Active Herts: Translating behavioural science into public health
Neil Howlett1, Andy Jones2, and Angel Chater1,3,4
1University of Hertfordshire; 2University of East Anglia; 3University of Bedfordshire; 4University College London
- Introduction: Translating behavioural science into public health
The Behavioural Science and Public Health Network (BSPHN) recently played a large role in developing and disseminating the national Behavioural and Social Sciences Strategy from Public Health England (PHE, 2018). The purpose of this strategy is to encourage public health professionals to apply key concepts and theory from behavioural and social science into their work to help improve individual and population health. This case study summarises an exemplar of a collaborative project between behavioural scientists, public health professionals, clinical commissioning groups, GPs, and those working in physical activity promotion.
The Active Herts programme aimed to change physical activity (and its drivers), sitting behaviour, health and wellbeing in inactive adults with multiple health issues related to cardiovascular disease risk and mental health, in four deprived areas of Hertfordshire. Collaborative research from the University of Hertfordshire, the University of Bedfordshire and the University of East Anglia, (in partnership with Hertfordshire County Council and Herts Sports Partnership) has informed the design, implementation, and evaluation of this programme.
The overall programme evaluation including outcome, process and cost-effectiveness evaluations has been led by the University of East Anglia. Research and expertise from the University of Hertfordshire and the University of Bedfordshire has informed the development, implementation, and evaluation of the programme, alongside the training of the health professionals delivering the programme, detailing the behaviour change techniques (BCTs) and theoretical considerations in programme delivery and outcomes. What follows is a detailed breakdown of the background research, training, fidelity, evaluation, wider impacts, and collaborations that provide a blueprint for a transdisciplinary approach combining behavioural science and public health.
- Background Research
Ideally any intervention approach should be underpinned by relevant recent research, including reviews of previous approaches, and draw upon appropriate theory.
2.1 Systematic review of the literature and meta-analysis
Previous reviews of the literature have identified that physical activity interventions have been effective in the short term (directly after an active intervention period), but there was very little evidence of which intervention techniques are most effective and whether these changes could be sustained over a longer period. We conducted a systematic review and meta-analysis of randomised controlled trials of physical activity interventions for healthy inactive adults (Howlett, Trivedi, Troop, & Chater, 2015a; Howlett, Trivedi, Troop, & Chater, 2018). The findings showed that changes in physical activity can be achieved through intervention up to a year after and highlighted several BCTs that were associated with effective interventions (action planning, instruction on how to perform the behaviour, prompts/cues, behaviour practice/rehearsal, graded tasks, and self-reward).
2.2 Drawing upon theory: Using the COM-B to explain physical activity behaviour
Previous research has suggested that theory has been used inconsistently, and has rarely been applied to the design, implementation, and evaluation of physical activity interventions. The COM-B model suggests that behaviour results from an individual having sufficient Capability, Opportunity, and Motivation towards Behaviour (Michie, Van stralen, & West, 2011). We analysed the COM-B and its ability to predict moderate-to-vigorous physical activity (MVPA; Howlett, Schultz, Trivedi, Troop, & Chater, 2017). The findings suggested that Capability (action planning, self-monitoring and ability to create habits through behavioural regulation) and Motivation (intention, self-efficacy, and exercise self-identity) were important drivers of regular MVPA, which was strongly predicted.
2.3 The Active Herts programme
Active Herts is a community-based physical activity programme for inactive adults residing in four Hertfordshire localities (Watford, Broxbourne, Hertsmere, Stevenage), who may also have had additional cardiovascular disease risk factors and/or mental health issues. The systematic review and theory work described above represents key development research for the Active Herts programme protocol (Howlett, Jones, Bain, & Chater, 2017), which was developed by the team to implement the most effective BCTs (highlighted from the systematic review) through the intervention materials and consultation and evaluate key drivers of MVPA from the COM-B as secondary outcomes. The evaluation tracked outcomes at baseline, 3, 6 and 12-month follow-ups, between November 2015 and November 2018.
In two areas, programme users received a behaviour change technique booklet, regular consultations, a booster phone call (two weeks after initial consultation), motivational text messages, and signposting to 12 weeks of exercise classes (standard delivery). In another two areas, programme users also received 12 weeks of free tailored exercise classes, with optional exercise ‘buddies’ available (enhanced group). An outcome evaluation assessed changes in physical activity, sporting participation, and sitting as the primary outcomes, alongside general health, life satisfaction, mental wellbeing, psychological capability, and reflective motivation as secondary outcomes. This evaluation allowed analysis of not only whether health outcomes and physical activity had increased, but also why from a theoretical perspective.
Anyone delivering a programme of this kind should be trained in the application of behavioural science and communication skills before the start and on an ongoing basis (Chater, 2017a). There was over 15 years’ experience in training professionals in this area within the team (AC). This training (Chater, 2015a) ensured confidence and competence in delivering the protocol as planned and allowed the programme developers and evaluators to feel confident in the programme’s fidelity. It drew from the IDDEAS (Intervention Design, Delivery, Evaluation and Adoption System: Chater, 2015a) approach used in training to enable health professionals to understand their role in the delivery of an intervention programme. This approach trains individuals in the interplay between Intervention Mapping (Bartholomew et al., 2011), the Behaviour Change Wheel which includes COM-B (Michie et al., 2011), and the EAST model (East, Attractive, Social, Timely: Behavioural Insights Team, 2014), alongside frameworks such as the Behaviour Change Technique Taxonomy version 1 (BCTTv1: Michie et al., 2013), the Theoretical Domains Framework (TDF: Cane, O’Connor & Michie, 2012) and TIDieR (Template for Intervention Description and Replication: Hoffman et al., 2014;) and communication skills such as Motivational Interviewing (Miller & Rollnick, 2014; Rollnick, Miller, & Butler, 2008) and Health Coaching (Whitmore, 1995).
A Get Active Specialist was employed by local organisations (e.g. borough councils or leisure providers) in each of the four localities (Watford, Broxbourne, Hertsmere, Stevenage) for the 3-year duration of the programme. The Get Active Specialists worked predominantly with local GPs to recruit eligible programme users. The Get Active Specialists all had a minimum of Level 3 Register of Exercise Professionals (REPs) and GP Exercise Referral qualifications. The Get Active Specialists also received the following training prior to the start: ‘British Heart Foundation: Promoting health behaviour change – A solution focused approach’ course; ‘The Wright Foundation Obesity and Diabetes’ course; ‘The Wright Foundation mental health’ course; ‘Recruiting and Retaining Volunteer’ course organised by Volunteer Centres, Hertfordshire.
An additional two-day workshop and quarterly boosters were developed and led by AC and supported by NH. This covered how to create a behavioural diagnosis from COM-B using a motivational interviewing (Miller & Rollnick, 2014; Rollnick, Miller, & Butler, 2008) congruent approach, and how to deliver the BCTs with an emphasis on expressing empathy and being client-focused (Jubraj et al., 2016). This training highlighted the need to engage the patient in the consultation process, resist telling them what to do, allowing focus on what is desired and achievable, to understand the patient’s perspective, evoke a sense of empowerment, and ensure that the client feels supported and has a plan going forward (Chater, 2018a). Core communication skills to support an effective consultation (Chater, 2015a; 2015b, 2016a) such as RULE (Resist the righting reflex; Understand your client’s motivation; Listen to your client; Empower your client) and OARS (Open-ended questions, Affirmations, Reflective listening, Summaries) were covered and linked to the delivery of the BCTs.
Furthermore, the training covered the GROW model from Health Coaching (Goal, Reality, Options, Will/Way forward; Whitmore, 1995) to help guide the Get Active Specialists through the consultation and use of BCTs effectively, acknowledging that clients may be in differing ‘stages of change’. Finally, the British Psychological Society’s Code of Ethics and Conduct (British Psychological Society, 2018) and the Health and Care Professions Council’s (2018) Standards of Conduct, Performance and Ethics were highlighted throughout (e.g. working within professional boundaries). This training enabled conversations with programme users that were user-led and allowed programme users to take ownership of developing their own goals, overcoming barriers, specifying plans, and rewards for progress.
An ideal evaluation plan involves an adequately powered test of effectiveness on a pre-specified primary outcome, over a period that gauges medium-to-long-term change. Additional best practice includes cost-effectiveness analysis and a detailed process evaluation covering key stages of the programme.
4.1 Effectiveness of change
The primary evaluation was based on a comparison between recorded data at baseline for the primary and secondary outcomes and those captured at 3, 6, and 12 months. For the purposes of this case study the interim analysis on two-year data is reported for 3 and 6-month outcomes. Two sets of analysis were completed at 3 and 6 months. The first was performed on only those who completed the measures at each time point (completers). The second utilised an ‘intention-to-treat’ approach; whereby, baseline scores were carried forward for all programme users missing 3 and 6 month data. Secondary analysis explored how well Capability (action planning and self-monitoring) and Motivation (intentions and self-efficacy) predicted MVPA performance at baseline, 3 and 6 months and then whether changes in these constructs predicted changes in reported MVPA at 3 and 6 months (compared to baseline).
To determine if investment in the Active Herts programme represented a good way of spending money, a software package called ‘MOVES’, developed by Sport England and the University of East Anglia, was used. The analysis looked at changes in physical activity that have been seen in those people taking part in Active Herts. From this it estimated how many fewer cases of depression, diabetes, stroke, coronary heart disease, dementia, colorectal cancer, breast cancer, and hip fracture there might be in the future due to the fact that Active Herts participants have been more physically active than they otherwise would have been.
Healthy people will save society money because they will be happier and more productive and the National Health Service will spend less money treating them. The MOVES software produced a figure called “the incremental cost-effectiveness ratio”, or ICER, which told us how big these cost savings were for each pound spent on Active Herts. We then used this ICER value with a series of recommendations from the National Institute for Health and Care Excellence (NICE) to see if Active Herts would be considered to be “cost-effective” or “good value for money”.
4.3 Process Evaluation
The process evaluation of Active Herts has taken place over three phases with each phase exploring a different theme. Data was collected in the form of one-to-one interviews with stakeholders, group interviews with the Get Active Specialists, and focus groups with programme users. The initial phase focused on areas related to the set-up of Active Herts, including developments in the method of recruitment or delivery of the programme, barriers and facilitators to reaching the target audience, partnership working, and engagement with primary and secondary care.
The second phase explored changes in programme delivery from those planned, potential mechanisms by which the programme works, and external factors which may have influenced the programme. A final phase has looked back over the programme and considered what worked well and what did not and identified examples of best practice. This phase also considered the future sustainability of Active Herts including exit routes for programme users and continuation of the programme where appropriate.
Fidelity is the extent to which a programme is delivered as intended (i.e. based on the protocol). It is important to plan, prior to the start, how fidelity will be considered and evaluated. This can provide important information about why (or why not) an approach was successful.
To ensure fidelity of programme delivery, a number of measures were put in place. Get Active Specialists were video-recorded at the onset of training to identify their baseline communication skills as related to behaviour change in a consultation scenario. They were then asked to audio-record (with permission from programme users) a random sample of consultations and reviewed the audios amongst themselves, the project lead and at quarterly booster sessions with the trainers (AC, NH).
The Get Active Specialists scored each consultation with the Motivational Interviewing Treatment Integrity coding scheme (MITI; Moyers, Martin, Manuel, Miller, & Ernst, 2010) and a checklist of BCTs included in the programme protocol (Howlett et al., 2017). The MITI was used to score the specialists on five domains core to motivational interviewing: Evocation; Collaboration; Autonomy/Support; Direction; Empathy. Their use of these skills, alongside the OARS and RULE, were assessed throughout at quarterly booster sessions and reflected upon with guidance where needed for skill development. Ongoing analysis by the team, led by AC and NH, will evaluate the development of Get Active Specialist skills over the duration of the three-year programme.
The Active Herts programme was successful at reaching its target population, who were inactive with a wide range of health conditions. The first 3 months of participation in Active Herts was the intensive stage of the programme, and analysis of completers at the end of this period showed moderate-to-large improvements in reported physical activity, sporting participation, and sitting time, regardless of group. Programme users showed improvement at 3 months in both groups on a range of secondary measures (perceived health, mental wellbeing, life satisfaction, action planning, self-monitoring, self-efficacy, and attitudes). The intention-to-treat analysis largely mirrored these results but with more modest effects, and a pattern of improvement in the enhanced group that was better than the standard group.
At 6 months there were still consistent small-to-moderate improvements in all primary outcomes regardless of group. Follow-up tests showed a pattern whereby programme users improved considerably from baseline to 3 months and then maintained this improvement at 6 months. Improvements in secondary outcomes were largely in line with primary outcomes on a range of measures (the same as 3 months), regardless of group, between baseline and 3 months, which were then maintained at 6 months. Again, the intention-to-treat analysis largely mirrored these results but with more modest effects, and a pattern of improvement in the enhanced group that was better than the standard group at 3 months but similar again at 6 months.
The Active Herts programme targeted Capability (action planning and self-monitoring) and Motivation (self-efficacy and intentions), and these factors were more closely linked to MVPA performance following the 3 and 6-month stages of the programme. Across time points self-monitoring was the most important driver of MVPA. Changes in Capability (action planning and self-monitoring) predicted a medium amount of change in Motivation (intentions and self-efficacy) and a small amount of change in MVPA. Changes in self-monitoring were also the key driver of changes in MVPA across time points.
Cost-effectiveness analysis suggested that every £1 invested in Active Herts will save the NHS 57p and will lead to improvements in general health and well-being to participants which are worth 97p. Active Herts would therefore be considered ‘good value for money’ based on NICE criteria.
The qualitative process evaluation has shown that Active Herts is a very healthy programme in many contexts. People that we spoke to told us that they see the programme as being highly effective and a unique, personalised approach to motivating people to increase their activity. Moreover, the programme has an important wellbeing strand and often has positive health and wellbeing outcomes for participants. Table 1 below summarises the ways in which it appears to be successful.
Table 1: Best practice summary from the process evaluation: some of the key successes of Active Herts.
How it works
Expertise and personal qualities of the Get Active Specialists
High quality and committed specialists ensure the effective local delivery of the programme
The motivational interviewing and application of COM-B and behaviour change techniques on initial referral and at 3, 6, and 12 months
Drawing from and being trained in an evidence-based approach to motivational interviewing and behaviour change enables the Specialist to understand participant capability, opportunity and motivation and work with them to set and monitor appropriate goals to increase physical activity levels
Effective engagement with local referrers
Ensures smooth and appropriate referral
A cohesive management structure with appropriate partners
Ensures the programme is effectively managed and partnership benefits are fully utilised
Good promotional literature and marketing strategies
These convey important and appropriate messages about the programme to its potential users
Good knowledge of local providers and networks to which participants can be signposted
The Get Active Specialist develops and uses an up-to-date map of local activity and partners where appropriate with other local providers
In some areas, availability of tailored and flexible group activity sessions
Tailored activity sessions can create a group community atmosphere and inspire participants to remain active
The use of innovative support components including the volunteer buddies and conversation cafes
Can support the motivations of participants and allowed for further recruitment of family and friends
The programme offers “something different” to more conventional activity schemes
By offering a personalised approach to motivation, goal setting and activity for individuals
- Wider impacts and dissemination
In addition to the primary results, it is good to track the impact of the programme in terms of further use of the approach, wider dissemination, and influence on policy and public guidance.
Sport England has featured Active Herts in their document on ‘Design principles for tackling inactivity’ (Sport England, 2016). Furthermore, the Active Living programme from Epping Forest District Council and the new Active Watford programme have both utilised the Active Herts approach in their materials, training of professionals and delivery. Early evaluation is already highlighting successful results in changing the physical activity of programme users in other areas.
Research and the training approach informing Active Herts has been presented at the British Psychological Society’s Division of Health Psychology annual conference (Howlett, Trivedi, Troop, & Chater 2015b), to a European audience at the European Health Psychology Society annual conference (Chater, Howlett, Trivedi, & Troop, 2016) and at an invited symposium at the British Psychological Society’s annual conference in Brighton (Chater, 2017b). The Active Herts approach and research behind it, have also been provided to the Moldovian government (Chater, Howlett, Trivedi, Troop, & Jones, 2018) to support the development of health promotion and behaviour change programmes for non-communicable diseases wider afield. The UCL Centre for Behaviour Change Summer School programme also features Active Herts as an example of translational behavioural science into public health practice (July/August 2017 & 2018). Furthermore, it has been used as a case study for a behavioural science webinar by Public Health England (Bunten, Constable, Chater, McManus & Chadborn, 2017).
The method and results from Active Herts have also been presented in a Sport England symposium at the International Society for Physical Activity and Health (ISPAH; Deans & Freeman, 2018) conference in October 2018 and have further been included in a number of keynotes across the country highlighting the benefit of integrating health psychology and behavioural science with public health to partners, stakeholders and the wider academic and public health communities (Chater, 2018b; 2018c; 2018d; 2018e; Chater, 2017c; 2017d; 2017e; Chater, 2016b; 2016c). The evidence-based approach to intervention content development and specialist training has been presented as an example of good practice to tackle weight management using physical activity in an invited All Party Parliamentary Group meeting on Understanding Obesity in November (Chater, 2018f). Finally, two-year interim results were presented at the annual UK Society for Behavioural Medicine conference in December 2018 (Howlett, Trivedi, Troop, Jones, & Chater, 2018).
Publications included in this body of work are open access through journals and University research portals. The Active Herts website also details the approach and encourages those wishing to draw from this programme of work to register their interest and download the relevant materials (http://www.activeherts.org.uk/healthcare-professionals/our-approach/).
- Transdisciplinary collaboration
The systematic review and COM-B analysis was completed by Neil Howlett, Nick Troop, Joerg Schulz, and Daksha Trivedi (University of Hertfordshire), and Angel Chater (University of Bedfordshire and University College London; UCL), between September 2014 and February 2016. The Active Herts programme was delivered and evaluated by the team above in partnership with Professor Andy Jones from UEA (lead evaluator), the Herts Sports Partnership (programme lead, Adan Freeman; previous programme lead, Joe Capon; project lead Fiona Deans; Get Active Specialists Alison Goodchild, Andrew Rix, Lee Bruce, and Hannah Marsh), and Hertfordshire County Council (public health lead, Piers Simey).
These partners form part of a comprehensive steering group which also includes representatives from local Clinical Commissioning Groups (East and North Herts and Herts Valley), Mind centres (Mind Mid Herts and Herts Mind Network), Stevenage Borough Council, Watford Borough Council, Broxbourne Borough Council, Hertsmere Borough Council, Hertsmere Leisure, Watford FC CSE Trust, and local GPs. This provides a blueprint for transdisciplinary working across a range of behavioural science academics, healthcare professionals, commissioners, public health consultants, and sports and leisure providers.
We would like to acknowledge key contributors in the delivery of the Active Herts programme; Piers Simey (Public Health Lead); Fiona Deans (Project Lead); Adan Freeman (Programme Lead); Joe Capon (Initial Programme Lead); Alison Goodchild (Get Active Specialist), Andrew Rix (Get Active Specialist), Lee Bruce (Get Active Specialist) and Hannah Marsh (Get Active Specialist). Without these individuals, this programme would not have been possible.
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