health psychology and the future of public health

www.fuse.ac.uk

Health Psychology and the future of Public Health

Falko Sniehotta, PhDNewcastle University

Why is health psychology relevant for Public Health?Actual Causes of Death

Leading Causes of Death*

Percentage (of all deaths)

Heart DiseaseCancer

Chronic lower respiratory disease

Unintentional Injuries

Pneumonia/influenzaDiabetes

Alzheimer’s disease

Kidney Disease

Stroke

0 5 10 15 20 25 30 35

Actual Causes of Death†

TobaccoPoor diet/lack of exercise

AlcoholInfectious agents

Pollutants/toxinsFirearms

Sexual behaviour

Motor vehiclesIllicit drug use

Percentage (of all deaths)0 5 10 15 20

*Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-20.†Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291 (10): 1238-1246.

Foci of behaviour change interventionsgeneral population

– primary prevention

– “Lifestyle” behaviours: major cause of illness and premature death 48% avoidable deaths in US in 2000 from

• smoking

• alcohol use

• poor diet

• physical activity

• unsafe sex

• driving habits

• violence

Mokdad et al, 2004

patients– secondary prevention– reduce delay in seeking help– adherence to treatment

health professionals– implementation of evidence-

based practice– Knowledge Translation Gap– Influence population behaviour

Behavioure.g., exercise;

physical activity

Health outcomes health, mobility

and quality of life

Hardeman, et al. (2005) A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20(6):676-687

Behavioural determinants

e.g. cognitive, social, motivational & environmental

Physiological & biochemical

variables e.g. neurological & muscular processes

Structure of the evidence basefor behaviour change interventions

InterventionsInterventions

Determinants of health

Where and how to intervene

IndividualIndividual interventions

• reduce motivation to engage in unhealthy behaviours

• increase motivation to engage in healthy behaviours

• motivation into action and sustain healthy behaviours (behavioural skills)

• enhance self-regulation

SocietalSocietal interventions

• attitudes and culture• Choice architecture (nudging)• incentive structures• restrict or enhance

opportunities

Dynamic process of interaction between societal and individual level. E.g. walking/cycling: motivation + opportunities

‘Behaviour change at population, community and individual levels’: NICE review 2007

Behavioure.g., exercise;

physical activity

Health outcomes health, mobility

and quality of life

Hardeman, et al. (2005) A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20(6):676-687

Behavioural determinants

e.g. cognitive, social, motivational & environmental

Physiological & biochemical

variables e.g. neurological & muscular processes

Structure of the evidence basefor behaviour change interventions

InterventionsInterventions

Behavioure.g., exercise;

physical activity

Health outcomes health, mobility

and quality of life

Hardeman, et al. (2005) A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20(6):676-687

Behavioural determinants

e.g. cognitive, social, motivational & environmental

Physiological & biochemical

variables e.g. neurological & muscular processes

Effects of behavioural interventions on health

InterventionsInterventionsGood evidence from systematic reviews of RCTs for effectiveness of behavioural interventions on all outcome levels

Key challenges:• Considerable heterogeneity of effect sizes• Small to medium effects• Lack of sustainability

RE-AIM: A model of sustainable implementation of effective, generalisable, evidence-based interventions

Reach - How do we reach the targeted population with the intervention?

Efficacy - How do we know our intervention is effective?

Adoption - How do we develop organizational support to deliver our intervention?

Implementation - How do we ensure the intervention is delivered properly?

Maintenance - How do we incorporate the intervention so that it is delivered over the long term?

Glasgow et al. (2001) The RE-AIM Framework for Evaluating Interventions: What Can It Tell Us about Approaches to Chronic Illness Management? Pt Educ Couns 2001;44:119-127.

Public Health interventions are often complex

• Number of interacting components

• Number and difficulty of behaviours involved

• Number of groups or organisational levels targeted

• Number and variability of outcomes

• Degree of flexibility or tailoring permitted

Features of Behaviour Change interventions

1. Behaviour change techniques (BCTs), e.g., prompt goal setting or self-monitoring of behaviour

2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc

3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention

4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training.

Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)

MRC framework for development and evaluation of complex interventions

Theory Modelling Exploratory trial Definitive RCT Long termimplementation

Pre-clinical

Phase I

Phase II

Phase III

Phase IV

Cumulative knowledge base

Development & evaluationof complex interventions

Craig P et al. (2008) BMJ 337, a1655

Warning

The next slide shows upsetting public health campaign posters. You might

wish to close your eyes for a moment

The problem with behaviour change

• Attempts to change people’s behaviour are often geared towards:

– Raising Knowledge (lecturing) • “Did you know that…”

– Providing Advice (instructing) • “Why don’t you…”

– Motivating (scaring) • “If you don’t … then …”

Why are many public health campaigns not informed by behaviour change evidence?

• Behaviour change evidence is not good enough?• Behaviour change evidence is not relevant for

public health?• Behaviour change evidence is not effectively

disseminated?• Commissioners don’t listen to psychologists?• A lack of sustainable infrastructure to co-

produce relevant evidence?

Why theory?

• Enables cumulative science• Provides a shared language• Summarises known evidence

• Explains observations• Allows prediction• Enables intervention

• Problem of ‘implicit’ theory

‘a theory is a set of statements that organizes, predicts and explains observations; it tells you how phenomena relate to each other, and what you can expect under still unknown conditions’

Bem, S and Looren de Jong, H (1997) Theoretical issues in Psychology, Sage publications: London. p. 15

How does Theory help in developing and delivering interventions?

• Identify targets (e.g., cognitive or social determinants of behaviour)

• Suggest behaviour change techniques • Suggest sequences or combinations of techniques

and determinants• Allows for tailoring of interventions (e.g., stage

theories such as the ‘TTM’ /’stages of change model’ Evidence very weak!

• Provides a ‘cover story’ for intervention content

Choosing a theoretical approach (too) many theories of behaviour

• 33 theories and 128 constructs generated

• In four overlapping areas: – motivation– action– organisation– behaviour change

• Simplified into 11 domains of theoretical constructs• Interview questions associated with each domain

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

Simplifying theory: domains of behavioural determinants

1. Knowledge2. Skills3. Role and identity4. Beliefs about capabilities 5. Beliefs about consequences6. Motivation and goals7. Memory, attention and decision processes8. Environmental context and resources9. Social influences 10. Emotion11. Plans

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

•Self-efficacy •Control – of behaviour, and material and social environment•Perceived competence •Self-confidence•Empowerment•Self-esteem•Perceived behavioural control•Optimism/pessimism

Progress in theorising:the decline of landmark theories

• Popular landmark theories such as the Transtheoretical Model and the Theory of Planned Behaviour have passed their prime.

• They conflict with experimental evidence and showed limited utility for research and practice

• Development of more comprehensive theories with better evidence fit is ongoing

West, R. (2005). Time for a change: Putting the Transtheoretical (Stages of Change) Model to rest. Addiction 100 (8), 1036-1039. Sniehotta, FF, Presseau, J & Araujo-Soares, V (2014-March). Time to retire the Theory of Planned Behaviour. Health Psychology Review.

Identifying the evidence base: My involvement in Systematic Reviews

Identifying the evidence base:Problems with systematic reviews of behaviour change interventions

• Interventions are often poorly reported in terms of content, delivery, theory and fidelity.

• Often considerable risk of bias within and across trials

• Limited evidence about sustainability of effects

• It is surprising how little we know about how best to change people’s health behaviour.

Are theory based interventions more effective?

• In depth analysis of studies included in two systematic reviews of physical activity and healthy eating interventions (k 190).

• Interventions based on Social Cognitive Theory or the ‘Transtheoretical’ Model were no more effective than interventions not explicitly based on theory

• Implementation of theory variable and overall poor

Prestwich, A., Sniehotta, F. F., Whittington, C., Dombrowski, S. U., Rogers, L., & Michie, S. (2013, June 3). Does Theory Influence the Effectiveness of Health Behavior Interventions? Meta-Analysis. Health Psychology.

Biomedicine vs behavioural science … Example of smoking cessation effectiveness

• Intervention content

• Mechanism of action– Activity at a subtype of the

nicotinic receptor where its binding produces agonistic activity, while simultaneously preventing binding to a4b2 receptors

• Intervention content– Review smoking history & motivation to

quit– Help identify high risk situations– Generate problem-solving strategies– Non-specific support & encouragement

• Mechanism of action– None mentioned

Varenicline JAMA, 2006 Behavioural counselling Cochrane, 2005

Behaviour change techniques: reliable taxonomy to change physical activity and healthy eating behaviours

1. General information 2. Information on consequences3. Information about approval4. Prompt intention formation 5. Specific goal setting 6. Graded tasks7. Barrier identification8. Behavioral contract9. Review goals10. Provide instruction11. Model/ demonstrate 12. Prompt practice13. Prompt monitoring 14. Provide feedback

15. General encouragement16. Contingent rewards17. Teach to use cues 18. Follow up prompts19. Social comparison20. Social support/ change21. Role model22. Prompt self talk23. Relapse prevention24. Stress management25. Motivational interviewing26. Time management

The person is asked to keep a record of specified behaviour/s.

This could e.g. take the form of a diary or completing a

questionnaire about their behaviour.

Involves detailed planning of what the person will do including, at least, a very specific definition of the

behaviour e.g., frequency (such as how many times a day/week), intensity (e.g., speed) or duration (e.g., for how long for). In addition, at least one of the following contexts i.e., where, when, how or with whom must be specified. This could include identification of sub-goals or preparatory behaviours and/or specific contexts in

which the behaviour will be performed.

Identifying Effective Change Techniques in Interventions Designed to Promote Physical Activity and Healthy Eating• Systematic review and meta-analysis• 84 interventions• average of 6 techniques• small effect d = 0.37 (95% CI 0.29 to 0.54, N = 28,838) • self-monitoring

– associated with effectiveness (14.6% variance explained). – Interventions including this technique had a medium effect size of d =

0.57. – Interventions combining self-monitoring with at least one other

technique derived from control theory were more than twice as effective as the other interventions with d = 0.60 d = 0.26 respectively

Michie S, et al (2009) Identifying Effective Techniques in Interventions: A meta-analysis and meta-regression Health Psychology

The Behaviour Change WheelBehaviour source

Intervention type

Policy type

Regulation

Env

ironm

enta

l/so

cial

pla

nnin

g

Communication/

marketing

LegislationFiscal

Per

suas

ion

Education

Coercion

Environmental

restructuringInce

ntiv

isat

ion

Enablement/ resources

Capability

Opportunity

Mo

tiva

tio

n

TrainingR

estrictionService provision

Guidelines

Modelling

Physical

Psychol-ogical

Reflec-tive

Non reflect-ive

Physical

Social

Michie, van Straalen & West 2010

Evaluating Public Health Interventions

– Newly introduced interventions often not evaluated– Ask Fuse – a feature for commissioners and

practitioners to collaborate with Fuse, the UK CRC Centre for Translational Research in Public Health

– Current work commissioned by the NIHR School of Public Health Research to develop guidelines for the evaluation of local public health interventions

Example 1: A&E admission after Stroke

• People often delay seeking medical help, typically 3-6h

• Pre-hospital delay prevents access to best treatment Teuschl et al., 2011

• Various reasons for delay including clinical, contextual and cognitive

Act FAST Campaign

• UK national awareness raising campaign• Rolled out in multiple waves:

– Feb 2009, Nov 2009, Feb 2010, May 2011, March 2012

• Targeted :– Population: television, press and radio– Health professionals: emails, newsletters, posters and

leaflets

Act FAST Campaign

• FAST = Face, Arms, Speech, Time to call 999• Developed for rapid ambulance protocol to

increase diagnostic accuracy of stroke in paramedical staff (Face, Arms, Speech, Test)

• High levels of diagnostic accuracy and good agreement between professionals

• Since been adapted as a public awareness instrument in English speaking countries

Act FAST Campaign

Recognition(Face, Arm, Speech)

Response(Time)

Call 999

Act FAST Campaign

Recognition(Face, Arm, Speech)

Response(Time)

Call 999

Research Question

Can people apply the FAST acronym to recognise and respond to stroke?

Study Design5000 people randomly selected from Electoral Roll from Newcastle upon Tyne and randomised to two groups

Reminder and 2nd pack sent after 2 and 8 weeks

n=2500 Questionnaire + FAST leaflet

n=2500 Questionnaire only

Hypotheses

Leaflet group will have:1.Better knowledge what FAST stands for

2.Better recognition of stroke

3.Better response to stroke

Results

• Familiar with Act FAST

The difference in proportions is significant, χ²(1, 1525) = 9.20, p=.001

Results• Knowledge of FAST elements• FAST right: 66.1% vs. 45.3%, t(1613)=9.30,

p<.001, d=0.46

Results

• Response to stroke scenarioAll 12 stroke scenarios t(1601)=-1.0, p=.32, d=0.05

FAST scenarios onlyt(1609)=-1. 05, p=.30, d=0.05

Non-FAST scenarios onlyt(1608)=-0.63, p=.53, d=0.03

Why?

Findings

Implic

ation

s

What helps and hinders

midwives in engaging with

pregnant women about

stopping smoking?

What and how?

Smoking at time of delivery, by region from 2004/05 to

2011/12

Why?

Service concernsService concerns

Good evidence baseGood evidence base

NICE guidance – behaviours described for health professionals

How to ask a pregnant woman about her smoking behaviour

How to refer a pregnant woman to the stop smoking service

How to give advice to a pregnant woman about her smoking behaviour

How to use a carbon monoxide monitor

What & How?

Survey based on theoretical domains of behavioural determinants and NICE guidance

Participants – all midwives employed by eight acute NHS trusts in North East region

Audit of NICE guidance in north east midwifery units

Advisory group

Workshop

Workshop

Mean domain scores (n= 364)Mean domain scores (n=364)

Trust Group Work

What are we going to do?

1.

2.

3.

4.

How will we do this?1.

2.

3.

4.

Trust name:

And by when?

What are we doing well – and should

keep doing?1.

2.

3.

4.

•Systematic approach to CO monitoring and referral by all midwives at first booking appointment•Standardised referral pathways•“Risk Perception” intervention by midwives at time of scan clinic•Skills training for midwives and NHS SSS staff (advisors and admin teams)•Supply of all key resources•Systematic monitoring and evaluation• Stepped Wedged Design Evaluation ongoing funded by the NIHR School of Public Health Research

babyClear systematic approach

Concluding remarks

• Let’s work together to improve public health by changing behaviour

• We need sustainable collaboration between Public Health and academic partners

• Joint agenda setting• Co-production of knowledge fit for implementation• Funding • Creating pathways to impact Healthy People

Acknowledgements

The work was undertaken by Fuse, a UKCRC Public Health Research: Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research council, Medical Research Council, and the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is greatly acknowledged.

Opinions expressed in this presentation do not necessarily represent those of the funders.

falko.sniehotta@ncl.ac.uk

Spare slides

Buildings blocks of behaviour change

Environment & Social influence

Knowledge & Skills

Motivation•Attitudes

•Perceived Norms• Self-efficacy

•Emotion

Planning• Action Planning• Coping Planning

Self-regulation• Self-monitoring

• Awareness of standards• Means and skills

Buildings blocks of behaviour change

Environment & Social influence

Knowledge & Skills

Motivation•Attitudes

•Perceived Norms• Self-efficacy

•Emotion

Planning• Action Planning• Coping Planning

Self-regulation• Self-monitoring

• Awareness of standards• Means and skills

Buildings blocks of behaviour change

Environment & Social influence

Knowledge & Skills

Motivation•Attitudes

•Perceived Norms• Self-efficacy

•Emotion

Planning• Action Planning• Coping Planning

Self-regulation• Self-monitoring

• Awareness of standards• Means and skills

Decisional phase

Implemental phase

Buildings blocks of behaviour change

Environment & Social influence

Knowledge & Skills

Motivation•Attitudes

•Perceived Norms• Self-efficacy

•Emotion

Planning• Action Planning• Coping Planning

Self-regulation• Self-monitoring

• Awareness of standards• Having means and skills

Decisional phase

Implemental phase

Would I like to change?

How can I change?

Intervention typesEducation Imparting knowledge e.g. on health risks

Persuasion Using communication to induce belief or knowledge

Incentivisation Creating expectation of reward

Coercion Creating expectation of punishment or cost

Training Imparting skills

Restriction Reducing availability

Environmental restructuring

Changing the physical context

Modelling Providing an example for people to aspire to

Enablement/ resources

Increasing means/reducing barriers

Policy typesCommunication/ marketing

Using print, electronic, telephonic or broadcast media

Guidelines Creating documents that recommend or mandate practice

Fiscal Using the tax system

Regulation Establishing rules or principles of behaviour or practice

Legislation Making or changing laws

Environmental/ social planning

Designing and/or controlling the physical or social environment

Service provision Delivering a service

Impact on behaviour (correlation)

Average number of messages in UK health leaflets

1 2 3 4 5 6 7

1. disease severity

2. knowledge/info

3. susceptibility

4. self-efficacy

5. others’ attitudes

6. attitudes to behaviour

7. intention to change

Persuasive communications and targeted cognitions: UK safer sex leaflets

Abraham, C., Krahé, B., Dominic, R., & Fritsche, I. (2002). Does research into the social cognitive antecedents of action contribute to health promotion? A content analysis of safer-sex promotion leaflets. British Journal of Health Psychology, 7, 227-246.

Motivation theoriesexplain why people want to do things

• Theory of Planned Behaviour• Theory of Reasoned Action• Protection Motivation Theory• Health Belief Model)• Social Cognitive Theory• Locus of control theories• Social Learning Theory• Social Comparison Theory• Cognitive Adaptation Theory• Social Identity Theory

• Elaboration Likelihood Model

• Goal Theories• Intrinsic Motivation

Theories• Self-determination theory• Attribution Theory• Decision making theories

eg. social judgment theory, “fast and frugal” model, systematic vs. heuristic decision making

• Fear arousal theory

Action theoriesexplain why people do things

• Learning theory• Operant theory• Modelling• Self-regulation theory• Implementation theory/automotive model• Goal theory• Volitional control theory• Social cognitive theory• Cognitive Behaviour therapy• Transtheoretical model• Social identity theory

Organisation theoriesexplain how groups and organisations

influence what people feel and do

• Effort-reward imbalance• Demand-control model• Diffusion theory• Group theory eg. group minority theory• Decision making theory• Goal theory• Social influence• Person situation contingency models