Behaviour change and the health of England

Mildred Blaxter looks at two recent publications - The Health Profile of England 2007 and NICE public health guidance Behaviour Change at Population, Community and Individual Levels

Around 1970 the registrar general first commented on the way in which the causes and the social distribution of disease were changing. Mortality from the old ‘diseases of poverty’ - infections, TB - had tumbled. They were giving way to the new ‘diseases of affluence’, which rapidly became called ‘lifestyle diseases’ – diabetes, coronary disease, some cancers. The ‘old’ diseases did persist, primarily among those living in the poorest environments. But at the same time the ‘new’ diseases, some of which had at one time a reverse social class gradient, spread rapidly through all the population – and more rapidly among those who were more disadvantaged. Thus increases in inequality in health became headline news. Virtually all causes of death were now ‘unequal’, and since much ‘lifestyle’ disease depended on behavioural habits, health might be said to be in the individual’s own hands.

For the following decades, ‘you are responsible for your health’ was the rallying cry. As the DHSS consultative document of 1976 proclaimed, prevention and health are ‘everybody’s business’. The importance of individual responsibility was underlined by the setting of national targets for behavioural change in The Health of the Nation : a strategy for health in England (1992), where four of the six key areas of health highlighted in the national health improvement strategy related specifically to behaviour.

Over the years there was some resistance to this emphasis on individual lifestyle, because it seemed to be ‘blaming the victim’ to an unhelpful extent. The Wanless report, Securing Good Health For The Whole Population (2004), while noting that the health of the nation ‘depends on a high level of individual commitment to keeping healthy’, suggested also that an effective infrastructure was required both to support healthy choices and to change social norms in order to make healthy choices easier. However, the 2004 White Paper, Choosing Health – Making Healthy Choices Easier, continued to focus on the behavioural aspects of the health priorities.

The Health Profile of England 2007

It is against this background that the latest account of the health of the nation should be considered. The things that are highlighted are, indeed, the growth of some ‘lifestyle diseases’ and the report also notes the persistence of social and geographical inequality in health. It must not be overlooked, however, that overall the news is good. Life expectancy at birth for both men and women rises regularly each year. Deaths before old age from both cancer and circulatory disease are declining. Notably, road injuries and deaths declined by 58% in the last five years. Suicide rates are falling. There are changes, though slow, in behaviour:

- in five years, the prevalence of smoking has fallen from 25% to 22% among women and from 27% to 25% among men

- there are small falls in binge drinking among both men and women, though the level of alcohol consumed by adults is rising a little

- there is a slow rise in healthy eating, by the marker of “five-a-day”, over the last five years – from 25% to 30% among women and from 23% to 26% among men

- the proportions of schoolchildren who smoke, drink and misuse drugs have all reduced over five years (though consumption of alcohol among those who do drink is going up); physical activity in school is markedly increased from a year ago; and the “five-a-day” dietary habit, though still small, has risen from 13% to 17%

Against this generally positive background, the report points out some negative trends – the rise in the prevalence of diabetes; the rapid rise in chlamydia; the continued rise in HIV infection; in particular, the steady rise in obesity in both males and females and the remarkable increase in obesity among children: “the proportion of obese children rose by over 50% in the decade ending in 2005”.

The report also shows that, for health related behaviour, the United Kingdom is still placed near the bottom of league tables comparing the member states of the EU. Alcohol consumption is a little higher than the EU average, the availability of fruit and vegetables is below the EU average, smoking-related mortality is relatively high, and the UK still has the highest proportion of births to mothers aged under 20 of the original EU-15 countries. Obesity rates are the highest in the EU-15 countries and the third highest in the wider OECD countries, exceeded only by the United States and Mexico. The general message is that, despite the slow movement in favourable directions of many indicators, the aim must still be to speed up behaviour change, and extend it to all sections of the population.

Public health guidance on behaviour change

The task offered to public health is not an easy one, for the way to change lifestyle habits is not yet fully understood, and many attempts have failed or only partially succeeded. It is not a simple matter of providing information. Everyone wants good health, and it is clear now that most people know what healthy behaviour is. However, many do not find it easy to change. There is evidence that behavioural patterns can be shifted, but change happens unevenly in populations. Some groups get left behind, and we need to know how best to reach everybody.

This is the theme and objective of a recently published NICE public health guidance – Behaviour Change at Population, Community and Individual Levels (NICE public health guidance no. 6, at http://guidance.nice.org.uk/PH006). This guidance is directed at a wide range of practitioners and policy makers in the NHS, and also in other public bodies and the voluntary sector – everyone who is concerned with promoting health.

The document offers general principles rather than guidance on specific topics, since it cannot be assumed that ‘one size fits all’ – no single method of promoting change can be universally applied to all sorts of people and all areas of life. It is meant to be read in conjunction with other topic-specific public health intervention and programme guidance issued by NICE. Primarily, the guidance argues that at present there is no strategic approach or generally applied principles across all the different levels, governmental and local, statutory and voluntary. A great deal of health promotion activity takes place, but it is often uncoordinated and not always evidence based.

At the level of public health, the recommendations stress particularly the importance of: - taking into account the social and environmental context building on the strengths of individuals and communities, and trying to ensure that local health education initiatives are joined up with national campaigns and policies.

- developing and maintaining supportive social networks and relationships, and working in partnership with local organizations and institutions in the planning and delivery of services that support health-promoting behaviour

- basing plans on needs assessments, with particular emphasis on removing barriers to change (e.g. the availability for healthy choices, changes to the physical environment, access to help)

- attempting to ensure that plans address health inequalities, recognizing that health education can have differential effects among different groups of the population that in fact increase inequality

- at the level of working with individuals, using key stages of life when people are most likely to be receptive to change (such as pregnancy, and entering or leaving school or the workforce), helping those who find change difficult to understand the consequences of their actions and feel positive about the benefits of change, and offering coping strategies to prevent them relapsing

- reviewing local education and training in this area, and ensuring that practitioners and volunteers have access to training and support

The guidance stresses the importance of evaluating the results of any initiatives or campaigns, pointing to the fact that they can very often be extremely cost-effective, though this may be difficult to calculate in a conventional way.

In general, the conclusions of the guidance may be welcomed as reinforcing many of the principles that already drive public health. ‘Evidence based’ public health is both possible and desirable, but in the area of behaviour change there are special difficulties – partly because the area is so complex and partly because so many different professions, models, and types of theory can be involved. A feature of the guidance is that, unusually, many different disciplines have worked together to examine the different sorts of evidence. It can be hoped that it will provide a supportive and coherent approach for all those involved in attempting to change the attitudes, habits and lifestyles that crucially affect the nation’s health profile.

Mildred Blaxter is a member of the Department of Social Medicine, University of Bristol and chair for NICE of the Programme Development Group for the Behaviour Change guidance