An overview of population-level behavioural science interventions that improve health in a way that is fair to everybody, with reflections from Dr Robb Rutledge. This blog is part of a series for the 2019 Rosenthal symposium: Behaviour change to improve health for all.
How to improve the health of an entire population while reducing health inequity?
Population-level interventions to improve health are delivered to everyone in a given population, regardless of their individual risk of developing a disease or condition of interest. The ambition is to improve the overall health of an entire population.
However, many of the most intractable health conditions facing populations around the world – obesity, excessive drug and alcohol use for example – arise as the result of a complex interaction between socioeconomic, cultural, behavioural, and environmental factors and biological effects. Each person experiences these factors differently.
How effective, equitable behavioural interventions can be achieved for whole populations was the focus of the second session of the 2019 Rosenthal symposium.
Helping populations make good choices: the value of simplicity
Every decision you make is influenced by a huge number of different social and environmental cues. Even the seemingly trivial task of deciding what to eat is not just a matter of picking something you think tastes nice. Your cultural upbringing and engrained opinions on what a ‘good choice’ looks like will influence your decision, as will a huge range of other environmental considerations, from advertising to cost, to what your friends are choosing. These often competing pressures mean that many people overconsume food and drink too many sugary drinks and alcohol. One way to address this, with the aim of addressing rising levels of obesity, is to change the environment to make it easier for people to engage in healthy behaviours.
As discussed by Professor Martin White, there are many population-level initiatives that aim to do just this by ‘resetting the system in which people make decisions’. Examples include minimum alcohol unit pricing, the ban on smoking in public places, and those directed at the commercial sector to reduce portion sizes and sugar content, to name just a few. Other measures focus less on removing an influence but aim to ‘add something’ to help promote the health of a population, such as including folic acid in flour and fluoride in tap water. Such population-level interventions can be a particularly effective way of reducing health inequalities and are often more effective than individual-focussed interventions.
Take, for example, the traffic light system on food packaging. Providing such information can help people make better food choices and maintain a healthy weight, but relies on people not only actively choosing to read the information but also understanding how to apply it to themselves.
If people of lower socioeconomic background are more likely to have difficulty understanding food packaging, they will be unable to benefit from the intervention, widening health inequalities. Instead of placing the onus on individuals to avoid risky behaviour, interventions that instead simplify the environment to reduce the number of difficult decisions you have to make can have the most far-reaching impact in improving health across an entire population.
Helping people to make good choices: the value of seizing the moment and simple instructions
Albeit it to varying degrees, many people know how to improve their health – whether it is making better food choices or reducing the amount they drink or smoke. However, knowing something and acting on that knowledge are often two different things. Motivations wane and other priorities take over. This can often mean that GPs are reluctant to give behavioural advice to patients, believing that while they might be receptive to it at the time, they will not act on it once they have gone back home.
But, as Professor Paul Aveyard explained in his presentation, GPs should take better advantage of the fact that the patient is in the room with them. Instead of simply providing advice or a leaflet of information, offering a practical way forward that encourages patients to initiate some sort of action ‘right then and there’ can have more value.
Referring to this as ‘the underused behavioural technique of simply acting in the moment’, Professor Aveyard noted that ‘we will, and can, achieve good things provided someone else arranges for us to do so.’
For example, evidence shows that patients who are signed up to stop-smoking classes by their GP are twice as likely to quit as those who are simply advised to do so on health grounds. The same effect is seen in overweight patients signed up to weight-loss support groups.
Evidence also shows that people are more likely to succeed if they are offered clear, simple instructions to follow. While this might not appeal to everyone, weight-loss groups that rely on ‘rules simplified to the maximum’ – such as only eat this, do not eat that – are on average more successful than approaches that aim to educate people about the types of food you should avoid. Behaviour change interventions that reduce the need for people to make difficult decisions about their own health can often be the most effective.
How a healthy lifestyle can prevent diabetes
In the US, one in 10 people are currently living with type 2 diabetes, and a further one in three have pre-diabetes, meaning they are expected to develop diabetes within five years. These are stark figures but since type 2 diabetes is mediated in large part by lifestyle, it follows that behavioural interventions could have immense value.
Encouragingly, this has been borne out in the findings of the US Diabetes Prevention Program, which shows that a lifestyle intervention to encourage weight loss through diet changes and physical activity is capable of preventing type 2 diabetes more successfully than a commonly used pharmaceutical intervention, metformin. A lifestyle intervention can cut the risk of developing type 2 diabetes by 58%, a figure that increases to 71% for people over 60 years old.
While diabetes is common, differences in the risk and burden of the condition occur because of the interactions between social and environmental factors. It therefore follows that efforts to stem the increasing number of new cases of type 2 diabetes could have an important knock-on effect of reducing health inequities, especially when an effort is made to be convenient and accessible to those of all backgrounds. It is exciting to see that, despite still being early days, the success of the US Diabetes Prevention Program may help flatten the nation's diabetes incidence.
How to practice what we preach and give everyone a voice
The success of programs such as the US Diabetes Prevention Program are a helpful reminder of the immense value an effective behaviour change intervention can have when done in the right way. It is especially frustrating that, despite this evidence and increasing understanding of behavioural science, many nations continue to struggle with excessive drug and alcohol use, a lack physical activity, and the overconsumption of unhealthy foods and high-sugar beverages. Why is this the case and how can we better tackle these issues? If we are able to generate evidence about how to alter behaviour, what are the challenges standing in the way of implementing it?
As discussed by Professor Marlene Schwartz, one way forward may be to ensure that everyone has a voice when devising research questions and developing public policies. This is important as while population-level polices should of course be rooted in scientific evidence, they are also moulded by the different incentives and priorities of various interest groups and commercial organisations, lobbying activities, and rapidly changing political priorities. However, rather than seeing these as a hindrance to the translation of evidence, researchers could improve the impact of their work by engaging with such organisations early on in the research process to make sure that a balance is found.
Reflections from the Chair
“I was delighted to chair the second session of the Rosenthal Symposium 2019, which heard from four speakers. Each drew on their expertise and experience to highlight the potential of behavioural science to improve population health for all, suggesting that, when done well, simple behavioural interventions can have dramatic effects.
Dr Robb Rutledge is an MRC Career Development Fellow at the Max Planck UCL Centre for Computational Psychiatry and Ageing Research at University College London.
On 17 January 2019, the UK Academy of Medical Sciences and U.S. National Academy of Medicine held a one-day symposium titled ‘Behaviour change to improve health for all.’ Read more about behaviour change and the 2019 Rosenthal symposium here. This blog reflects the views expressed by participants at the meeting but does not necessarily represent the views of all participants, all members of the Steering Committee, the Academy of Medical Sciences or the National Academy of Medicine.