Behaviour change:
NICE public health
Antony Morgan (on behalf of Catherine
Associate Director
Centre for Public Health Excellence
• NICE public health guidance
• Changing behaviour
• Discussion
Audiences for public health
• The NHS
• Local government
• The workplace
• Education
• The utilities
• Private and voluntary
• Other arms of government
• The public
CPHE: context
A Health Map, Barton and Grant 2006 concept by Whitehead and Dahlgren 1991
CPHE: conceptual
CPHE Methods 2009 and Kelly et al (Public Health 123; 1, pp e14-20) 2009
The life course approach.
Critical points on life’s journey.
Those critical points are like gateways.
Different for different groups.
The direction people go at each gateway has a
profound effect on their future.
• A cumulative profit and loss health account.
Centre for Public Health
Produces two types of public health guidance:
• Intervention guidance
• Programme guidance
Intervention guidance
• Focus on local, clearly circumscribed actions aiming to
reduce the risk of developing a disease or condition, or
that help to promote or maintain good health.
• Usually delivered by front line staff, targeted at certain
populations, communities or individuals, e.g.:
– The most effective school-based method of
preventing children and young people from smoking
• Just over one year to develop
• Public Health Interventions Advisory Committee
Programme guidance
• Provides a multi- agency and multi-faceted package
of policies, services and interventions.
• May be topic, setting or population –based and may
involve changes to organisational infrastructure, e.g.:
– management of long-term sickness and incapacity
for work, for primary care and employers.
– the nutrition of pregnant and breastfeeding mothers
and children in low-income households
– Prevention of cardiovascular disease at population
• Emphasis on preventive, population-based approaches
• 18 - 24 Months
• Programme Development Groups (PDG)
2005 referral from the
Department of Health:
‘The most appropriate means of generic and
specific interventions to support attitude and
behaviour change at population and
community levels’
Policy context:
• A community of public health workers engaged day-today in processes (often) aimed at changing behaviour
• The public health white paper ‘Choosing Health’ (DH,
2004): Emphasis on ‘informed choice’ and effective
mechanisms for achieving change
• Wanless report (2002): Signalled the need to strike an
informed balance between clinical and public health
• Cabinet Office discussion paper, Halpern et al (2004):
Sophisticated approaches to supporting behaviour
change could enhance government policy, & positively
influence public behaviour
The need for guidance on
behaviour change:
• Public health activities frequently directed towards
• Public health interventions tend to be more effective
when delivered from within a coherent theoretical
• Many different models and approaches aimed at
promoting or supporting knowledge, attitude and
behaviour change exist
• Predictive power of models is often limited, and many
have been criticised for other limitations
Need for guidance continued:
• Health is experienced – and produced – at individual,
group (community) and population levels, through
complex interactions between biological, psychological
and social factors.
• Public health interventions can operate at any one (or
more) of these levels
• Key life-points or transitions (e.g. pregnancy,
bereavement, entering the workforce) may optimise
the potential for change, or make change particularly
unlikely – and different approaches may be required
Who does what?
NICE – manages the overall production of the guidance
(evidence, Programme Development Group,
consultation, publication and dissemination,
PDG - independent advisory committee of professional,
practice and ‘lay’ experts, consider the evidence, have
formal responsibility for developing the guidance
Collaborating Centre (CC) – use established NICE
methods and processes to collate and synthesise
-develop scope (clarification, review,
-appoint PDG
-reviews of effectiveness and cost effectiveness
-economic analysis
- draft guidance
-QRG and full guidance
Key questions
• What is effective? And how?
• What is ineffective? And what should we disinvest
• What is harmful or dangerous?
• What is cost effective? What is the business case
for public health and which interventions give the
best return on investment – in the very short, short
and long term
Reviews of effectiveness
Stirling, Cardiff, London
A review of the effectiveness of interventions,
approaches and models at individual, community
and population level that are aimed at changing
health outcomes through changing knowledge,
attitudes or behaviour
Review of the effectiveness of road-safety and
pro-environmental interventions
Resilience, coping and salutogenic approaches
to maintaining and generating health: a review
A review of the use of the health belief model
(HBM), the theory of reasoned action (TRA), the
theory of planned behaviour (TPB), and the
trans-theoretical model (TTM) to study and
predict health-related behaviour change
The influence of social and cultural context on the
effectiveness of health behaviour change
interventions in relation to diet, exercise and
smoking cessation
Social Marketing: a review
Expert report: Evidence for the effect on
inequalities in health of interventions designed to
change behaviour
Cost effectiveness review: The cost-effectiveness
of behaviour change interventions designed to
reduce coronary heart disease: a thorough
review of existing literature
Economic analysis: The cost-effectiveness of
population level interventions to lower cholesterol
and prevent coronary heart disease:
extrapolation and modelling results on promoting
healthy eating habits from Norway to the UK
Despite sometimes a weak evidence
• Still possible to produce recommendations that support
the improvement of standards in practice through:
– Mix method approaches to collecting and collating
– Expert opinion
– Lay knowledge
– Stakeholder testing and validation
Community and service user perspectives
• What are the important
outcomes to service users
and carers?
• What are their views about
specific interventions or
• What have their experiences
of accessing services and
treatments been like?
NICE Guidance on Effective
Community Engagement
‘What community engagement
approaches and methods are
effective and cost effective in
improving health and reducing
health inequalities’
Development: drafting the
• Programme Development Group: Meet 10-12 times
• Recommendations
– strength and applicability of evidence
– cost effectiveness
– impact, including on inequalities in health
– risks, benefits
– implementability
Recommendations - principles
• Principle 1: planning
• Principle 2: social context
• Principle 3: education and training
• Principle 4: individuals
• Principle 5: communities
• Principle 6: populations
• Principle 7: effectiveness
• Principle 8: cost effectiveness
• Work in partnership with individuals, communities,
organisations and populations to develop plans for the
target audience based on their needs and the
challenges facing them
• Take people’s circumstances into account (especially
the socioeconomic and cultural context)
• Prioritise evidence-based approaches that can be
tailored and used at key times when people are likely to
be open to change
Social context
• Identify and try to remove social, financial and
environmental barriers to change
• Take into account the social and environmental context
• Support changes to the physical environment or the
way services are delivered to help those who find it
difficult (or who are not motivated) to change
Education and training
• Review current education and training practice in this
area, and disinvest in approaches that lack supporting
• Ensure practitioners and volunteers have fair and equal
access to training and support
• Relevant national organisations should consider
developing standards for these skills
Working with individuals:
Work with people to –
• understand the consequences of their behaviour and
feel positive about changing it to benefit their health
• make a personal commitment to health-enhancing
behaviours by setting goals and sharing these goals
with others
• plan change in easy steps and develop coping
strategies to take account of social situations that may
lead to relapse
Working with communities:
Invest in approaches that:
• develop and maintain supportive social networks and
relationships and build people’s resilience and skills
• promote and support positive relationships between
children and their parents or carers
• help organisations and institutions to promote local
in planning and delivering services and to participate
voluntary activities
• promote access to the financial and material
needed to help people make changes to improve
their health
Working with populations
• Use the needs and behaviours of the target population
as the basis for all interventions and programmes
• Ensure population-based activities complement those
delivered to individuals and communities
• Ensure population-based activities are assessed in
terms of the risks, costs and benefits for all target
Effectiveness – evaluation and
learning from experience
• Ensure funding applications and project plans include
specific provision for evaluation and monitoring
• Ensure appropriate process and outcome measures are
Cost effectiveness:
• Collect data for cost-effectiveness analysis, including
quality of life measures
• When researching or evaluating interventions and
programmes estimate the cost savings involved (for
instance, the cost of primary prevention versus clinical
Implementing the principles:
• Some aspects, such as training and evaluation, will
involve extra cost
• However, effective interventions should lead to cost
savings within the NHS and other public sector
organisations in the longer term
Since publication
• Lots of other organisations have become interested in
behaviour change –
– Thaler, RH & Sunstein, CR (2008) Nudge: improving
decisions about health, wealth and happiness. Yale
University Press
– Institute for Government (2010) Mindspace:
influencing behaviour through public policy. Cabinet
• We are about to begin the review and revision process
Experience teaches us that:
• It is generally quite hard to change individuals behaviour, working
one-to-one in a conscious process aimed at change
• Individual approaches can work – when appropriately intense,
sustained, targeted, signposted
• It can be easier and cheaper to work at community or population
level, and / or focus on changing the systems, environment and
opportunities around people
• The process of change can be slow – don’t expect miracles
(although they can happen)
• Intervening simultaneously at different levels, with coherent
messages and reinforcing information and education with policy
and environmental changes is a good idea

Antony Morgan presentation 16 11 10