Health Psychology and the future of
Public Health
Falko Sniehotta, PhD
Newcastle University
www.fuse.ac.uk
Why is health psychology relevant for Public Health?
Actual Causes of Death
Leading Causes of Death*
Actual Causes of Death†
Heart Disease
Tobacco
Cancer
Poor diet/lack of exercise
Stroke
Chronic lower
respiratory disease
Unintentional Injuries
Alcohol
Infectious agents
Pollutants/toxins
Firearms
Diabetes
Pneumonia/influenza
Alzheimer’s disease
Sexual behaviour
Kidney Disease
Illicit drug use
Motor vehicles
0
5
10
15
20
25
30
Percentage (of all deaths)
35
0
5
10
15
20
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.
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 evidencebased practice
– Knowledge Translation Gap
– Influence population behaviour
Structure of the evidence base
for behaviour
Interventions
change 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
Determinants of health
Where and how to intervene
Individual interventions
Societal 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
•
•
•
•
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
Structure of the evidence base
for behaviour
Interventions
change 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
Effects of behavioural interventions on
health
Interventions
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
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
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.
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
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)
MRC framework for development
and evaluation of complex
interventions
Phase IV
Phase III
Phase II
Phase I
Pre-clinical
Theory
Modelling
Exploratory trial
Definitive RCT
Cumulative knowledge base
Long term
implementation
Development & evaluation
of complex interventions
Craig P et al. (2008) BMJ 337, a1655
Warning
The next slide shows upsetting public
health campaign posters. You might
wish to close your eyes for a moment
The problem with behaviour change
•
Attempts to change people’s behaviour are often geared towards:
–
Raising Knowledge (lecturing)
•
–
Providing Advice (instructing)
•
–
“Did you know that…”
“Why don’t you…”
Motivating (scaring)
•
“If you don’t … then …”
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 coproduce relevant evidence?
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
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
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.
Simplifying theory: domains of
behavioural determinants
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Knowledge
Skills
Role and identity
•Self-efficacy
Beliefs about capabilities
•Control – of behaviour,
and material and social
Beliefs about consequences
environment
Motivation and goals
•Perceived competence
Memory, attention and decision processes•Self-confidence
•Empowerment
Environmental context and resources
•Self-esteem
Social influences
•Perceived behavioural
Emotion
control
•Optimism/pessimism
Plans
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.
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.
Identifying the evidence base:
My involvement in Systematic Reviews
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.
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.
Biomedicine vs behavioural science …
Example of smoking cessation effectiveness
Behavioural counselling
Varenicline JAMA, 2006
• Intervention
content
• Mechanism of action
Cochrane, 2005
• Intervention content
•
– Activity at a subtype of the
nicotinic receptor where its binding
produces agonistic activity, while
simultaneously preventing binding
to a4b2 receptors
– Review smoking history & motivation to
quit
– Help identify high risk situations
– Generate problem-solving strategies
– Non-specific support & encouragement
Mechanism of action
– None mentioned
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.
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
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
The person is asked to keep a
25.
Motivational
interviewing
record
of specified behaviour/s.
26.
ThisTime
could management
e.g. take the form of a
diary or completing a
questionnaire about their
behaviour.
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
The Behaviour Change Wheel
Behaviour source
Intervention type
Modelling
Environmental/
social planning
Policy type
Michie, van Straalen & West 2010
Physical
Reflective
Non reflective
Social
Psychological
Physical
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
Example 1:
A&E admission after Stroke
• People often delay
seeking medical help,
typically 3-6h
• Pre-hospital delay
prevents access to best
treatment
• Various reasons for delay including
clinical, contextual and cognitive
Teuschl et al., 2011
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
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
Act FAST Campaign
Recognition
(Face, Arm, Speech)
Response
(Time)
Call 999
Act FAST Campaign
Recognition
(Face, Arm, Speech)
Response
(Time)
Call 999
Research Question
Can people apply the FAST
acronym to recognise and
respond to stroke?
Study Design
5000 people randomly selected from
Electoral Roll from Newcastle upon
Tyne and randomised to two groups
n=2500
Questionnaire + FAST
leaflet
n=2500
Questionnaire
only
Reminder and 2nd pack sent after 2 and 8 weeks
Hypotheses
Leaflet group will have:
1.Better knowledge what FAST stands for
2.Better recognition of stroke
3.Better response to stroke
Results
• Familiar with Act FAST
100
90
80
70
60
Leaflet
50
No leaflet
40
30
20
10
0
Leaflet
No leaflet
The difference in
proportions is
significant, χ²(1,
1525) = 9.20,
p=.001
Results
• Knowledge of FAST elements
• FAST right: 66.1% vs. 45.3%, t(1613)=9.30,
p<.001, d=0.46
100
% correctly naming element
90
80
70
60
Leaflet
50
40
No leaflet
30
20
10
0
F correct
A correct
S correct
T correct
Results
• Response to stroke scenario
100
All 12 stroke scenarios
t(1601)=-1.0, p=.32, d=0.05
90
% correct response
80
70
60
50
Leaflet
40
No leaflet
30
20
10
0
All 12
FAST only
Non-FAST
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
What helps and
hinders
midwives in
engaging with
pregnant women
about stopping
smoking?
Smoking at time of delivery, by
region from 2004/05 to 2011/12
30%
Percentage
25%
England
North East
20%
North West
Yorkshire & Humber
15%
East Midlands
West Midlands
10%
East of England
5%
London
South East Coast
0%
South Central
South West
Year
Why?
 Service concerns
 Good evidence base
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
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
Workshop
Mean
domain
scores
(n=
364)
Mean domain scores (n=364)
Extent of agreement
Strongly 5
agree
4
3
2
1
Strongly 0
disagree
Domain
Trust Group Work
Trust name:
What are we doing well
– and should keep
doing?
1.
2.
3.
4.
How will we do this?
1.
2.
3.
4.
What are we going
to do?
1.
2.
3.
4.
And by when?
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
Concluding remarks
• Let’s 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
Acknowledgements
falko.sniehotta@ncl.ac.uk
The work was undertaken by Fuse, a UKCRC Public Health Research: Centre of Excellence. Funding from the British Heart
Foundation, Cancer Research UK, Economic and Social Research council, Medical Research Council, and the National Institute
for Health Research, under the auspices of the UK Clinical Research Collaboration, is greatly acknowledged.
Opinions expressed in this presentation do not necessarily represent those of the funders.
Spare slides
Buildings blocks of behaviour change
• Self-monitoring
• Awareness of standards
• Means and skills
Planning
• Action Planning
• Coping Planning
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Environment & Social influence
Increased likelihood of behaviour change
Self-regulation
Buildings blocks of behaviour change
• Self-monitoring
• Awareness of standards
• Means and skills
Planning
• Action Planning
• Coping Planning
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Environment & Social influence
Increased likelihood of behaviour change
Self-regulation
Buildings blocks of behaviour change
Implemental
phase
• Self-monitoring
• Awareness of standards
• Means and skills
Planning
• Action Planning
• Coping Planning
Decisional
phase
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Environment & Social influence
Increased likelihood of behaviour change
Self-regulation
Buildings blocks of behaviour change
Implemental
phase
• Self-monitoring
• Awareness of standards
• Having means and skills
How can I
change?
Planning
• Action Planning
• Coping Planning
Decisional
phase
Motivation
•Attitudes
•Perceived Norms
• Self-efficacy
•Emotion
Knowledge & Skills
Environment & Social influence
Would I like
to change?
Increased likelihood of behaviour change
Self-regulation
Intervention types
Education
Imparting knowledge e.g. on health risks
Persuasion
Incentivisation
Using communication to induce belief or
knowledge
Creating expectation of reward
Coercion
Creating expectation of punishment or cost
Training
Imparting skills
Restriction
Reducing availability
Environmental
restructuring
Modelling
Changing the physical context
Enablement/
resources
Increasing means/reducing barriers
Providing an example for people to aspire to
Policy types
Communication/
marketing
Guidelines
Fiscal
Regulation
Using print, electronic, telephonic or
broadcast media
Creating documents that recommend
or mandate practice
Using the tax system
Legislation
Establishing rules or principles of
behaviour or practice
Making or changing laws
Environmental/ social
planning
Service provision
Designing and/or controlling the
physical or social environment
Delivering a service
Persuasive communications and
targeted cognitions: UK safer sex leaflets
1. disease severity
2. knowledge/info
3. susceptibility
4. self-efficacy
5. others’ attitudes
1
2
3
4
5
6
7
6. attitudes to
behaviour
7. intention to
change
Impact on behaviour (correlation)
Average number of messages in UK health leaflets
Krahé, B., Dominic, R., & Fritsche, I. (2002). Does research into the social cognitive antecedents of action contribute to health
ontent analysis of safer-sex promotion leaflets. British Journal of Health Psychology, 7, 227-246.
Motivation theories
explain 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
Action theories
explain 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
Organisation theories
explain 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