Changing Lives, Changing Society, University of the West of England 28th June 2012

Professor Mike Kelly, Director of the Centre for Public Health Excellence, The National Institute for Health

and Clinical Excellence (NICE) and Institute of Public Health University of Cambridge.

,

Behaviour Change: Social and

individual approaches.

Human behaviour and health

Evolutionary Trends

. Source: The Economist, 12 November 2003.

Preventable disease – the scale of

the problem

• In 2008, the total disease burden attributable to preventable deaths

in England and Wales under the age of 75 was 44 years of life lost

per 1000 population or about 2.6 million life years lost each year.

• If the NHS is prepared to pay £20,000 per life year gained at full

health, as the lower boundary of the cost effectiveness threshold

used by NICE implies, the value of this loss, for England and

Wales as a whole, is about £51 billion per year.

• The current level of tobacco use is estimated to cost the

NHS around £2.7 billion every year.

• Treating people with health problems related to being

overweight or obese is estimated to cost the NHS £4.2

billion annually.

• Physical inactivity is estimated to cost the NHS £1.06

billion per year.

• The costs of treating the chronic and acute effects of

alcohol misuse up to £1.7 billion per year.

Health Inequalities

Age standardised death rates per 100,000 population for

circulatory diseases under 75 by area of deprivation

0

20

40

60

80

100

120

140

160

180

Most

deprived

3rd Least

deprived

1995-97

2002-4

Age standardised death rates per 100,000 population for cancer under 75 by

area of deprivation

0

20

40

60

80

100

120

140

160

most

deprived

3rd Least

deprived

1995-97

2002-04

The health gradient

Health state

Social status

Hi Lo

Lo

Hi

The nanny state

• “It is simply not possible to promote healthier lifestyles

through Whitehall diktat and nannying about the way

people should live. One size fits all is no good. We

need a new approach that empowers people to make

healthier choices...”

White Paper November 2010 pp 2-3

“The nation, which is but the aggregate of us all is

…little disposed to endure a medical tyrant…Mr

Chadwick and Dr Southwood Smith have been

deposed, and we prefer to take our chance of

cholera and the rest than be bullied into health…”

The Times 1st August 1854, p8.

Nudge?

• Thaler RH and Sunstein CR. Nudge: Improving

decisions about health, wealth and happiness New

Haven, CT: Yale University Press, 2008.

Sons of Zeus

Apollo Dionysus

The sons of Zeus

Apollo

• order

• discipline

• system

• predictability

• logic

• rationalism

• method

The sons of Zeus

Apollo

• order

• discipline

• system

• predictability

• logic

• rationalism

• method

Dionysus

• pleasure,

• the vine,

• drunkenness,

• disorder.

• complexity

• empiricism

• sponteaity

The Dual Process system.

• The reflective system.

– Reflective, goal oriented system driven by our values

and intentions requiring cognitive capacity or thinking

space, which is limited.

– Many traditional approaches to health promotion

depend on engaging this system.

– Often based on providing information designed to

alter beliefs and attitudes, motivate people with the

prospect of future benefits, or help them develop self

regulatory skills.

– At best, these approaches have been modestly

effective in changing behaviour.

The automatic system

• The automatic, affective system that requires little or no

cognitive engagement, being driven by immediate

feelings and triggered by our environments.

• This automatic system is the focus of nudge theory.

Choice Architecture

http://pumabydesign001.wordpress.com/2010/10/07/michael-bloomberg%E2%80%99s-

agenda-to-nudge-new-yorkers-using-food-stamps/

• MARTEAU, T.M., OGILVIE, D., ROLAND, M.,

SUHRCKE, M., KELLY, M.P. (2011) Judging nudging:

can „nudging‟ improve population health? British

Medical Journal. ; BMJ 2011;342:d228.

http://www.bmj.com/content/342/bmj.d228.full

Worrying about nudging.

The individual and social levels of

explanation

Variables used in public health are

either :-

Individual Relational

Variables

Individual characteristics

Relational characteristic

Variables

Individual characteristics

• Blood pressure

• Height

• Personality –Introversion –

extraversion

• Morbidity

• Occupation

• Sex

Relational characteristic

Variables

Individual characteristics

• Blood pressure

• Height

• Personality –Introversion –

extraversion

• Morbidity

• Occupation

• Sex

Relational characteristic

• Social class

• Gender

• Social status

• Tribe

• Caste

• Some variables are both,

• And many relational variables are treated as if they

were individual ones.

• Much public health evidence tends to muddle these two

things anyway.

• Crude nudge fails to distinguish between them at all.

• The importance of distinguishing between the individual

level explanation and the social level explanation.

• The importance of distinguishing between the individual

level explanation and the social level explanation.

• Individual disease outcomes

• Patterning of disease at population level

Causal Pathways

•Is the issue one of individual level change?

•Is the causal pathway from the intervention to the

outcome short?

X Y

K

J

I

D

H

C

G

B A

F

E

L

Solutions: Another look at cause

Y X

Y X D C B A X1

Y

X4

X5

X3

X1

X2

M

N

O

P

H

G

F E

D C B A

L

K

J I

T

S

R

Q

Y

4

X5

X3

X1

M

N

O

P

H

G

F E

D C B A

L

K

J I

T

S

R

Q

Solutions: rethinking patterns of

behaviour

Outer zones of the lifeworld

Zone of relevance

Zone of relevance

Zone of relevance

Centre of the lifeworld

Overlapping lifeworlds

Conclusions

Altering choice architecture to change population

health behaviour: a large-scale conceptual and

empirical scoping review of interventions within

micro-environments

Gareth J. Hollands, Ian Shemilt, Theresa M. Marteau*,

Susan A. Jebb, Michael P. Kelly, Ryota Nakamura, Marc

Suhrcke, David Ogilvie

References KELLY, M.P. (2009) The individual and the social level in public health, in Killoran, A. & Kelly, M.P. (eds), Evidence

Based Public Health: Effectiveness and Efficiency, Oxford : Oxford University Press.

SWANN, C., OWEN, L.,CARMONA, C., KELLY, M.P., WOHLGEMUTH, C., HUNTLEY,J. (2009) A nudge in the right

direction: developing guidance on changing behaviour, in Killoran, A. & Kelly, M.P. (eds), Evidence Based Public

Health: Effectiveness and Efficiency, Oxford : Oxford University Press..

BAXTER, S. KILLORAN, A., KELLY, M.P., GOYDER. E. (2010) Synthesising diverse evidence: the use of primary

qualitative data analysis methods and logic models in public health reviews. Public Health 124: 99-106

http://dx.doi.org/10.1016/j.puhe.2010.01.002

KELLY, M.P. (2010) The axes of social differentiation and the evidence base on health equity. Journal of the

Royal Society of Medicine, 103: 266-72, DOI .1258/jrsm.2010.100005

.

KELLY, M.P. (2010) A theoretical model of assets: the link between biology and the social structure. In Morgan, A.

Davies, M ., Ziglio, E. (eds) Health Assets in a Global Context: Theory, Methods, Action, , New York: Springer.

http://bit.ly/auIY7y

KELLY, M.P., MORGAN, A., ELLIS, S., YOUNGER, T., HUNTLEY, J., SWANN, C. (2010) Evidence based public health: A

review of the experience of the National Institute of Health and Clinical Excellence (NICE) of developing public health

guidance in England , Social Science and Medicine, 71 :1056 - 1062 http://dx.doi.org/10.1016/j.socscimed.2010.06.032

KELLY, M.P. & MOORE, T.A. (2011) The judgement process in Evidence Based Medicine and Health Technology

Assessment. Social Theory and Health, advance online publication, 14 December 2011; doi:10.1057/sth.2011.21

http://www.palgrave-journals.com/sth/journal/v10/n1/full/sth201121a.html