, which is necessary when presenting invest-to-save under the preventative agenda.

Key concepts and theories

Market failures: Any time the health and healthcare sectors are characterised by the presence of public goods, externalities, asymmetric information, or monopoly, there is a rationale for public intervention in health.

C. Behavioural operational research

Operational research uses modelling to find optimal solutions to complex decisions; behavioural operation research is a sub-field that studies behavioural factors affecting model-based problem solving and decision making processes. It evaluates three aspects of model-based problem solving and decision making processes (64): (i) behaviour in models (how human behaviour is represented in models and how variations in behaviour impact model outcomes); (ii) behaviour with models (how decision makers use models to inform their decisions); and (iii) behaviour beyond models (how models impact upon organisational processes and behaviour). Behavioural operational research can help with the improvement of screening campaigns, policy making in the management of long-term conditions, workforce planning, optimisation of resources in organisational units (e.g. hospital, A&E areas, bed utilisation), and facilitation of organisational change programmes, to name a few examples (65).

Key frameworks and tools for public health practitioners

Behavioral Operational Research, Theory, Methodology and Practice (64): an overview that connects together theory, methodology and practice and offers the “state of the art” on Behavioral Operational Research theory and practice. 

Special Issue “Healthcare Behavioural OR” to be published by the Journal of the Operational Research Society (forthcoming in 2018/9), including a review of implementation of behavioural aspects in the application of OR in healthcare (65).

D. Psychology

Psychology is a broad set of disciplines and perspectives, which range from the study of individual cognition to the study of group behaviours and many more aspects besides. For example, the psychology of leadership and diversity is of increasing importance to public health practice.

The aspiration underlying this strategy is to integrate the use of science and disciplines but here we discuss just three disciplines – health psychology, cognitive psychology, and social psychology – as starting points for public health’s engagement with the broad spectrum of psychologies.

Health psychology

Health Psychology uses the bio-psycho-social model to promote and maintain health, enhance the wellbeing of those affected by illness and disease, and improve the health care system and support health policy formation. Behaviour is complex and often people are unaware that they are engaging in detrimental behaviours, or feel unmotivated or unable to make a change. Understanding how people think, feel and learn can help us to understand and predict how they will act, and to understand how to change behaviours for better health. Within public health, health psychology can be used to identify target behaviours for change, create a behavioural diagnosis of key determinants of behaviour, identify behaviour change techniques and ways to effectively deliver them (e.g. education, incentivisation, restructuring the environment), develop and evaluate services, suggest low-cost changes to existing interventions and identify how best to communicate risk.

Key concepts and theories

Behaviour change theories and models, such as COM-B (Capability, Opportunity, Motivation – Behaviour) (29, 30) take into consideration the dual-process of motivation via conscious (reflective) and less conscious (automatic) decision-making processes including habits, impulses and drives.

The Health Action Process Approach (65): introduces the distinction between motivation to change behaviour and the enactment of this motivation, integrating a range of self-regulation processes.

Key frameworks and tools for public health practitioners

Intervention development frameworks:

  • Intervention Mapping (66), a step-by-step approach to intervention development;
  • the Person-Based Approach (67), a ‘person-centred’ approach to developing digital health interventions which combines ongoing qualitative research at all stages of development with the identification of guiding principles that highlight the ways the intervention will address behavioural issues;
  • the Experimental Medicine Model (68) a programmatic approach which emphasises experimental testing of targets or mechanisms of change;
  • Multiphase Optimization Strategy (MOST) (69), a three stage process for digital design in which intervention components are screened, refined and confirmed.

Combining psychological theories: the Theoretical Domains Framework (70).

Building intervention content:

  • the Behaviour Change Technique (BCT) Taxonomy (71), with free BCT Online training;
  • Oxford Food and Activity Behaviors (OxFAB) taxonomy and questionnaire to explore the cognitive and behavioral strategies used by individuals during weight management attempts (72).

The TIPPME (Typology of Interventions in Proximal Physical Micro-Environments) intervention typology for changing environments to change behaviour (73).

Delivery approaches: Motivational interviewing, an approach used to increase motivation to change behaviours (74).

Networks to support intervention developers:

  • the Behavioural Science and Public Health Network (BSPHN) (formerly the Health Psychology in Public Health Network) for practitioners and academics, a community of practice for those working within the behavioural and social sciences and public health to come together to share best practice both virtually and physically at regular events;
  • the Division of Health Psychology, a society membership for health psychologists trained in intervention design, delivery and evaluation.

Manchester Implementation Science Collaboration open access elearning website about behaviour change for health professionals. 

Division of Health Psychology’s specialist knowledge database (available from September 2018).

Cognitive psychology

Cognitive psychology is the study of internal mental processes such as attention, language use, memory, perception, problem solving, and thinking.

Key concepts and theories

Dual-process theories (75): propose that human cognition can be conceptualised as two types of processes: System 1 (automatic, fast, and non-conscious) and System 2 (slow, deliberative and conscious). The idea that people often use mental shortcuts and rules of thumb to speed up decision making can inform interventions to support positive health decision making (76).

Key frameworks and tools for public health practitioners

Review of cognitive biases and heuristics in medical decision making (77).

Review of how cognitive biases affect clinicians (78).

Social psychology

Social psychology is the scientific study of how people's thoughts, feelings, and behaviours are influenced by the actual, imagined, or implied presence of others (79). Social psychology is an interdisciplinary domain that bridges the gap between psychology and sociology.

Key concepts and theories

Social norms: these are implicit rules about behaviours and standards that are socially acceptable and/or commonly enacted by relevant others. Social norms can be descriptive (what others do) or injunctive (what others approve of).

Social comparison theory (80): this theory proposes that individuals are motivated to compare themselves with others when evaluating their behaviours, attitudes and opinions, and to adjust behaviour accordingly.

Social learning theory (81): this theory suggests that individuals learn behaviours via observational learning of others performing the behaviour.

Theory of reasoned action (82, 83): this theory sees intention as the main determinant of behaviour and, in turn, intention is determined by a person's attitudes towards that behaviour and the subjective norms of influential people and groups that could influence those attitudes.

Theory of planned behaviour (84): this theory builds on the theory of reasoned action by including the individual’s perceived behavioural control over the outcome as a factor influencing the probability of undertaking a behaviour.

Key frameworks and tools for public health practitioners

Behaviour-centred design (85): unites the latest findings about how brains learn with a practical set of steps and tools to design successful behaviour change programmes.

E. Sociology

Sociology examines the individual’s social action (agency) and the community’s social and physical context (structure). The focus lies predominantly on the context in which people live, interact, work, and play (rather than on the individual, which is the focus of psychological disciplines).The influence of social class on health status, health behaviour, and access to and use of health services, is one of the earliest and most examined social influences on health.

Key concepts and theories

Social determinants approach to public health (86): public health programmes that intend to address social determinants and to have a great impact on health equity.

Social practice theory (87): the study of social practices and how they change over time, incorporating an understanding of both individual human agency and the social structures that individuals act within.

Normalisation process theory (88): this theory is concerned with factors that promote or inhibit the implementation of complex interventions, from early implementation up to the complete integration (or normalisation) of the intervention into everyday practice. It can be useful for developing and evaluating interventions.

Social model of health (89): this model depicts the relationship between the individual, the contexts in which they live (i.e., from social communities to wider socioeconomic and structural factors), and their health.

Key frameworks and tools for public health practitioners

ISM Model (90, 91): a practical tool for designing effective policy interventions, bringing together Individual, Social, and Material factors that affect behaviour..

Social Model of Health (92): this model depicts the relationship between the individual, the contexts in which they live (i.e., from social communities to wider socioeconomic and structural factors), and their health.

F. Other useful public health tools

  • Behaviour Change Wheel (32, 33)
      • The Behaviour Change Wheel is a synthesis of 19 frameworks from multiple domains, sectors and disciplines. It includes COM-B at the hub (capability, opportunity, motivation as influencing factors in a model of behaviour), surrounded by ‘intervention functions’ to deliver behaviour change techniques (BCTs) and ‘policy categories’ as the outer layer.
  • EPOC taxonomy
  • TIDieR for reporting of interventions: template, checklist and guide
  • PARiHS framework for implementing research into practice
  • Health Behaviour Change Competency framework
  • Lifeguide for creation of interactive web-based interventions
  • NIHR/CIHR Guidance on taking context into account in population health research (forthcoming)

Evaluation