There is overwhelming evidence that changing people's health-related behaviour can have a major impact on some of the largest causes of mortality and morbidity. The Wanless report (Wanless 2004) outlined a position in the future in which levels of public engagement with health are high, and the use of preventive and primary care services are optimised, helping people to stay healthy. This 'fully engaged' scenario, identified in the report as the best option for future organisation and delivery of NHS services, requires changes in behaviours and their social, economic and environmental context to be at the heart of all disease prevention strategies.
Behaviour plays an important role in people's health (for example, smoking, poor diet, lack of exercise and sexual risk-taking can cause a large number of diseases). In addition, the evidence shows that different patterns of behaviour are deeply embedded in people's social and material circumstances, and their cultural context.
Interventions to change behaviour have enormous potential to alter current patterns of disease. A genetic predisposition to disease is difficult to alter. Social circumstances can also be difficult to change, at least in the short to medium term. By comparison, people's behaviour – as individuals and collectively – may be easier to change. However, many attempts to do this have been unsuccessful, or only partially successful. Often, this has been because they fail to take account of the theories and principles of successful planning, delivery and evaluation. At present, there is no strategic approach to behaviour change across government, the NHS or other sectors, and many different models, methods and theories are being used in an uncoordinated way.
Identifying effective approaches and strategies that benefit the population as a whole will enable public health practitioners, volunteers and researchers to operate more effectively, and achieve more health benefits with the available resources.
Social and economic position is directly linked to health. In the UK, there is a health inequalities gradient, with the least advantaged experiencing the worst health. Social and economic conditions can prevent people from changing their behaviour to improve their health, and can also reinforce behaviours that damage it.
Health inequalities are the result of a set of complex interactions, including:
the long-term effects of a disadvantaged social position
differences in access to information, services and resources
differences in exposure to risk
lack of control over one's own life circumstances
a health system that may reinforce social and economic inequalities.
These factors all affect people's ability to withstand the stressors – biological, social, psychological and economic – that can trigger ill health. They also affect the capacity to change behaviour.
Actions to bring about behaviour change may be delivered at individual, household, community or population levels using a variety of means or techniques. The outcomes do not necessarily occur at the same level as the intervention itself. For example, population-level interventions may affect individuals, and community- and family-level interventions may affect whole populations.
Significant events or transition points in people's lives present an important opportunity for intervening at some or all of the levels, because it is then that people often review their own behaviour and contact services. Typical transition points include: leaving school, entering the workforce, becoming a parent, becoming unemployed, retirement and bereavement.
This guidance provides a systematic, coherent and evidence-based approach, considering generic principles for changing people's health-related knowledge, attitudes and behaviour, at individual, community and population levels.
Strategies for reaching and working with disadvantaged groups are considered and the health equity implications assessed.