Evidence
How we made the decision
How we made the decision
We check our guidelines regularly to ensure they remain up to date. We based the decision on surveillance 10 years after the publication of behaviour change: general approaches (2007) NICE guideline PH6.
For details of the process and update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
Surveillance update decisions for the guideline are on our website.
New evidence from 10-year surveillance review on NICE guideline PH6
A literature search was undertaken to identify randomised controlled trials and systematic reviews published between 1 July 2012 to 14 June 2017 on behaviour change interventions that identified behaviour change techniques; and a focused literature search for any study published between 1 July 2012 and 8 June 2017 on choice architecture interventions[1] was also undertaken.
All relevant abstracts were assessed for their impact on the recommendations within NICE guideline PH6.
We reviewed studies highlighted by topic experts for any potential impact on the guideline scope and remit, with 7 studies (including 1 ongoing piece of research) meeting inclusion criteria. These are summarised in the evidence summary (appendix A).
We checked for ongoing and newly published research from NIHR and Cochrane as well as new policy developments. Two reports and 2 published studies were included as evidence, and 3 pieces of ongoing research were identified.
See appendix A: evidence summary for references and assessment of the abstracts for all new evidence considered.
Consideration of the evidence
We found a total of 61 new studies, 2 reports and 4 pieces of ongoing research through surveillance of this guideline. None of the evidence indicated that NICE guideline PH6 should be updated:
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We found 8 new studies on behaviour change interventions that identified behaviour change techniques in interventions involving children (an additional 49 studies were identified that were directly relevant to the related NICE guideline on behaviour change: individual approaches [NICE guideline PH49]). This evidence was not thought to have an effect on current recommendations in NICE guideline PH6.
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Forty-five new studies were identified on choice architecture interventions. While there is a sufficient body of evidence to develop recommendations on the use of choice architecture interventions for diet, there is insufficient evidence on the effectiveness of these interventions for any other behaviours. A previous surveillance review of the NICE guideline on preventing excess weight gain in 2017 recommended a partial update which should include consideration of evidence on choice architecture interventions such as packaging, individual unit or tableware size on consumption of food by adults and children. Because the evidence base on choice architecture interventions is specific to diet, we recommend that this evidence contributes to the update of NICE's guideline on preventing excess weight gain rather than an update of NICE guideline PH6, as the latter provides recommendations on interventions that are applicable across a range of behaviours.
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Ongoing research was identified on choice architecture interventions, understanding the mechanisms of change in group-based behaviour change interventions, effectiveness of mass media behaviour change campaigns and the costs and effects of public health programmes. Publications of this work will be looked at when NICE guideline PH6 undergoes its next surveillance review, if available.
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We found some new evidence related to a gap in the evidence that noted few studies explicitly address the comparative effects that behaviour change interventions can have on health inequalities, particularly in relation to cultural differences. This new evidence was not considered to fully address the gap in the evidence or affect current recommendations. We did not find any new evidence that related to other gaps in the evidence or research recommendations.
See appendix A for details of the evidence reviewed.
We did not find any new evidence related to 'Principle 3: education and training' or 'Principle 8: assessing cost effectiveness'.
Previous surveillance reviews:
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The first surveillance review in 2010 lead to the development of behaviour change: individual approaches (NICE guideline PH49). This updated (but did not replace) recommendations in NICE guideline PH6 that covered individual-level interventions (Principle 4: individual-level interventions and programmes).
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At the last surveillance review in 2014 it was recommended that the whole guideline should be reviewed and refreshed for terminology and contextual issues and that 'Principle 6: population-level interventions and programmes' should be fully updated to include new and emerging evidence on:
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choice architecture interventions (see above)
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mass media and social marketing
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social environments including the digital environment
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changes to the physical environment
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changes to the economic environment.
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At the time of the 10 year surveillance review, the update of NICE guideline PH6 proposed in 2014 had not yet been scheduled. As such, the above areas recommended for update were considered in the 10 year surveillance review:
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The literature search for the current surveillance review was not designed to specifically identify all population level behaviour change interventions. However initial intelligence gathering identified 2 Cochrane reviews on mass media behaviour change interventions which broadly support the use of mass media but indicates that the evidence-base on mass media campaigns currently appears limited. An ongoing piece of research on the effectiveness of mass media behaviour change campaigns was also identified. It is therefore recommended that this is not an area for update at this time.
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Literature relevant to technology and the digital environment was identified as part of the surveillance review for behaviour change: individual approaches (NICE guideline PH49).
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Evidence supporting the modification of the physical environment as a means of encouraging physical activity is being reviewed as part of the in-development NICE guideline physical activity and the environment (update), due to publish in March 2018.
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Policy level evidence concerning the economic environment that relates to the influence on behaviour from changes in pricing through minimum pricing and/or taxes of alcohol, high sugar/high fat foods, and tobacco products is no longer the remit of NICE.
Implementation
Nothing identified through implementation feedback indicates a need to update the guideline.
Equalities
No evidence has been found to indicate that the guideline does not comply with anti-discrimination and equalities legislation. During stakeholder consultation on NICE guideline PH6 one respondent noted the importance of retaining recommendations for research that address health inequalities.
Implications for other NICE programmes
There is a referred public health quality statement (QS): 'Programme management: effective ways to run public health programmes to generate a change in behaviour' which plans to use NICE guideline PH6 as a resource. The decision to not update NICE guideline PH6 should not have any implications on the development of this QS.
Views of topic experts
We considered the views of topic experts, including those who helped to develop the guideline and other correspondence we have received since the publication of the guideline. Two topic experts responded, both thought the guideline should be updated in line with the previous 2014 surveillance review recommendation. The following additional issues were highlighted by topic experts:
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New ways of evaluating evidence and cost-effectiveness, the importance of assessing intervention fidelity and Medical Research Council (MRC) guidance on process evaluation of complex interventions and on using natural experiments were highlighted. It is recommended that principle 7 on evaluating effectiveness refers to behaviour change: individual approaches (NICE guideline PH49), recommendation 16 which provides detailed recommendations on evaluating behaviour change interventions, including reference to intervention fidelity and reference to the MRC guidance on complex evaluations. The MRC reference on using natural experiments should also be added to principle 7.
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New theory concerning the impact of interventions on widening and narrowing inequalities was referenced. These were relevant to principle 2 on assessing social context and a gap in the evidence on the comparative effects that behaviour change interventions can have on health inequalities, however there remains a lack of evidence in this area.
Views of stakeholders
Stakeholders commented on the decision not to update the guideline.
See appendix B for stakeholder's comments and our responses.
Four stakeholder organisations responded to the consultation on the review proposal, 3 of whom agreed with the proposal not to update the guideline. One respondent disagreed with the proposal not to update the guideline on the basis that they felt NICE should issue guidance in the area of digital behaviour change interventions. Literature relevant to the technology and digital environment was identified as part of the surveillance review for behaviour change: individual approaches (NICE guideline PH49); please see the surveillance review decision from 2017 for this guideline for further details. No other areas were identified as requiring update in relation to NICE guideline PH6.
Additionally, Public Health England was contacted in order to get their feedback on the proposed surveillance decision. They noted that while NICE guideline PH6 is factually correct and that they did not disagree with the 'no update' decision, the behaviour change agenda is now broader: they noted that NICE guideline PH6 focuses on behaviour change within lifestyle risk factors and that the lack of guidance on system level behaviour change represents a gap in NICE's portfolio.
Overall decision
After considering all the new evidence, views of topic experts and related work in development within NICE, we are proposing that this guideline is not updated; but it should be refreshed with reference to behaviour change: individual approaches (NICE guideline PH49) and Medical Research Council guidance.
NICE Centre for Guidelines Surveillance project team
Kay Nolan
Associate Director
Emma McFarlane
Technical Advisor
Charlotte Haynes
Senior Technical Analyst
The NICE project team would like to thank the topic experts who participated in the surveillance process.
ISBN: 978-1-4731-2764-7
[1] Interventions which change the context in which someone will make a decision in order to influence how they act. For example, placing healthier snacks closer to a shop checkout and putting sugary and high-fat options out of reach may influence people to make a healthier choice because it is more accessible. Behaviour change approaches based on choice architecture are also referred to as 'nudge' or 'nudging' interventions.
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