From behaviour change to public health improvement: re aiming our efforts

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.

From behaviour change to public health improvement:re-aiming our efforts

Laurence Moore


• Motivations• Frameworks / perspectives• Food – vindaloo, bake-off, masterchef,

paella• Key points• Way forward


Motivations

• Frustration with mis-match between• behaviour change science (individual, efficacy, inequalities)• public health policy and practice (complex, upstream, impact)

• Observation of risk of continued divergence of• Discipline-led science (reductionist)• Complexity of solutions (holistic, system, interdisciplinary)

• Not to be too dull


Frameworks / Perspectives

• Dahlgren and Whitehead• Socio-ecological theory• RE-AIM• Complexity theory (complex adaptive systems)• Automaticity• A focus on change


The main determinants of health


Policy debates

• Individual level actionvs» Macro level policy

• Social, Community, Organisational intervention often overlooked

• Critical interdependencies between levels often overlooked

• Synergistic, multiple actions at multiple levels not prioritised

• Search for silver bullet (at best silver pellet)


Socio-ecological model

(Bronfenbrenner, 1979)


Levels of change Approach and target

Intrapersonal Individual characteristics that influence behaviour such as attitudes and beliefs

Interpersonal Interpersonal and group influences such as social networks and social support, family

Organisational Rules, regulations, policies and ethos that may promote or endanger health

Community Shared identities, relationships

Environment/Policy Policies, advocacy, environments and structures that impact on health

SOCIO-ECOLOGICAL FRAMEWORK (McLeroy et al 1988)


Evidence base conundrum

• Good quality trials successfully conducted, evaluating• Individually-focussed• Highly standardisedinterventions. Small or zero effect sizes; intervention-generated inequalities. Even where efficacious, not often translated / reproduced in real world.

• Theory-driven, complex, higher- and multiple-level interventions and policies poorly evidenced and continue to be under-evaluated.


10

Building Programsand Policies

with a Large Public Health Impact

Adoption

RE-AIM framework

EfficacyEffectiveness

Reach

Implementation

Maintenance


RECOMMENDED PURPOSE OF TRANSLATION/EFFECTIVENESS RESEARCH

• Reach large numbers of people, especially those who can most benefit

• Be widely adopted by different settings

• Be consistently implemented by staff members with moderate levels of training and expertise

• Produce replicable and long-lasting effects (and minimal negative impacts) at reasonable cost

Glasgow RE et al Am J Public Health. 2003;93:1261–1267

To determine the characteristics of interventions / policies / programmes that can:



Cynefin framework(Snowden and Boone, 2007)


Simple, complicated, complex…Simple

Flat pack furniture

Complicated

Rocket to the moon

Complex

Raising a child

The components and instructions are essential

Formulae are critical and necessary

Formulae have limited application. Adaptation and flexibility are key

If all the bits are there and instructions are followed in order, the result is consistent

Sending one rocket to the moon increases assurance that the next will be okay

Raising one child provides experience but no assurance of success with the next

No particular expertise is required but helpful to be good with an allen key

High levels of expertise in a variety of fields are necessary for success

Expertise can contribute but is neither necessary nor sufficient

Produces standardised furniture

Rockets are similar in critical ways

Every child is unique and must be understood and responded to as an individual

The designed furniture will be reproduced

There is a high degree of certainty of outcome

Uncertainty of outcome remains

Adapted from Rogers, 2008


Complexity theory

A system is said to be complex (as opposed to simple or complicated) when:

• It is composed of many elements which interact dynamically, and non-linearly.

• The behaviour of the system as a whole cannot be predicted from, or reduced to, the parts of the system in isolation.

• Volition, or agency, can come to be understood as a phenomenon of relationality, rather than being assumed to be originary [viz. automaticity]• New focus for “interventions” – create conditions

for change From Robin Durie


Automaticity……dual process theory

• Deliberation v automaticity• Reason v reaction• Reflective v habitual• Slow v fast

• Deliberative, reflective, reasoned behaviour represents a small minority of all behaviour

• Majority of behaviour is automatic, reactive, habitual

• Need to stop reliance on targeting reflective processes• Need to alter environments (physical, [social, cultural, economic,

media, policy])• Or target automatic associative processes (priming)

Marteau et al 2012, Kahneman 2011, Neal et al 2006


A focus on change

• Discipline-led focus on measuring, understanding, explaining behaviour• Psychology• Sociology• Epidemiology• Economics, organisational science, anthropology..

• May provide great insights in understanding behaviour• Not necessarily useful in delivering behaviour change

Phases of RCTs of complex interventions: MRC April 2000


A focus on change

• Discipline-led focus on measuring, understanding, explaining behaviour• Psychology• Sociology• Epidemiology• Economics, organisational science, anthropology..

• May provide great insights in understanding behaviour• Not necessarily useful in delivering behaviour change

• Interdisciplinary problem / solution driven is required• Focus on sustained change and all aspects of REAIM


Evidence base conundrum

• Good quality trials successfully conducted, evaluating• Individually-focussed• Highly standardisedinterventions. Small or zero effect sizes; intervention-generated inequalities. Even where efficacious, not often translated / reproduced in real world.

• Research methods and applied interdisciplinary research groups to develop sophisticated interventions that can achieve impact at scale

• Theory-driven, complex, higher- and multiple-level interventions and policies poorly evidenced and continue to be under-evaluated.

Behaviour change laboratory

Public health policy


Examples

• FFIT (Wyke et al Lancet 2014)

• Core programme materials informed by BC theories• Organisational context for delivery – football club• Gender specific throughout, with clear targeting (SES, BMI)• Social support, common bond of club• Effective and strong on all REAIM dimensions

• ASSIST school based smoking prevention (Campbell et al Lancet 2008)

• Core programme materials informed by BC theories• Identified most influential pupils• Who spread information, norms through social networks• Didn’t depend on curriculum time, teacher delivery• Quality assured licensing of external trainers


Population impact of hypothetical BCI

0.15 Behaviour is reflective

0.33 Relative risk reduction

0.2 Target population reached

0.2 Adopted by x% of Local Authorities

0.7 Fidelity of implementation


Population impact

0.15 Behaviour is reflective

0.33 Relative risk reduction

0.2 Target population reached

0.2 Adopted by x% of Local Authorities

0.7 Fidelity of implementation

0.0014

0.14%


Population impact

0.15 Behaviour is reflective 0.05

0.33 Relative risk reduction 0.1

0.2 Target population reached 0.1

0.2 Adopted by x% of Local Authorities 0.1

0.7 Fidelity of implementation 0.5

0.0014 0.000025

0.14% 0.0025%


Reliance on individual focussed BCIs


As much impact as astrand of cress in a

vindaloo



State responsibility for health and well-being

The success or failure of any government in the final analysis must be measured by the well-being of its citizens. Nothing can be more important to a state than its public health; the state’s paramount concern should be the health of its people.

Franklin D. Roosevelt

• If research agenda and evidence base is dominated by interventions that target the individual, those responsible for the environment / context / conditions for change get off the hook.


Ingredients?

• Flour, eggs, fat, milk, sugar• Bake-off cakes• Pancakes• Yorkshire pudding• Pastry• Bread……………………

• Masterchef• Standard ingredients challenge• Hugely varied dishes produced


Recipes are key [theories]

• How the ingredients are brought together• And delivered• Consistently• Cost effectively• At scale

• Not a fantastically complex recipe

• Greggs!• M&S ready meal


Recipes for sustained behaviour change at scale

• Can still develop focused understanding and action, but recognise that it is just one ingredient?

• Look outward, interdisciplinary• Look to the complex real world and less to the clean

laboratory• Look upstream• Look at behaviour change rather than simply behaviour• Understand and tackle processes, contexts, conditions that

determine population impact


Theory• Theory of the problem

• Causal processes• Intervention theory

• Key components and their impact [logic model]• Program (implementation) theory

• How will the intervention bring about change, interact with context, setting, system


Transdisciplinary solutions!


Variations

• Seafood paella• Vegetarian paella• Valencian paella• Mixed paella

• Select the right disciplines / team for the purpose


Making it happen

• What is the sofrito? (onion, tomato, garlic)• How to facilitate the combination of ingredients to

create a satisfying meal?• How to facilitate cross-disciplinary working to tackle

applied issues?• ..the rice….

• How to provide substance and glue to the meal / collaboration?


From disciplines to solutions……laboratory to policy

• Ingredients to recipes• Reductionist to big picture• Explanation to intervention

• Engage in interdisciplinary / transdisciplinary work• Or at least understand dependencies on other disciplines /

levels – contextualise

• Work with policy, practice, public partners throughout• Focus on not just efficacy / effectiveness, but reach,

adoption, implementation, maintenance

• More paella, less cress


Thank you……what’s for dinner?


• Marteau TM et al. Changing Human Behavior to Prevent Disease: The Importance of Targeting Automatic Processes Science 21 September 2012: Vol. 337 no. 6101 pp. 1492-1495 DOI: 10.1126/science.1226918

• Kahneman D. Thinking, Fast and Slow. Penguin Books• Neal DT et al (2006) Habits- a repeat performance https://

dornsifecms.usc.edu/assets/sites/208/docs/Neal.Wood.Quinn.2006.pdf• Rogers P. Using programme theory to evaluate complicated and complex

aspects of interventions. Evaluation 2008 14(1) 29-48 http://www.rismes.it/pdf/rogers_complex.pdf

• Snowden DJ Boone ME A leader’s framework for decision making. Harvard Business Review (2007) http://www.mpiweb.org/CMS/uploadedFiles/Article for Marketing - Mary Boone.pdf

https://dornsifecms.usc.edu/assets/sites/208/docs/Neal.Wood.Quinn.2006.pdf



http://www.rismes.it/pdf/rogers_complex.pdf



http://www.mpiweb.org/CMS/uploadedFiles/Article

http://www.mpiweb.org/CMS/uploadedFiles/Article

Health & Medicine

From behaviour change to public health improvement: re aiming our efforts