3 Recommendations

3 Recommendations

This document is the Institute's formal guidance on generic principles that should be used as the basis of initiatives to support attitude and behaviour change. When developing the principles the PDG (see appendix A) considered the evidence of effectiveness (including cost effectiveness), relevant theory, fieldwork data and comments from stakeholders. Full details are available on the Institute's website.

The reviews that informed this guidance are listed in appendix B. The evidence reviews, supporting evidence statements and economic appraisal are available on the Institute's website.

Key theories, concepts, and other evidence that informed this guidance are listed in appendix C.

On the basis of the evidence considered, the PDG believes that where interventions and programmes are applied appropriately, according to the principles outlined in this guidance and in conjunction with other topic-specific NICE guidance, then they are likely be cost effective. In some circumstances, they will save money.

For the research recommendations and other gaps in the evidence see section 5 and appendix D, respectively.

The guidance highlights the need to:

  • Plan carefully interventions and programmes aimed at changing behaviour, taking into account the local and national context and working in partnership with recipients. Interventions and programmes should be based on a sound knowledge of community needs and should build upon the existing skills and resources within a community.

  • Equip practitioners with the necessary competencies and skills to support behaviour change, using evidence-based tools. (Education providers should ensure courses for practitioners are based on theoretically informed, evidence-based best practice.)

  • Evaluate all behaviour change interventions and programmes, either locally or as part of a larger project. Wherever possible, evaluation should include an economic component.

Planning

Principle 1: planning interventions and programmes

Target audience

Policy makers, commissioners, service providers, practitioners and others whose work impacts on, or who wish to change, people's health-related behaviour.

Recommended action
  • Work in partnership with individuals, communities, organisations and populations to plan interventions and programmes to change health-related behaviour. The plan should:

    • be based on a needs assessment or knowledge of the target audience

    • take account of the circumstances in which people live, especially the socioeconomic and cultural context

    • aim to develop – and build on – people's strengths or 'assets' (that is, their skills, talents and capacity)

    • set out how the target population, community or group will be involved in the development, evaluation and implementation of the intervention or programme

    • specify the theoretical link between the intervention or programme and its outcome

    • set out which specific behaviours are to be targeted (for example, increasing levels of physical activity) and why

    • clearly justify any models that have been used to design and deliver an intervention or programme

    • assess potential barriers to change (for example, lack of access to affordable opportunities for physical activity, domestic responsibilities, or lack of information or resources) and how these might be addressed

    • set out which interventions or programmes will be delivered and for how long

    • describe the content of each intervention or programme

    • set out which processes and outcomes (at individual, community or population level) will be measured, and how

    • include provision for evaluation.

  • Prioritise interventions and programmes that:

    • are based on the best available evidence of efficacy and cost effectiveness

    • can be tailored to tackle the individual beliefs, attitudes, intentions, skills and knowledge associated with the target behaviours

    • are developed in collaboration with the target population, community or group and take account of lay wisdom about barriers and change (where possible)

    • are consistent with other local or national interventions and programmes (where they are based on the best available evidence)

    • use key life stages or times when people are more likely to be open to change (such as pregnancy, starting or leaving school and entering or leaving the workforce)

    • include provision for evaluation.

  • Disinvest in interventions or programmes if there is good evidence to suggest they are not effective.

  • Where there is poor or no evidence of effectiveness (or the evidence is mixed) ensure that interventions and programmes are properly evaluated whenever they are used.

  • Help to develop social approval for health-enhancing behaviours, in local communities and whole populations.

Principle 2: assessing social context

Target audience

NHS and non-NHS policy makers and commissioners planning behaviour change interventions or programmes for communities or populations, especially disadvantaged or excluded groups.

Recommended action
  • Identify and attempt to remove social, financial and environmental barriers that prevent people from making positive changes in their lives, for example, by tackling local poverty, employment or education issues.

  • Consider in detail the social and environmental context and how it could impact on the effectiveness of the intervention or programme.

  • Support structural improvements to help people who find it difficult to change, or who are not motivated. These improvements could include changes to the physical environment or to service delivery, access and provision.

Principle 3: education and training

Target audience

Policy makers, commissioners, trainers, service providers, curriculum developers and practitioners.

Recommended action
  • Provide training and support for those involved in changing people's health-related behaviour so that they can develop the full range of competencies required. These competencies include the ability to:

    • identify and assess evidence on behaviour change

    • understand the evidence on the psychological, social, economic and cultural determinants of behaviour

    • interpret relevant data on local or national needs and characteristics

    • design, implement and evaluate interventions and programmes

    • work in partnership with members of the target population(s) and those with local knowledge.

  • Appropriate national organisations (for example, the Faculty of Public Health, the British Psychological Society, the Chartered Institute of Environmental Health and the Nursing and Midwifery Council) should consider developing standards for these competencies and skills. The standards should take into account the different roles and responsibilities of practitioners working both within and outside the NHS.

  • Ensure fair and equitable access to education and training, to enable practitioners and volunteers who help people to change their health-related behaviour to develop their skills and competencies.

  • Review current education and training practice in this area, and disinvest in approaches that lack supporting evidence.

Delivery

Principle 4: individual-level interventions and programmes

Target audience

Commissioners, service providers and practitioners working with individuals.

Recommended action
  • Select interventions that motivate and support people to:

    • understand the short, medium and longer-term consequences of their health-related behaviours, for themselves and others

    • feel positive about the benefits of health-enhancing behaviours and changing their behaviour

    • plan their changes in terms of easy steps over time

    • recognise how their social contexts and relationships may affect their behaviour, and identify and plan for situations that might undermine the changes they are trying to make

    • plan explicit 'if–then' coping strategies to prevent relapse

    • make a personal commitment to adopt health-enhancing behaviours by setting (and recording) goals to undertake clearly defined behaviours, in particular contexts, over a specified time

    • share their behaviour change goals with others.

Principle 5: community-level interventions and programmes

Target audience

NHS and non-NHS policy makers and commissioners planning behaviour change interventions and programmes for communities or subgroups in the population.

Recommended action
  • Invest in interventions and programmes that identify and build on the strengths of individuals and communities and the relationships within communities. These include interventions and programmes to:

    • promote and develop positive parental skills and enhance relationships between children and their carers

    • improve self-efficacy

    • develop and maintain supportive social networks and nurturing relationships (for example, extended kinship networks and other ties)

    • support organisations and institutions that offer opportunities for local people to take part in the planning and delivery of services

    • support organisations and institutions that promote participation in leisure and voluntary activities

    • promote resilience and build skills, by promoting positive social networks and helping to develop relationships

    • promote access to the financial and material resources needed to facilitate behaviour change.

Principle 6: population-level interventions and programmes

Target audience

National policy makers, commissioners and others whose work impacts on population-level health-related behaviour.

Recommended action
  • Deliver population-level policies, interventions and programmes tailored to change specific, health-related behaviours. These should be based on information gathered about the context, needs and behaviours of the target population(s). They could include:

    • fiscal and legislative interventions

    • national and local advertising and mass media campaigns (for example, information campaigns, promotion of positive role models and general promotion of health-enhancing behaviours)

    • point of sale promotions and interventions (for example, working in partnership with private sector organisations to offer information, price reductions or other promotions).

  • Ensure population-level interventions and programmes aiming to change behaviour are consistent with those delivered to individuals and communities.

  • Ensure interventions and programmes are based on the best available evidence of effectiveness and cost effectiveness.

  • Ensure the risks, costs and benefits have been assessed for all target groups.

Evaluation

Principle 7: evaluating effectiveness

Target audience

Researchers, policy makers, commissioners, service providers and practitioners whose work impacts on, or who wish to change, people's health-related behaviour.

Recommended action
  • Ensure funding applications and project plans for new interventions and programmes include specific provision for evaluation and monitoring.

  • Ensure that, wherever possible, the following elements of behaviour change interventions and programmes are evaluated using appropriate process or outcome measures:

    • effectiveness

    • acceptability

    • feasibility

    • equity

    • safety.

Principle 8: assessing cost effectiveness

Target audience

Policy makers, research funders, researchers and health economists.

Recommended action
  • Collect data for cost-effectiveness analysis, including quality of life measures. Where practicable, estimate the cost savings (if any) when researching or evaluating behaviour change interventions and programmes. This is particularly pertinent for research:

    • on mid- to long-term behaviour change

    • comparing the effectiveness and efficiency of interventions and programmes delivered to different population groups (for example, low- versus high-income groups, men versus women, young versus older people)

    • comparing the cost effectiveness of primary prevention versus clinical treatment for behaviour-related diseases.