Facilitating health behaviour change in looked after young people; evaluation of an intervention targetting multiple risk behaviours.

Hannah Dale, Health Psychologist, NHS Fife hannahdale@nhs.net

Lorna Watson, NHS FifePauline Adair, University of StrathclydeGerry Humphris, University of St Andrews

Overview

Background

Results

Challenges

Methods

Discussion

Conclusions & Recommendations6

5

4

3

2

1

• Looked after young people (LAYP) have poorer health outcomes

• No reported interventions on LAYP evaluate on outcomes• ‘Hard-to-reach’ • Risk behaviours have been linked (Aicken et al, 2010)• Factors such as feelings of safety and belonging

(neighbourhood, school, family) may protect against multiple risk behaviours (Brooks et al, 2012)

• Physical activity associated with reduced risk for all substances and sexual risk behaviour (Nelson et al, 2006)

Background

Objectives were to develop and evaluate a health behaviour

change intervention for LAYP to improve their lifestyle around

multiple risk behaviours

Development of intervention through 3 main sources

Methods

Qualitative – focused on sexual health initially.

Needs assessment

Behaviour and behaviour change theories

Theory

3Effective interventions for young people around lifestyle.

Evidence

1. Needs assessment revealed gap between knowledge and behaviour, need for flexible services and interventions spanning all lifestyle issues

2. Theories include Social Cognitive Theory, Theory of Planned Behaviour and Health Action Process Approach

3. Evidence mixed for some areas, especially for vulnerable populations

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Research, theory and evidence

around health behaviour

change

Behaviour change interventions

Consultancy

Teaching and training

Intervention Scope

• The intervention was delivered by a health psychologist in a personally tailored way to individuals

• It aimed to motivate and provide LAYP with the skills for change and is very flexible to needs, targeting:– Sexual health– Smoking– Activity– Healthy eating– Alcohol and drugs

• Considered to have 2 phases – motivational and volitional

Behaviour change interventions

With thanks to Jilly Martin

With thanks to Jilly Martin

All young people eligible to take part in the evaluation

• Consent for the evaluation taken

• Evaluation measures taken at the start and end of the intervention and a 6-month follow-up questionnaire also sent

• Measures:- Range of measures to assess behaviour and intention

- How many cigarettes do you usually smoke in a week? - How much do you plan to stop smoking in the next month? (5 point

likert scale from strongly disagree to strongly agree

- Well-being (Warwick-Edinburgh Mental Wellbeing Scale; WEMWBS)

- Audit of behaviour change techniques (Michie et al., 2011)

Evaluation methods

Results

Baseline evaluation data (n=93)

Post-intervention evaluation data (n=52)

Discontinued intervention early (n=41)• Didn’t re-attend drop-in (n=12)• Dropped out of sessions early

(n=20)• Moved away from Health Board

area (n=2)• No consent (n=7)

No baseline data (n=32)• Written consent not gained due

to physical disability or dislike of written documents (n=2)

• Consent not gained due to time limitations during drop-in sessions (n=11)

• Person did not engage with intervention longer than 1 appointment (n=9)

• Due to focus on building rapport, evaluation consent not pursued (n=10)

Eligible for the evaluation (n=125)

Young people referred into service (n=144)

Ineligible for evaluation (n=19)Drop-out before first appointment (n=10)Still receiving intervention (n=9)

N (unless otherwise stated)

Sex Females Males

5637

Age Mean=14.43Range=11-21

Residence type Residential school Residential home Foster care Kinship care Living with parents Supported accommodation Living in own flat

3321263532

Referral type Self-referral Social worker NHS Worker Foster carer Residential care staff Private agency

3530141

85

Referral month Range= March 2009-October 2013

Number of sessions Mean=6.2, SD=5.778, Range=1-40

Health issues discussed Sexual health Smoking Healthy eating Physical activity Drugs Alcohol Mental Health Physical condition Self esteem Hygiene Anger Sleep Oral Health

5943312422223232141

Behaviour N in analyses Pre-score Mean (median)

Post-score Mean (median)

Significance value and effect size

Smoking (number/week) 38 26(0)

16(0)

p=0.01 r=-.30

Exercise (hours/week) 25 3(2.5)

6(5)

P=0.000r=-.52

Fruit and vegetable intake (number/day)

25 .98(1)

2.58(2)

p=.001r=-.48

N NIntention to use condoms Do not intend to Unsure Intend to Strongly intend to

236872

14126

p=0.003 r=-.44

Condom use Never Not very often About half the time Most of the time Always

923112

10134

P=0.026r=-.53

Pregnancy contraceptive Yes No

279 18

198

McNemar’s test p=0.006

Undertaken STI test Yes No

17314

89

McNemar’s testP=0.219

Alcohol (units per week) 24.52(.000)

.333(.000)

p=.715

Cannabis use (number/month) 22 0.18(.000)

0.00(.000)

p=.180

Wellbeing 19 Mean= 40.32Median= 39SD=11.28

Mean= 50.05Median= 53SD=10.68

p=.002r=-.49

47 techniques (33 from 40 item taxonomy of BCTs) used across sessions, most commonly (25+ sessions):

Audit of behaviour change techniques

• Goal setting (behaviour)• Action planning• Barrier identification/problem

solving• Set graded tasks• Review behavioural goals• Plan social support/social

change• Building confidence to say ‘no’

to sex• Provide general

encouragement

VolitionalTechniques

• Motivational interviewing• Provide information on

consequences of behaviour in general

• Provide information on consequences of behaviour to the individual

• Discrepancy assessment (between own standard and actual behaviour)

• Provide normative information about others’ behaviour

• Promoting positive values and attitudes towards sexual health and relationships

• Elicit aspirations about the future

Motivational Techniques

Discussion

• Enabled consideration of multiple health issues throughout involvement

• Numbers in analyses are low, however the data is promising

• Engaged young people in health issues and making changes

• Range of motivational and volitional techniques were utilised

• Due to the sometimes complex backgrounds of LAYP, many may require intensive tailored interventions to assist in behaviour change and include motivational elements

• Flexibility is also key in initiation and maintenance of engagement

Challenges

• Barriers to engaging and evaluating vulnerable groups

• Challenges of trying to evaluate drop-ins

• People dropping out due to changed priorities and people moving away from the health board area

• Also suggests more rigorous research such as RCTs may be even more problematic

• LAYP generally geographically sparse so even snowball sampling methods difficult

Some possible solutions

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• Drop-ins and flexibility help with engagement

• Questions that can be asked informally and verbally, rather than a structured paper questionnaire, may assist in engagement with research questions

• First appointments could be set up to build rapport and inform about the service or research then evaluation questions asked later

• N-of-1 studies may be possible

• Verbal consent for evaluation may be preferable

Conclusions & Recommendations

• Due to the vulnerable and hard-to-reach nature of LAYP there was a lack of data

• The development of a tailored one-to-one service for LAYP around healthy lifestyle issues is, however, possible and can result in behaviour change

• A whole-person approach is achieved through targeting multiple risk behaviours

• Interventions for LAYP may need to be of high intensity

• Due to the sometimes difficult nature of engaging young people, training for staff in behaviour change techniques may be important

Thank youAny questions?

Hannah Dale, Health Psychologisthannahdale@nhs.net

Health Psychology fringe session

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