An Insight on behaviour change and inequality in Salford

Understanding our market:how do

Tesco do it?

A segmentation and modelling system based on customer shopping behaviour - Goal was to understand factors that drive shopping behaviour, for example price, promotions, or healthy eating.

“We wanted to capture more spend from each customer, and nudge them into buying products from Tesco that they might buy elsewhere.”

Used products that are predictive of a need or a lifestyle, such as weight-watching goods, to develop 25 shopping dimensions, or typologies

Then developed segmentation of the target market by studying purchasing of the 25 dimensions - Eight million Tesco customers now carry a Lifestyles code, used to target mailings

They applied the segmentation, offering targeted ideas on summer activities and discounts on related products.

By modeling Lifestyles to geodemographic and Electoral Roll information, Tesco can predict the lifestyle make-up of a store before it opens

Key to this was the intelligence capacity to analyse the data from the club cards, equivalent to two man-years of analytical effort for Tesco

“The challenge was to make sense of the 104 billion rows of data stored at any one time”

The NHS has some history of market segmentation, but it is rudimentary and generally done by mapping the outcome eg here we map Life Expectancy to deprivation.

So not starting with a blank sheet but do we really understand why / how people behave?

Source: Association of Public Health Observatories

The lifestyle challenges

WeightSmoking

Alcohol

Busy, hectic and “mad” Larger families

Lots of single parents

Lack of money is a major issue

High levels of unemployment

Work just to make ends meet

Lack control of their life

High levels of depressionHardResigned to struggle

“It’s groundhog day for me, it’s

always the same thing.” (mum,

deprived)

Threatening

Don’t own a home or car

Routine and boring, based around the home

Lack motivation

Live day-to-day

We See unhealthy lifestyle choices as:- A Health problem- Requiring treatment- Investment into what works- A behaviour wrapped around a target

Local people seeunhealthy lifestyle choices as:- Normalised- Part of the glue for their social life- Something they can control, they can stop at a time they choose- Stress release- Builds in “me time”

Understanding the behaviour

Understanding the audience

Profiling using TGI to develop pen portraits of audience groups according to demographics, lifestyles and health behaviours

Older groups – 45+ C2DE males living alone are heaviest smokers, C2DE women have highest levels of obesity. Heavy daily drinking highest among more affluent groups

Adults – 25 – 44 - likely to be increasing –high risk drinkers and smokers, highest levels of overweight among 35+ males

Young singles – 18 – 24 – binge drinkers, smokers and highest levels of unhealthy eating among C2DE males

Underage - drinking, smoking, unsafe sex highest among most deprived groups with known risk factors – YOS, LAC, exclusions etc

Pregnant - smoking, unhealthy weight highest among younger more deprived women

Source: The 14 Motivators of Personal Action – Drummond et al, 2008

Social connection

Pleasure, stress relief, relaxation,

reward, escape, “me time”, relieves

boredom

Culturally normalised behaviour

Part of who I am, builds confidence to

be a better “me”, signifies freedom to

choose

Part of my daily routine I can stop whenever I want /know my own limits

Helps me control my life

Motivations for “unhealthy” Behaviours

Behaviours are culturally normalised• Image mapping showed perceptions of “normal” weight to be wide, many

HCP would see this as above a healthy size

In the land of happy denial, it’s easy to justify behaviour - there is always evidence of someone who is worse than you, others who “got away with it” and “its just the luck of the draw” anyway – fatalism prevails

Barriers to change are high

There’s a crack addict who lives up the road – she’s had two kids and they’re fine…a bit small but they’re fine. I don’t think it’s fair to blame

things on smokers when you’ve got crack and smackheads popping kids out left, right and

centre.

They say smoking causes premature birth and low birth weight but she [the baby] was over 8lbs and arrived on time,

so it did her no harm.

“my dad smoked 80 a day and lived to be 90 – it didn’t

shorten his life

Once your life’s made out for you, there’s nothing you can do

For everyone who’s died of a smoking related illness, I know someone else who

hasn’t

Using Insight to inform service development:

Weight managementAlcohol misuse

Smoking cessation

Example: Family Weight

Management Service

INSIGHTS•Hectic lifestyles – juggling work/ life •Lack of time is the key barrier to healthier eating and activity•Believe younger kids active and older kids don’t do enough activity•Know what they SHOULD be eating but don’t practice this which fuels guilt•Feel they do the best they can but give in to kids for an easy life•Concern about child weight triggered by buying up clothes sizes, emotional impact most salient•Easier to act to control exercise than diet – don’t know how to raise subject with children sensitively and unaware of support available

CONNECTIONS•Leverage children’s wellbeing and self esteem to attract into services•Wide communication of flexible family WMS with tools to support and maintain change at all stages•Conversation starters, self help “Fit Kit” toolbox (activity, diet and “head work”), 1 -1 personal plan, family groups, website to track progress, phone support for parents•Offer rewards and celebrate success (inc. points 4 life)•Use imaging software to motivate•Ongoing weight monitoring throughout early years using graphs (health visitor red books)

She’s not happy because she’s overweight. It runs in

our family, some people just need to exercise more

It’s my fault he’s overweight because I feed him crap. I

come in from work so tired that I can’t be bothered to

cook or argue

Segment: families (more affluent)

INSIGHTS•Larger families – many single parents•Life a struggle day to day – no money, low confidence, parenting skills•Lack of money is the key barrier to healthier eating and activity – both are expensive and junk food is cheaper and easier•Similar parenting challenges and emotions to more affluent groups, but lower sense of control as lack skills and knowledge to act•More likely to resist change and to not recognise the problem - feel “victimised” by system (school) and feel obesity is “not us”

CONNECTIONS•Same as more affluent families, with additional focus on overcoming cost barrier:•Costed diet options – e.g family meals for under a fiver•Promotion of local free activities they would value (e.g. self defence classes for teens)•Free leisure passes•Greater outreach as less likely to seek out support - Fit caravan roadshow to take messages out to communities•Availability of free, local support using peer ambassadors to share tips and success stories to provide inspiration

Segment: families (more deprived)

I went to the community centre where they did healthy eating.

The kids and parents went and it was really good

You can go to Cool Trader or Iceland and get five ready meals

for a pound, it’s as cheap as chips

• Universal offer with optional units to suit audience

• Pre programme 1:1

• Delivered in local venues at evenings and weekends with materials posted on line and printed work books

• Strong emphasis on parenting skills

• Focus on self esteem and celebration of success

• Ongoing support offered via existing mainstream activity

• Strong links to National Child Measurement Programme

Using insight to drive forward service delivery:The Family Weight Management Service

Example:

Alcohol Tier 2 Service

The Alcohol Social Marketing Insight

• Salford people who drink unhealthily see little reason to change

• Service needs to be – discrete – subtle – cover lifestyle issues

• Brief Advice and Interventions

• Target key segments of problem drinkers

• Tier 1 - G.P. keystone - target, early delivery, discharge follow up

• Targeted patients – extended brief interventions Tier 2

Worked Example: Alcohol Tier 2 Service

• Future Tier 2 Service = reach priority segment

• Targeting = age, gender, postcode

• Tier 1 G.P. / Practice Nurse screen via AUDIT C

• Referral Tier 2 - hold / stabilise / triage for Tier 2/3/4

• SMS / call / brief letter• Volunteers support patients

• Self help ‘drink-watchers group waiting AND follow up – also role AA

• Extended Brief Alcohol Interventions

• Outcomes = reduce units, improve social functioning

• Christo Inventory (NTA) / Triangle Consulting Alcohol Star (DoH)

• User Satisfaction Q

Helping smokers to quit smoking

Stop Smoking Services supported by wrap around programmes,

at community level

Smoker – Owen from Ordsall, aged 42

Owen works in a warehouse. He has very traditional macho values and sees his role as to provide for his wife and kids. He works to survive and is quite fatalistic about his life. He goes to the pub with the lads to unwind and likes a few pints at the end of the day. He doesn’t pay much attention to what he eats and loves his Friday night curry. Although he’s strapped for cash, he still spends money to keep up with the demands from his wife and kids. He likes nothing better than to watch the footie with a couple of cans and is a big City fan. He has smoked all his life and believes he needs it to control his temper

“Ciggies help me relax and control my temper”

Insight tells us:• Many smokers give quitting a go on their own, but very quickly

relapse (so at least there is interest in quitting)• The support / influence of local successes, people they know have

quit, so maybe I can too?• The local smoking culture plays a big influence on encouraging

smoking, so can we try to Influence it too?• Offer an achievable change around smoking• Motivate a longer term intention to quit• Signpost into support, if that is what will make the difference

Summary recommendations

Stick• Hard and emotive real facts around the

direct impact of smoking on loved ones to harness guilt

• Babies who are suffocated inside the womb • Children who suffer asthma and fail to

make friends • Husbands who can’t manage their

labouring job and are no longer able to provide for the family

• Grandparents and others who didn’t love us enough to stop smoking and stick around

Carrot• The positive immediate impact of

quitting both on themselves and their families

• Accessible local services that make it easy to retrain your brain and break the cycle for good

• Grass roots material to encourage families and friends to quit together

• Ongoing personal rewards to reinforce benefit such as Quit and win incentives

• Smoke free homes pledge linked to rewards

Level ‘0’ stop smoking programmes

• Smoke Free PlacesOutcomes - changed smoking behaviour

• Reenergise: 1 on 1, open ended discussion leading to individual lifestyle target setting Outcome – an agreed goal for a change in smoking behaviour

• Time banking: generating local skills in helping people to think about quitting. Exchanging skills for local ‘goods’Outcome – build social capital / health skills / change in smoking behaviour

• The ideal service:

– Holistic approach – Tailored support services – Products and tools– Goal setting, such as a family

event or other incentive– Ambassadors from the local

area– Family based approaches– Maintenance support– Non stigmatising

• Less stigmatising• Access to health and wider• Initial single point of contact 1

to 1 assessment• Tier 0 built into all

commissioning for lifestyle services– Social advertising– Community initiatives e.g.

time bank– Self care etc

Way to Wellbeing service model

Conclusions

1. For many life is a struggle 2. Behaviours are embedded as the norm3. All broadly know what they should do4. Barriers to behaviour change are high5. Health impacts do not motivate action6. For many, unhealthy behaviour is a symptom of bigger

issues7. The role of employment can’t be underestimated8. Sensitivity and stigma limit inclination for accessing support

INSIGHT and Primary Care Services:

Application of social marketing to general practice services?

Benefits to be gained?

Services where you may want to pilot this approach?

Reaching those people who are ‘hard to engage / reach’?