Integrating behavioural science expertise into public health.
*Emily A. Fulton, DPsych1, 2, Katherine. E. Brown, PhD1,2, John Linnane, MD2, Tim Chadborn, PhD3, Jim McManus, PhD4, Michelle Constable, MSc4, Kristina Curtis, PhD1,2, Neil Howlett MSc5, Angel Chater PhD5,6.
1 Centre for Advances in Behavioural Science, Coventry University, Priory St, Coventry CV1 5FB firstname.lastname@example.org Emmie.email@example.com Kristina.firstname.lastname@example.org
2 Public Health Warwickshire, Warwickshire County Council, Barrack Street, Warwick, CV34 4RL email@example.com
3Behavioural Insights Team, Public Health England, Skipton House, 2nd Floor London Road, London, SE1 6LH firstname.lastname@example.org
4Public Health Hertfordshire, Hertfordshire County Council, 2nd Floor Farnham House, Six Hills Way, Stevenage, SG1 2FQ email@example.com firstname.lastname@example.org
5Department of Psychology and Sport Sciences, University of Hertfordshire, College Lane, Hatfield, Herts, AL10 9AB email@example.com
6Centre for Health, Wellbeing and Behaviour Change. Institute for Sport and Physical Activity Research, University of Bedfordshire, Polhill Avenue, Bedford, MK41 9EA, firstname.lastname@example.org
Dr Emmie Fulton
Centre for Advances in Behavioural Science
Coventry University, Priory Street, CV1 5FB
Tel: 024 7688 7460
Aims: Given the increasing proportion of morbidity and mortality due to non-communicable and behavioural factors, Behavioural Scientists need to become increasingly engaged in supporting Public Health strategy and practice. Behaviour change theory and evidence and Behavioural Insights approaches are used to understand and change preventive health-related behaviour, and could be more consistently applied in interventions in real-world public health settings.
Methods: The authors draw on their experience of collaboration between local public health departments and universities and working within Public Health England to reflect on the potential that behavioural science has for contributing to the work of public health.
Results: Case study examples of applying behavioural insights and behaviour change approaches in public health by the authors are outlined, including the development and evaluation of an intervention to target sexual health service access; using social norms feedback to reduce GP antibiotic prescribing, and an intervention to increase physical activity in inactive adults.
Conclusions: Recommendations for the development of similar partnerships are outlined including the benefits of this form of partnership working. Working in partnership in this way will contribute to disciplinary development in public health and the behavioural sciences, strengthening the evidence for what works to improve health outcomes.
Keywords: Behavioural Science, Behavioural Insights, Health Psychology, Public Health, Behaviour change, Evidence-based interventions, Evaluation
With a continued national focus on the prevention of lifestyle related illness (DH, 2011a;2011b; 2018), largely created by modifiable health–related behaviour, there is increasing necessity to understand the most important factors influencing those behaviours, in order to tailor the content of public health interventions, services and campaigns accordingly (NICE, 2014; BIT, 2010). Designing interventions that target the most important determinants of behaviour, based on research evidence in the field of ‘Behavioural Science’ (BS), provides the best chance of changing behaviour and demonstrating a positive impact in terms of health outcomes and cost effectiveness at a population level. However knowing what works and how to apply it presents an on-going challenge (Peters, de Bruin & Crutzen, 2015).
Public health departments in local authorities are required to commission and design evidence based public health interventions, and increasingly this means searching the scientific literature in order to inform decision making about what an intervention should include and the appropriate mode of delivery (Jacobs, 2012). Where the evidence is lacking, or specific insights are required for a particular population or target behaviour, collecting data locally in order to better understand the predictors of the given behaviour may also be desirable. However, a lack of knowledge about how best to do this, and time and resource constraints can make this a challenge. Training for public health staff and access to resources may be insufficient (LaPelle, Dahlen, Gabella, Juhl, & Martin, 2014), especially as the translation of theory and evidence into practical intervention can be a challenge for even the most experienced behavioural scientist. Though not the only relevant disciplinary approach, The National Institute for Health and Care Excellence (NICE) specifically recommends use of behaviour change theory and evidence within both individual (PH49) and population based (PH6) interventions (NICE, 2014). The guidance includes examples of recommended behaviour change techniques (BCTs) to include in generic behaviour change interventions. However, guidance about the optimal application (e.g. environmental context, frequency, and timing) and the range of potential ways to operationalise these BCTs is lacking. Therefore, support for both commissioners and public health service providers about how to put this guidance into practice is missing, especially if the target health behaviours and populations are under-researched.
As a result of this challenge, a new strategy: ‘Improving People's Health: Applying behavioural and social sciences to improve population health and wellbeing in England’ (PHE, 2018) was launched with the aim of helping to apply the growing insights relating to this field. It aims to maximise the use and impact of BS in public health practice and development, with suggestions of tools and frameworks to utilise, and where to access information and specialist expertise. A plan for embedding BS in public health over the coming years is outlined, with suggestions for new training, events, resources, dissemination in order to embed BS in public health at a local and national level. Alongside a growing network of behavioural science and public health specialists, the ‘Behavioural Science and Public Health network’ and Public Health England Behavioural Insights Team (PHEBI) will play an integral role in facilitating the success and recommendations of this strategy alongside other key stakeholders.
One possible solution to embed BS at a local level, and outlined briefly in the strategy, is for public health to partner with Behavioural Scientists and academics skilled in the application of a relevant evidence base. Various disciplines have relevant expertise and may offer valuable insight and support to address behavioural and lifestyle related preventive intervention. These include anthropology, economics, cognitive neuroscience, sociology, political science and psychology (and various sub-disciplines within these). To date however, academics, in particular health psychologists and those with behavioural insights expertise have arguably shown most interest in engaging in such partnership working and application of their skillset to Public Health (Gillinsky et al., 2010). Authors KB, EF, MC, KC, NH and AC are psychologists with expertise in health psychology, behaviour change theory and intervention development. Five are based in a University setting, with embedded roles in a UK public health department (EF, KB, KC, AC, NH) and one is employed by Public Health (MC). The roles are multifaceted and include novel behaviour change intervention design, development and evaluation; training others to apply such knowledge; application of behavioural insights approaches and consulting on commissioning and service development. Author TC leads the behavioural insights team at Public Health England where he and his team have been responsible for developing numerous low cost interventions to support public health initiatives. Furthermore, the Behavioural Science and Public Health Network (BSPHN) aims to support the integration of behavioural science and public health. Authors AC, JM, MC, NH are founding members of the BSPHN (formally developed as the Health Psychology in Public Health Network – HPPHN: see McManus, 2014; Chater, 2014a; Constable, 2014; Howlett, 2014; Chater, 2014b; Chater & McManus, 2016; Chater, 2017; McManus, 2017) and alongside KB have executive committee roles within the Network with AC serving as the current Chair.
Theoretical models and Intervention Development Frameworks
Familiar theoretical models such as the ‘Theory of Planned Behaviour’ (TPB)(Ajzen, 1991); ‘The Health Belief Model’ (HBM)(Rosentock, 1974); and the ‘Transtheoretical Model’, commonly referred to as the ‘Stages of Change model’(Prochaska & DiClimente, 1984), are applicable to numerous target behaviours. However, no single theoretical model has been found to sufficiently explain multiple behaviours in multiple contexts (Borland, 2013), and neither do they provide a framework for designing the specific content of interventions based on their constructs. The COM-B model (Michie, van Stralen & West, 2011) identifies ‘Capability’, ‘Opportunity’ and ‘Motivation’, as the key predictors of ‘Behaviour’ and is based on empirical research which amalgamates all existing behaviour change theory at the point of its development. It accounts for automatic motivation (i.e. habitual and emotional drivers of behaviour) and social and environmental factors that influence behaviour. In addition, it has been devised in the context of a framework to support systematic intervention development (‘The Behaviour Change Wheel’(Michie & West, 2014)); supporting identification of appropriate intervention functions (exactly what the intervention should do) and the specific active components, broken down into the smallest possible unit – Behaviour Change Techniques (BCTs), listed in the Behaviour Change Technique taxonomy (BCTv1)(Michie et al., 2013).
Debates continue however, about the extent to which these models of behaviour change take into account automatic and non-conscious cues to act (Ajzen, 2015). Evidence indicates we act far more automatically, responding more subconsciously to cues in our environment and ‘going with the flow’ (Ostafin & Palfai, 2012) than has been accounted for historically. For this reason, applications of ‘behavioural insights’ approaches, that recognise the role of automatic cues, have gained leverage within Government. In the UK, the Department of Health and Public Health England now employ a behavioural insights team (BIT). Our fourth author (TC) leads the latter.
A Behavioural Insights Approach
Behavioural Insights (BI) describes a broad approach that includes the application of theory from psychology, anthropology and behavioural economics, applied to understand health behaviour (BIT, 2010). BI may be considered well suited to public health for several reasons. Firstly, it explores behaviour at an individual, but also community and population level, whereas extant behaviour change models have tended to focus on the individual. Secondly as a result of this, it takes into account systems, wider determinants, environmental context, policy and so on, that might influence behaviour choice (BIT, 2010). The Nuffield Council on Bioethics’ Ladder of Interventions (DH, 2011b) illustrates the range of interventions we can adopt from outright bans to doing nothing. BI aims to intervene within the middle stages to enable and guide healthy choices by changing default options, providing cues to act and adapting the environment to make healthy choices easier. In relation to this, ‘Nudge Theory’ (Thaler & Sunstein, 2009) suggests the need for Governments to provide a ‘guiding hand’, encouraging and coaxing behaviours that will improve quality of life, rather than forcefully pushing the issue at play. Finally, a BI approach gives a greater focus on automatic processes (behaviours that we do without thinking), compared with traditional models. The Local Government Association (LGA) outlined recommendations for councils (where English Public Health departments are now based) to apply BI approaches and to nominate BI leads to support this process (LGA, 2014). The PHE BIT team works together with public, private and third sector organisations to develop and evaluate innovative, evidence-based solutions to facilitate effective health behaviour change. Recent work includes the application of BI in the evaluation of methods to increase uptake at NHS Health Checks (Sallis et al., 2016).
Other work has sought to provide us with new dual systems of behaviour change to explain both rational and automatic processes alongside a greater focus on the need for the maintenance of behaviour (e.g. West & Brown, 2013). Many theories help to explain factors associated with the initiation of behaviour, which can be relatively easy to achieve compared with long term maintenance which has arguably not been sufficiently theoretically explained (Borland, 2013).
Frameworks for Intervention Development
The aforementioned theoretical models and frameworks applied to behaviour change operate at an individual level. As public health is also concerned with community and population-based interventions, many working in this field utilise a wider range of theoretical models and intervention planning frameworks in the design of their interventions. Examples include ‘MINDSPACE’ (Dolan, Hallsworth, Halpern, King & Vlaev, 2010), a shortened version which includes practical guidance on the implementation of the approach - ‘EAST’ (InsightsB, 2014), and ‘Intervention Mapping’ (Batholomew, Parcel & Kok, 1998; Kok, Schaalma, Ruiter, Van Empelen & Brug, 2004). Furthermore ‘TIPPME’ (Typology of Interventions in Proximal Physical Micro-environments) provides a new method for consistently categorising these interventions, and has so far been applied to food consumption, alcohol and tobacco (Hollands et al., 2017). EAST and MINDSPACE may be particularly attractive to public health practitioners and policy makers by virtue of their simplicity; however, as the authors openly report, they do not claim to include all possible predictors of behaviour, thus there is a risk of omitting crucial elements in any intervention. Furthermore, they do not offer guidance regarding intervention component choice and mode of delivery, such that variation in their application between users is likely. Nonetheless, the alternative choices – The Behaviour Change Wheel and Intervention Mapping, may pose challenges in terms of time and necessary expertise, such that neither prospect appears ideal. Where a novel intervention is required, for an under researched target behaviour or population, there are benefits to involving a Behavioural Scientist to lead the project. Equally the Behavioural Scientist is equipped to support staff to begin to embed simpler frameworks, such as EAST and MINDSPACE where appropriate, for example when sufficient evidence already exists in the literature about the appropriate behaviour change techniques that should be used. Furthermore, they can also support staff to use the relevant NICE guidance for key target behaviours such as smoking, exercise and alcohol, for which the evidence base is relatively strong.
Several opportunities exist for Behavioural Scientists to establish partnerships with public health departments. For example, they can be approached for open discussions about working together in a range of capacities. Possibilities include short pieces of commissioned work, collaborative proposals for external funding of a joint project (see ‘Respect Yourself’ case study in Table 1 below and ‘Stop-app’ case study in Supplementary online Table 1), public health based projects for PhD students ( case study in Table 2 below and see Health Heroes in Supplementary online table 2), and research placements to enable students to complete short pieces of research, for example for an applied MSc or doctoral thesis as part of clinical or health psychology training. There may also be the option of becoming a visiting research fellow or professor, to support research collaboration. For example, the Director of Public Health at Hertfordshire County Council has a PhD and is an honorary Professor at The University of Hertfordshire. Behavioural Scientists have access to research and can generate ideas but may not know where the immediate priorities lie, and how the research fits in with local and national policy and service provision. Therefore, partnerships with public health enable the field of health psychology to keep abreast of developments and the areas of key focus in Public health.
The first two authors’ (EF & KB) working relationship with public health began as discrete projects and developed into an on-going partnership with the plan to become self-sustaining, as the authors look to secure external funding to continue research projects for public health priorities. We have been able to employ a third person (KC) full-time to contribute greater capacity, and we offer workshops, training, the development of behaviour change tools and consultancy expertise alongside the design and development of behaviour change interventions (see summary of skills of Behavioural Scientists in Table 4 below). We have strong support from co-author JM our Director of Public Health. Similarly, co-author (JM) is Director of Public Health in Hertfordshire and employs another co-author (MC) to support embedding the application of behaviour change approaches in their activities. Their links with co-authors AC and NH facilitated the development of the HPPHN, now BSPHN, and work in the local area such as the Active Herts programme (see case study example in Table 2 below). AC leads the Centre for Health, Wellbeing and Behaviour Change at the University of Bedfordshire, alongside a Special Interest Group on Intervention Design and Communication and is an Associate to the University College London Centre for Behaviour Change. In collaboration with NH at the University of Hertfordshire, they routinely integrate behavioural science into public health through research, training and consultancy as displayed through the Active Herts case study (Table 2). Co-author TC supports the behavioural science and public health agenda at the national level as lead of the BI team at PHE. He has provided a case study of relevant work in Table 3 below. Other case studies are provided online in supplementary Tables S1 and S2.
Table 1. Warwickshire’s Respect Yourself Case Study: A website targeting increased access to sexual health services amongst young people.
Target population and health behaviour:
Young people aged 13 to 24 years
Sexual Health Service access
Literature review and needs analysis using focus groups with the target audience were carried out to identify the full range of barriers to and facilitators of sexual health service access. A Young Person’s Partnership Board was set up to support the development of the website and contribute to decisions such as who to appoint to develop the site and what the content should be and look like. Strategies from both Intervention Mapping and the Behaviour Change Wheel were applied to map barriers and facilitators of the target behaviour to specific content in the ‘services’ section of the Respect Yourself website (Newby et al., 2017).
Outcomes and evaluation:
Pilot evaluation of the website showed that females who engaged with the site improved on several measures of barriers to service access. Males who engaged with the site self-reported increased service access by 100%. Objective service access data comparing the eight months before website launch with the same eight months in the following year suggested that there was significant increase in service access in the two most deprived areas of Warwickshire (Brown, Newby, Caley, Danahay, & Kehal, 2016.).
Table 2. Hertfordshire Case Study: Active Herts
Target population and health behaviour:
Inactive adults with cardiovascular risk factors and/or mild depression or anxiety in areas of deprivation.
Activity levels and/or participation in sport.
The results of a locally conducted mapping exercise resulted in the development of a successful funding bid to Sport England. A significant gap between primary care and the sports sector had been identified as a key priority that needed addressing to improve the health of Hertfordshire residents. The bid was led by Hertfordshire County Council’s Public Health Service and both Hertfordshire CCGs and involved key partner organisations, Herts Sports Partnership and Mind in Mid Herts as part of the steering group and additional delivery partners providing sporting opportunities.
The programme was built by behavioural scientists on evidence from a systematic review of the literature which identified key behaviour change techniques (BCT) that were shown to be in effective physical activity interventions for inactive adults (Howlett et al., 2015; Howlett et al., 2018) and these BCTs were incorporated into intervention resources targeting physical activity. An analysis of the COM-B model related to physical activity revealed psychological capability and reflective motivation to be key drivers of physical activity (Howlett, Schulz et al., 2017). Measures covering these constructs were embedded in the evaluation. The Get Active Specialists delivering the intervention were trained in health behaviour change, motivational interviewing and health coaching techniques to support the effective delivery of the intervention (Chater, 2015; Chater, 2016; Chater, 2018). To enable replication, a protocol of the programme was written and published open access (Howlett, Jones et al., 2017).
Outcomes and evaluation:
The University of East Anglia led an objective process evaluation in conjunction with the University of Hertfordshire and University of Bedfordshire. Results have shown the programme, which had both a standard and enhanced delivery, to be effective at enhancing physical activity and wellbeing alongside highlighting core constructs from COM-B that facilitate behaviour change. Additionally, the training of the Get Active Specialists has been highlighted as a core strength to the programme.
Table 3. PHE BIT intervention: Social Norm feedback to reduce antibiotic prescribing by GPs
Target population and health behaviour:
General Practitioners in primary care settings prescribe around 80% of all antibiotics. Antimicrobial resistance is a growing problem and there is evidence that over-prescribing (i.e. prescribing when not clinically necessary) is contributing significantly to the problem.
A literature search identified evidence about key behaviours that support antibiotic stewardship in primary care. A ‘behavioural analysis’ using the theoretical domains framework (TDF) and COM-B model was also carried out to assess important influences on behaviour. Outcomes from this work suggested that many primary care prescribers admit that even some of their own prescribing will not be clinically beneficial. This is because it is the norm, because they fear what might happen should they withhold antibiotics, and because they perceive that their patients will be dissatisfied (Pinder, Sallis, Berry & Chadborn, 2015). As part of a pragmatic randomised controlled trial GPs were randomised to receive either a social norm feedback intervention about how their surgery performed relative to others or no communications. Intervention surgeries were told they were prescribing antibiotics at a higher rate than 80% of other practices.
Outcomes and evaluation:
Based on data from 1581 GP practices randomised to either the control or intervention condition, those in the intervention condition prescribed significantly fewer (73, 406 fewer) antibiotic items compared to controls (Hallsworth, Chadborn, Sallis et al., 2016).
Table 4. Summary of skills that behavioural scientists can offer public health.
i) Access to and condense of the evidence base.
ii) Apply theory to the design of public health services, programmes and campaigns.
iii) Evaluate existing services and interventions.
iv) Support providers of services to incorporate evaluation– For example emphasising the need to collect baseline data, gather people’s views and experiences independently, and to evaluate behaviour change and impact in terms of health and wellbeing.
v) Disseminate findings and success to help raise the profile of behavioural science and public health.
vi) Create links to those with expertise in academia.
vii) Create opportunities for student work placements as part of PhD and professional doctoral work.
The potential benefits of partnership working between behavioural scientists and public health departments are various, with advantages for both parties. Behavioural Scientists (including health psychologists and other experts in behavioural insights approaches), benefit from up to date knowledge about key public health challenges and gain access to policy makers, practitioners and end-users. Public health staff understand the priority needs of the local population and where the focus of research should lie. They have existing relationships with other departments in the local authority, NHS, commissioning groups and other relevant organisations, providing vital links that can help drive research activity, funding applications and the implementation of findings forward. As a result, Universities are likely to welcome the opportunity to partner with local authority-based public health departments.
Public health benefits from enhanced evidence based decision-making and intervention design, potentially improving the quality and effectiveness of public health commissioning and campaigns. As public health moves ever more towards an ethos of evaluation, evidence-based practice and engagement with behavioural science; these relationships will help to foster these requirements bridging the gap between research knowledge and practice. Behavioural scientists should be encouraged to support Public Health to conduct more rigorous evaluations, in order to create more robust evidence on the use of health psychology theory in the real world. Better recording of outcomes and impact and the use of behaviour change techniques in particular contexts will help to improve our understanding of how well Health Psychology and behavioural science theory truly works in practice.
List of abbreviations
NICE – National Institute for Health and Care Excellence
PH49 – Public Health guidance 49
PH6 – Public Health guidance 6
BCTs – Behaviour Change Techniques
TPB – Theory of planned behaviour
HBM – Health Belief Model
BIT – Behavioural Insights Team
BI – Behavioural Insights
PHE – Public Health England
LGA – Local Government Association
NHS – National Health Service
COM-B – Capability, Opportunity, Motivation – Behaviour
All of the case studies included in this debate article gained full ethical approval from the appropriate authority and involved participants providing full informed consent.
The authors declare that they have no competing interests.
Funding for the research outlined in case studies within this debate article came from various sources and is detailed in the referenced articles where the research is published.
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