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Public Health: An Art and a Science

Behaviour Change interventions: An Art and a Science

Stuart King, CEO and Head of Distraction at BeeZee Bodies

 

The World Health Organisation define Public Health as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988). Over the past two decades, obesity, and changing the behaviours that contribute to it, has become an increasing focus for public health practitioners. Initially, the focus was on various in-house attempts to design behaviour change interventions, but increasingly focusing on the commissioning of providers to deliver services. It is a governmental priority to halt and reverse the national obesity picture in both adults and children. Not only will effective intervention save money through reduced medical and social care bills, but people are more likely to have a higher quality of life, putting life into their years, not just years on their life.

 One of the key issues facing intervention designers attempting to change behaviour effectively has been not just knowing what to do, but also knowing how to do it. Many behaviour change programmes do not have the feedback mechanisms built within them to establish whether the behaviour change methodology is; a). effective in the real world (and not just in a controlled trial), and b). is being executed properly and in a way that is having the desired effect on the intended audience.

 The BeeZee Bodies Approach and its Evolution

BeeZee Bodies have been delivering behaviour change services for 15 years. In the beginning there was very little behavioural science involved in the public health markets, with most interventions being delivered very much in line with ‘common sense’. We were using the best available psychological evidence of behaviour change during the early iterations of our services (for example; Self Determination Theory (Ryan & Deci, 2000), Cognitive Evaluation Theory (Deci & Ryan, 1985), Achievement Goal Theory (Dweck and Elliott (1983), Self-Efficacy (Bandura, 1995) and Self-Presentation (Denzin, 2008)), but COM-B was nowhere close to being released and behavioural economics was still being curated by the now Nobel Prize winners, to be released to the masses. The upside was that it forced us to find delivery methods that really engaged people, and to look elsewhere for complementary skillsets and disciplines to deliver engaging and (at least anecdotally) effective programmes. We conducted a randomised controlled trial (RCT), and failed miserably with our first ever control cohort because we had not understood the disappointment people would feel about being in the ‘delayed treatment’ group. However, we learned many lessons about what worked and what did not in the treatment groups.

 

We began delivering psychological behaviour change services but with sociology firmly at its heart. Most notably, our programmes started to draw on Bourdieu’s  concept  of Habitus (Guilianotti, 2016; Grenfell, 2008; Craig, 2016), as well as the insights regarding the social construction of the body associated with the work of other prominent theorists, such as Michel Foucault (Taylor, 2010) and Chris Shilling (Shilling 2012). The point to emphasise here is that by drawing these theories and concepts together, we moved away from the rather sterile idea that people and the changes they are seeking to make merely reflect the motivations of autonomous individuals. In reality, people exist in a world where the constraints and expectations of everyday social norms, responsibilities and deeply influential social structures are constantly present and impacting the social architecture (Bourdieu would refer to this as the ‘field’) impacting their decision making. As the experience of delivering our programmes powerfully evidences, each individual and family are influenced by circumstances that they may have little direct control over.

 

 Essentially, we have learnt to deliver our services in the context of peoples’ real lives, developed in a way that:

  • ensured that we, as deliverers, were credible in the messaging
  • allowed the slow process of change to take place in a protected environment
  • normalised failure as part of the process of change and encouraged it whilst on the programme in a protected and supportive environment
  • delivered with reciprocity in mind, engaging with feedback in real-time and adapting as we went, noting how to improve the art of delivery for future programmes.

 

This process of growth set the tone for our organisation now: use qualified, career professionals who are ‘people-people’ and train them to be able to deliver dynamically using behavioural science, delivered in context of peoples’ real lives and with the ability to evaluate how the information and approach is landing with individuals and groups. This makes it hard for commissioners of behaviour change services to see the difference between organisations that deliver ‘evidence-based behaviour change’ in theory and evidence-based behaviour change in practice. There is a subtle distinction. Being able to write a programme that conforms with NICE standards and guidance, Government strategies and the latest evidence base is the easy part. Any university undergraduate can have a really good go at this in an afternoon. What is missing is the art.

 Scientifically building in ‘the art’

Having just lamented the lack of art in behaviour change interventions, describing it almost as an indescribable quality that is hard to characterise, I want to share, in a small way, how we are building the art into interventions systematically.

 Before the behaviour change science

Building an intervention is like starting a completely new business and can, and should be planned as such. A good model to use when creating a business idea is the Business Model Canvas (Osterwalder & Pigneur, 2010); see below:

 

Figure 1. Business Model Canvas (Osterwalder & Pigneur, 2010) (downloaded from www.Strategyzer.com copyright Strategyzer AG)

 https://www.strategyzer.com/canvas/business-model-canvas

 

Some of the sections may be more necessary than others with intervention design, however some areas that might not immediately seem important, have very pragmatic and logistical ramifications and are worth considering early on. The accompanying Value Proposition Canvas is also useful in designing interventions.

 

Figure 2. The Value Proposition Canvas (downloaded from www.Strategyzer.com copyright Strategyzer AG)

 https://www.strategyzer.com/canvas/value-proposition-canvas 

Using this as a starting point for intervention design allows a genuine understanding of the people whose behaviour you are trying to change, the possible reasons for change and in what direction. It focuses marketing efforts (one of the key missing pieces in most public health campaigns – a fully coherent marketing effort), partners, the practical tasks that need doing and builds an intervention with the users truly at the heart of it. Of course, this is a starting point with research from many sources informing the planning canvases and the involvement of the very people for whom you are building the intervention.

 Layering in behaviour change science

Once the foundations of the intervention are built, we need to understand what we are trying to change. It is time to create layers of behaviour change science throughout the intervention, using the literature and national guidance to inform some of the key elements to be used in the intervention. Various NICE and government guidance can be used to help inform these and they should always contribute to the value proposition you are curating, relieving pain or creating gains for the people using the service. But most important is that you describe the expected mechanism of action. Why do you think that doing X will result in Y? This provides a testable hypothesis; however, it is not couched in behavioural science just yet. Let us take a couple of steps back.

 We are not a team of academics, we are real-world behaviour change practitioners. So we have spent a decade iterating services that work using a mixture of academic literature, government advice and guidance, and combining valuable learnings from different industries. This has helped to create services that have organically evolved to be informed by behaviour change science, but also by AB testing and trial and error (including a lot of error!). We are now at the stage where we have gone back through all of our practices to determine why things we know work, work. Whilst much of this was built into the services purposefully, it is surprising just how much of what we found was most effective, was the result of artful, passionate delivery that we could later systematise and characterise scientifically and behaviourally.

 Since the evolution of the Behaviour Change Wheel (BCW) system and approach, there is a new language for describing and developing our work that has brought further benefit through COM-B (Michie, Van Stralen, & West, 2011), the Theoretical Domains Framework (TDF, Michie et al., 2005) and Behaviour Change Techniques (Michie et al., 2013) systems to code every deliverable element of our services. This is advantageous for a number of reasons:

  1. We are reassured that the content and delivery of our practice is based on evidence about what works, not just some parts, but every element.
  2. We are able to test the individual elements for success, partial success or failure, making our iterative approach to gradual and continual improvement robust.
  3. We are able to train our team to genuinely understand why what they are doing is working and not working, which has two outcomes:
  4. They are able to develop their knowledge and skills to truly become behaviour change expert practitioners.
  5. They feedback invaluable data about each aspect of the programme that allows either continuation; modification; or removal of certain elements based on their impact within delivery.

 

One of the most important aspects of this approach is to describe how this influences and/or causes change. This is our hypothesis regarding what we expect to happen and why. Our assumptions are often wrong, misguided, useful in a completely different way than we anticipated, or right. In any of these cases, the learning is incredibly useful, both organisationally and personally for the learning and development of the team.

 An example of this approach from our men’s weight management service; Gutless, is set out in table 1 below. For context, when a man completes Gutless, he has the opportunity to join our ‘Gutless Loser’s’ programme, continuing to participate in weekly physical activity and weigh-ins. Many also choose to support new participants in their first session.

 

Table 1. Session 1; Introduction Subcomponent; Introduction from previous Gutless participant (Gutless Loser)

COM B

TDF

BCT

How this brings about or contributes to behaviour change

Reflective Motivation

Beliefs about capabilities

6.2 Social Comparison

The members of the group are identifying with the beginning of the Gutless Loser’s story and recognising that someone in a similar position has managed to effectively make change.

 

Social identity

6.3 Information about others' approval

Seeing the reaction from other group members towards the achievement of the Gutless loser provides an aspiration to emulate that success.

 

Beliefs about consequences

6.3 Information about others' approval

The narrative of the Gutless loser describes the positive reaction of other people to their success in making changes to the behaviour and/or weight

 

Beliefs about consequences

9.1 Credible Source

The person making the statements can back up what they have said because they have demonstrated the effectiveness of their efforts.

 

Beliefs about consequences; Beliefs about capabilities; Optimism

9.3 Comparative imagining of future outcomes

Using the similarities that people see between where the Gutless Loser was at the beginning and where they are now (at the start of their programme) and where the participant is starting from, they are able to develop a sense of belief in their potential for positive change.

 

Beliefs about consequences

10.8 Incentive (Outcome)

Evidence (verbal and non-verbal) that going through the Gutless process will provide them with the reward of achieving their goals

 

Optimism

11.2 Reduce negative emotions

Gutless loser provides credible information about how they felt about change and how they overcame barriers, stressors and/or negative events. Often these will come in the form of examples and stories

 

Social/professional role/identity

13.1 Identification of Self as a role model

The Gutless Loser realises the impact they are able to have on improving the lives of others. This creates greater automatic and reflective motivation, a sense of autonomy and responsibility and ultimately, enhances global self-esteem.

 

Social/professional role/identity

13.1 Identification of Self as a role model

If enough similarities are perceived between the participants and the Gutless Loser, they may identify the impact that they wish to have on others which would act as an additional motivator.

 

Social/professional role/identity

13.5 Identity associated with changed behaviour

Gutless loser has a realisation that they are happier within their new/evolving identity. This supports further motivation to continue changing or maintain the changes.

 

Intentions

 

Participants may notice or sense that the Gutless Loser has embraced this new identity and this supports their (the participant) aspiration to follow their journey.

 

Beliefs about capabilities

15.1 Verbal persuasion about capability

"If I can do it, you can do it" Enhancing self-belief through the comparison of participants and Gutless Loser.

 

Beliefs about consequences

16.3 Vicarious Consequences

Participants see the positive impact that the changes made has had on the Gutless Loser's life and admire the associated benefits.


The above example represents approximately 10 minutes of the first session in our Gutless service. Our services are generally between 12 and 17 weeks long, 2 hours each week, plus follow up. It should be clear that coding every element of every service is not a small task! However, this investment improves our services in a symbiotic way; improving the quality and consistency of delivery for the public, whilst significantly educating and upskilling the team delivering the service. This learning further hones the deliverable content with updated hypotheses, which further connects the team to the science underpinning the services. This is a model for improving the delivery of services to the public by an order or magnitude compared with what has gone before.

 

Summary

This approach is helping us take our ethos of passionate, artful delivery and position it within robust behaviour change science, allowing the training and development of genuine behaviour change specialists. Understanding the underlying science is not a ‘nice to have’ if we are trying to develop people who can genuinely help people change their behaviour and change their lives. Equally important is our ethos of ‘employing people-people’, i.e. people who love working with the public, people who you ‘warm to’ straight away. This is as important as having a robust and scientific approach to behaviour change. Without it, you may as well send the public the programme delivery notes and tell them to get on with it. The messenger counts.

 

Putting the art back into public health delivery, does not mean losing the science. But it is a recognition of the fact that this comes down to people interacting with other people. Upskilling these practitioners is crucial if we want to see high-quality behaviour change take place in our public facing services. Real behaviour change cannot be delivered by sessional staff reading session notes from a book, it has to be more dynamic and reciprocal than that.

 We have created a system where the learning can be captured, and services improved by focusing on science and art.

 

References

Bandura, A. (1995). Self-Efficacy in Changing Societies. Cambridge University Press: Cambridge.

 Craig, P. (2016). Sport Sociology. Chapter 7 Sport and the Body (Edition 3) Sage: London.

 Deci, E. & Ryan, R. (1985). Intrinsic Motivation and Self-Determination in Human Behaviour. Springer: US.

 Denzin, N. (2007). Symbolic Interactionism and Cultural Studies: The Politics of Interpretation. Wiley: UK.

 Dweck, C. & Elliott, E. (1983). Achievement Motivation. In P. Mussen (Gen. Ed.), & E. Hetherington (Ed.), Handbook of Child Psychology (Vol. 4, pp. 643-691). Wiley: New York.

 Giulianotti, R. (2016). Sport – A Critical Sociology (Edition 2) Routledge: London.

 Grenfell, M. (2008). Pierre Bourdieu (Key Concepts), Routledge: London.

 Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D., & Walker, A. (2005). Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality and Safety in Health Care, 14(1), 26-33.

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

 Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., &  Wood, C. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of Behavioural Medicine, 46(1), 81-95.

 Osterwalder, A. & Pigneur, Y. (2010). Business Model Generation. Wiley, USA.

 Ryan, R. & Deci, E. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68-78.

 Taylor, D. (2010). (Edit) Michel Foucault (Key Concepts), Routledge: London.

 Shilling, C. (2012). The Body and Social Theory, Chapter 4 The Socially Constructed Body (Edition 3). Sage: London.