Health Psychology and the future of Public Health

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Health Psychology and the future of Public Health

• Falko Sniehotta, PhD
• Newcastle University

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Why is health psychology relevant for Public
Health? Actual Causes of Death
Minino AM, Arias E, Kochanek KD, Murphy SL,
Smith BL. Deaths final data for 2000. National
Vital Statistics Reports 2002 50(15)1-20. Mokda
d AH, Marks JS, Stroup DF, Gerberding JL. Actual
causes of death in the United States, 2000. JAMA.
2004291 (10) 1238-1246.
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Foci of behaviour change interventions

• general 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

4
Structure of the evidence base for behaviour
change interventions
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
5
Determinants of health
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Where and how to intervene

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

• Individual 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

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
7
Structure of the evidence base for behaviour
change interventions
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
8
Effects of behavioural interventions on health

• Good 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

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
9
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 200144119-127.
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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

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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)
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MRC framework for development and evaluation of
complex interventions
Cumulative knowledge base
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Development evaluationof complex interventions
Craig P et al. (2008) BMJ 337, a1655
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Warning

• The next slide shows upsetting public health
  campaign posters. You might wish to close your
  eyes for a moment

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The problem with behaviour change

• Attempts to change peoples behaviour are often
  geared towards
• Raising Knowledge (lecturing)
• Did you know that
• Providing Advice (instructing)
• Why dont you
• Motivating (scaring)
• If you dont then

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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 dont listen to psychologists?
• A lack of sustainable infrastructure to
  co-produce relevant evidence?

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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
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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

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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.
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Simplifying theory domains of behavioural
determinants

1. Knowledge
2. Skills
3. Role and identity
4. Beliefs about capabilities
5. Beliefs about consequences
6. Motivation and goals
7. Memory, attention and decision processes
8. Environmental context and resources
9. Social influences
10. Emotion
11. Plans

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

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.
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Progress in theorisingthe 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.
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Identifying the evidence base My involvement in
Systematic Reviews
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Identifying the evidence baseProblems 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 peoples health behaviour.

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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.
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Biomedicine vs behavioural science Example of
smoking cessation effectiveness
Varenicline JAMA, 2006
Behavioural counselling Cochrane, 2005

• 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

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Behaviour change techniques reliable taxonomy
to change physical activity and healthy eating
behaviours
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.
15. General encouragement 16. Contingent
rewards 17. Teach to use cues 18. Follow up
prompts 19. Social comparison 20. Social
support/ change 21. Role model 22. Prompt self
talk 23. Relapse prevention 24. Stress
management 25. Motivational interviewing 26.
Time management

• 1. General information
• 2. Information on consequences
• 3. Information about approval
• 4. Prompt intention formation
• 5. Specific goal setting
• 6. Graded tasks
• 7. Barrier identification
• 8. Behavioral contract
• 9. Review goals
• 10. Provide instruction
• 11. Model/ demonstrate
• 12. Prompt practice
• 13. Prompt monitoring
• 14. Provide feedback

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.
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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
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The Behaviour Change Wheel
Behaviour source
Service provision
Regulation
Intervention type
Modelling
Training
Education
Policy type
Fiscal
Restriction
Persuasion
Capability
Physical
Psychol- ogical
Reflec- tive
Environmental/ social planning
Motivation
Coercion
Physical
Non reflect- ive
Incentivisation
Social
Opportunity
Legislation
Environmental restructuring
Enablement/ resources
Guidelines
Communication/marketing
Michie, van Straalen West 2010
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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

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Example 1 AE 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

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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

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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

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Act FAST Campaign
Recognition (Face, Arm, Speech)
Response (Time)
Call 999
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Act FAST Campaign
Recognition (Face, Arm, Speech)
Response (Time)
Call 999
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Research Question

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

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Study Design
5000 people randomly selected from Electoral Roll
from Newcastle upon Tyne and randomised to two
groups
n2500 Questionnaire FAST leaflet
n2500 Questionnaire only

• Reminder and 2nd pack sent after 2 and 8 weeks

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Hypotheses

• Leaflet group will have
• Better knowledge what FAST stands for
• Better recognition of stroke
• Better response to stroke

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Results

• Familiar with Act FAST

The difference in proportions is significant,
?²(1, 1525) 9.20, p.001
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Results

• Knowledge of FAST elements
• FAST right 66.1 vs. 45.3, t(1613)9.30,
  plt.001, d0.46

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Results

• Response to stroke scenario

All 12 stroke scenarios t(1601)-1.0, p.32,
d0.05
FAST scenarios only t(1609)-1. 05, p.30, d0.05
Non-FAST scenarios only t(1608)-0.63, p.53,
d0.03
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What helps and hinders midwives in engaging with
pregnant women about stopping smoking?
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Smoking at time of delivery, by region from
2004/05 to 2011/12
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Why?

• Service concerns
• Good evidence base

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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

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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

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Workshop
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Mean domain scores (n 364)
Mean domain scores (n364)
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Trust Group Work
Trust name
What are we going to do?
What are we doing well and should keep doing?
1. 2. 3. 4.
1. 2. 3. 4.
How will we do this?
And by when?
1. 2. 3. 4.
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babyClear systematic approach

• 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

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Concluding remarks

• Lets 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

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• falko.sniehotta_at_ncl.ac.uk

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Spare slides
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Buildings blocks of behaviour change

• Self-regulation
• Self-monitoring
• Awareness of standards
• Means and skills

Increased likelihood of behaviour change

• Planning
• Action Planning
• Coping Planning

• Motivation
• Attitudes
• Perceived Norms
• Self-efficacy
• Emotion

Knowledge Skills
Environment Social influence
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Buildings blocks of behaviour change

• Self-regulation
• Self-monitoring
• Awareness of standards
• Means and skills

Increased likelihood of behaviour change

• Planning
• Action Planning
• Coping Planning

• Motivation
• Attitudes
• Perceived Norms
• Self-efficacy
• Emotion

Knowledge Skills
Environment Social influence
57
Buildings blocks of behaviour change

• Self-regulation
• Self-monitoring
• Awareness of standards
• Means and skills

Increased likelihood of behaviour change

• Planning
• Action Planning
• Coping Planning

Implemental phase

• Motivation
• Attitudes
• Perceived Norms
• Self-efficacy
• Emotion

Decisional phase
Knowledge Skills
Environment Social influence
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Buildings blocks of behaviour change

• Self-regulation
• Self-monitoring
• Awareness of standards
• Having means and skills

Increased likelihood of behaviour change

• Planning
• Action Planning
• Coping Planning

Implemental phase
How can I change?

• Motivation
• Attitudes
• Perceived Norms
• Self-efficacy
• Emotion

Decisional phase
Would I like to change?
Knowledge Skills
Environment Social influence
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Intervention types Intervention types Intervention types Intervention types
Education 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
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Policy types Policy types Policy types Policy types
Communication/ 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
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Persuasive communications and targeted
cognitions UK safer sex leaflets

1. disease severity
2. knowledge/info
3. susceptibility
4. self-efficacy
5. others attitudes
6. attitudes to behaviour
7. intention to change

1 2 3 4 5 6
7

Impact on behaviour (correlation)
Average number of messages in UK health 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.
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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

63
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

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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