Health Psychology and the future of Public Health

1. Health Psychology and the future of Public Health Falko Sniehotta, PhD Newcastle University

2. Why is health psychology relevant for Public Health? Actual Causes of Death Actual Causes of Death† Leading Causes of Death* Heart Disease Tobacco Cancer Poor diet/lack of exercise Stroke Alcohol Infectious agents Chronic lower respiratory disease Unintentional Injuries Pollutants/toxins Firearms Diabetes Sexual behaviour Pneumonia/influenza Alzheimer’s disease Motor vehicles Kidney Disease Illicit drug use Percentage (of all deaths) Percentage (of all deaths) *Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-20. †Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291 (10): 1238-1246.

3. 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 Foci of behaviour change interventions

4. Structure of the evidence base for behaviour change interventions Interventions Behavioural determinants e.g. cognitive, social, motivational & environmental Behaviour e.g., exercise; physical activity Physiological & biochemical variables e.g. neurological & muscular processes Health outcomes health, mobility and quality of life 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

6. Where and how to intervene Individualinterventions 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 Societalinterventions attitudes and culture Choice architecture (nudging) incentive structures restrict or enhance opportunities 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 Interventions Behavioural determinants e.g. cognitive, social, motivational & environmental Behaviour e.g., exercise; physical activity Physiological & biochemical variables e.g. neurological & muscular processes Health outcomes health, mobility and quality of life 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 Interventions Behavioural determinants e.g. cognitive, social, motivational & environmental Behaviour e.g., exercise; physical activity Physiological & biochemical variables e.g. neurological & muscular processes Health outcomes health, mobility and quality of life • 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 2001;44:119-127.

10. 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

11. Features of Behaviour Change interventions Behaviour change techniques (BCTs), e.g., prompt goal setting or self-monitoring of behaviour Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc Theory: theoretical mediators, rationale for combining elements, cover story of intervention 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)

12. MRC framework for development and evaluation of complex interventions Cumulative knowledge base

13. Development & evaluationof complex interventions Craig Pet al. (2008) BMJ 337, a1655

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

16. The problem with behaviour change Attempts to change people’s behaviour are often geared towards: Raising Knowledge (lecturing) “Did you know that…” Providing Advice (instructing) “Why don’t you…” Motivating (scaring) “If you don’t … then …”

17. 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 don’t listen to psychologists? • A lack of sustainable infrastructure to co-produce relevant evidence?

18. 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

19. 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

20. 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.

21. Simplifying theory: domains of behavioural determinants Knowledge Skills Role and identity Beliefs about capabilities Beliefs about consequences Motivation and goals Memory, attention and decision processes Environmental context and resources Social influences Emotion 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.

22. Progress in theorising:the 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.

23. Identifying the evidence base: My involvement in Systematic Reviews

24. Identifying the evidence base:Problems 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 people’s health behaviour.

25. 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.

26. Biomedicine vs behavioural science …Example of smoking cessation effectiveness • 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 • VareniclineJAMA, 2006 • Behavioural counselling Cochrane, 2005 • 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

27. Behaviour change techniques: reliable taxonomyto change physical activity and healthy eating behaviours 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 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 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.

28. Identifying Effective Change Techniques in Interventions Designed to Promote Physical Activity and Healthy Eating Michie S, et al (2009) Identifying Effective Techniques in Interventions: A meta-analysis and meta-regression Health Psychology • 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

29. The Behaviour Change Wheel Behaviour source Service provision Regulation Intervention type Modelling Training Education Policy type Fiscal Restriction Persuasion Capability Physical Reflec- tive Psychol- ogical 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

30. 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

31. Example 1: A&E 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

32. 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

33. 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

34. Act FAST Campaign Recognition (Face, Arm, Speech) Response (Time) Call 999

35. Act FAST Campaign Recognition (Face, Arm, Speech) Response (Time) Call 999

36. Research Question Can people apply the FAST acronym to recognise and respond to stroke?

37. Study Design 5000 people randomly selected from Electoral Roll from Newcastle upon Tyne and randomised to two groups Reminder and 2nd pack sent after 2 and 8 weeks n=2500 Questionnaire + FAST leaflet n=2500 Questionnaire only

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

39. Results • Familiar with Act FAST The difference in proportions is significant, χ²(1, 1525) = 9.20, p=.001

40. Results • Knowledge of FAST elements • FAST right: 66.1% vs. 45.3%, t(1613)=9.30, p<.001, d=0.46

41. Results • Response to stroke scenario All 12 stroke scenarios t(1601)=-1.0, p=.32, d=0.05 FAST scenarios only t(1609)=-1. 05, p=.30, d=0.05 Non-FAST scenarios only t(1608)=-0.63, p=.53, d=0.03

42. Why? What helps and hinders midwives in engaging with pregnant women about stopping smoking? Findings What and how? Implications

43. Smoking at time of delivery, by region from 2004/05 to 2011/12

44. Why? • Service concerns • Good evidence base

45. 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 NICE guidance – behaviours described for health professionals

46. 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 What & How?

48. Workshop Helping pregnant women to stop smoking What are your views? Questionnaire for Midwives Private and Confidential

49. Mean domain scores (n=364) Mean domain scores (n= 364)

50. 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.