behaviour change: social and individual approaches. · decisions about health, wealth and happiness...
TRANSCRIPT
Changing Lives, Changing Society, University of the West of England 28th June 2012
Professor Mike Kelly, Director of the Centre for Public Health Excellence, The National Institute for Health
and Clinical Excellence (NICE) and Institute of Public Health University of Cambridge.
,
Behaviour Change: Social and
individual approaches.
Human behaviour and health
Evolutionary Trends
. Source: The Economist, 12 November 2003.
Preventable disease – the scale of
the problem
• In 2008, the total disease burden attributable to preventable deaths
in England and Wales under the age of 75 was 44 years of life lost
per 1000 population or about 2.6 million life years lost each year.
• If the NHS is prepared to pay £20,000 per life year gained at full
health, as the lower boundary of the cost effectiveness threshold
used by NICE implies, the value of this loss, for England and
Wales as a whole, is about £51 billion per year.
• The current level of tobacco use is estimated to cost the
NHS around £2.7 billion every year.
• Treating people with health problems related to being
overweight or obese is estimated to cost the NHS £4.2
billion annually.
• Physical inactivity is estimated to cost the NHS £1.06
billion per year.
• The costs of treating the chronic and acute effects of
alcohol misuse up to £1.7 billion per year.
Health Inequalities
Age standardised death rates per 100,000 population for
circulatory diseases under 75 by area of deprivation
0
20
40
60
80
100
120
140
160
180
Most
deprived
3rd Least
deprived
1995-97
2002-4
Age standardised death rates per 100,000 population for cancer under 75 by
area of deprivation
0
20
40
60
80
100
120
140
160
most
deprived
3rd Least
deprived
1995-97
2002-04
The health gradient
Health state
Social status
Hi Lo
Lo
Hi
The nanny state
• “It is simply not possible to promote healthier lifestyles
through Whitehall diktat and nannying about the way
people should live. One size fits all is no good. We
need a new approach that empowers people to make
healthier choices...”
White Paper November 2010 pp 2-3
“The nation, which is but the aggregate of us all is
…little disposed to endure a medical tyrant…Mr
Chadwick and Dr Southwood Smith have been
deposed, and we prefer to take our chance of
cholera and the rest than be bullied into health…”
The Times 1st August 1854, p8.
Nudge?
• Thaler RH and Sunstein CR. Nudge: Improving
decisions about health, wealth and happiness New
Haven, CT: Yale University Press, 2008.
Sons of Zeus
Apollo Dionysus
The sons of Zeus
Apollo
• order
• discipline
• system
• predictability
• logic
• rationalism
• method
The sons of Zeus
Apollo
• order
• discipline
• system
• predictability
• logic
• rationalism
• method
Dionysus
• pleasure,
• the vine,
• drunkenness,
• disorder.
• complexity
• empiricism
• sponteaity
The Dual Process system.
• The reflective system.
– Reflective, goal oriented system driven by our values
and intentions requiring cognitive capacity or thinking
space, which is limited.
– Many traditional approaches to health promotion
depend on engaging this system.
– Often based on providing information designed to
alter beliefs and attitudes, motivate people with the
prospect of future benefits, or help them develop self
regulatory skills.
– At best, these approaches have been modestly
effective in changing behaviour.
The automatic system
• The automatic, affective system that requires little or no
cognitive engagement, being driven by immediate
feelings and triggered by our environments.
• This automatic system is the focus of nudge theory.
Choice Architecture
http://pumabydesign001.wordpress.com/2010/10/07/michael-bloomberg%E2%80%99s-
agenda-to-nudge-new-yorkers-using-food-stamps/
• MARTEAU, T.M., OGILVIE, D., ROLAND, M.,
SUHRCKE, M., KELLY, M.P. (2011) Judging nudging:
can „nudging‟ improve population health? British
Medical Journal. ; BMJ 2011;342:d228.
http://www.bmj.com/content/342/bmj.d228.full
Worrying about nudging.
The individual and social levels of
explanation
Variables used in public health are
either :-
Individual Relational
Variables
Individual characteristics
Relational characteristic
Variables
Individual characteristics
• Blood pressure
• Height
• Personality –Introversion –
extraversion
• Morbidity
• Occupation
• Sex
Relational characteristic
Variables
Individual characteristics
• Blood pressure
• Height
• Personality –Introversion –
extraversion
• Morbidity
• Occupation
• Sex
Relational characteristic
• Social class
• Gender
• Social status
• Tribe
• Caste
• Some variables are both,
• And many relational variables are treated as if they
were individual ones.
• Much public health evidence tends to muddle these two
things anyway.
• Crude nudge fails to distinguish between them at all.
• The importance of distinguishing between the individual
level explanation and the social level explanation.
• The importance of distinguishing between the individual
level explanation and the social level explanation.
• Individual disease outcomes
• Patterning of disease at population level
Causal Pathways
•Is the issue one of individual level change?
•Is the causal pathway from the intervention to the
outcome short?
X Y
K
J
I
D
H
C
G
B A
F
E
L
Solutions: Another look at cause
Y X
Y X D C B A X1
Y
X4
X5
X3
X1
X2
M
N
O
P
H
G
F E
D C B A
L
K
J I
T
S
R
Q
Y
4
X5
X3
X1
M
N
O
P
H
G
F E
D C B A
L
K
J I
T
S
R
Q
Solutions: rethinking patterns of
behaviour
Outer zones of the lifeworld
Zone of relevance
Zone of relevance
Zone of relevance
Centre of the lifeworld
Overlapping lifeworlds
Conclusions
Altering choice architecture to change population
health behaviour: a large-scale conceptual and
empirical scoping review of interventions within
micro-environments
Gareth J. Hollands, Ian Shemilt, Theresa M. Marteau*,
Susan A. Jebb, Michael P. Kelly, Ryota Nakamura, Marc
Suhrcke, David Ogilvie
References KELLY, M.P. (2009) The individual and the social level in public health, in Killoran, A. & Kelly, M.P. (eds), Evidence
Based Public Health: Effectiveness and Efficiency, Oxford : Oxford University Press.
SWANN, C., OWEN, L.,CARMONA, C., KELLY, M.P., WOHLGEMUTH, C., HUNTLEY,J. (2009) A nudge in the right
direction: developing guidance on changing behaviour, in Killoran, A. & Kelly, M.P. (eds), Evidence Based Public
Health: Effectiveness and Efficiency, Oxford : Oxford University Press..
BAXTER, S. KILLORAN, A., KELLY, M.P., GOYDER. E. (2010) Synthesising diverse evidence: the use of primary
qualitative data analysis methods and logic models in public health reviews. Public Health 124: 99-106
http://dx.doi.org/10.1016/j.puhe.2010.01.002
KELLY, M.P. (2010) The axes of social differentiation and the evidence base on health equity. Journal of the
Royal Society of Medicine, 103: 266-72, DOI .1258/jrsm.2010.100005
.
KELLY, M.P. (2010) A theoretical model of assets: the link between biology and the social structure. In Morgan, A.
Davies, M ., Ziglio, E. (eds) Health Assets in a Global Context: Theory, Methods, Action, , New York: Springer.
http://bit.ly/auIY7y
KELLY, M.P., MORGAN, A., ELLIS, S., YOUNGER, T., HUNTLEY, J., SWANN, C. (2010) Evidence based public health: A
review of the experience of the National Institute of Health and Clinical Excellence (NICE) of developing public health
guidance in England , Social Science and Medicine, 71 :1056 - 1062 http://dx.doi.org/10.1016/j.socscimed.2010.06.032
KELLY, M.P. & MOORE, T.A. (2011) The judgement process in Evidence Based Medicine and Health Technology
Assessment. Social Theory and Health, advance online publication, 14 December 2011; doi:10.1057/sth.2011.21
http://www.palgrave-journals.com/sth/journal/v10/n1/full/sth201121a.html