Incorporating behavioural science into an agile digital service design in public health PHE Digital: NHS Health Check Dr Chryssa Stefanidou - Principal Behavioural Insights Advisor, PHE Eleanor Wilkinson - NHS Health Check Digital Exemplar Lead, CVD Prevention Team May 2019
Scale of the problem 30
NHS Health Check A national risk reduction programme that aims to improve the health and wellbeing of adults aged 40-74. It is key to preventing Cardiovascular Disease, which is the leading cause of death worldwide. 31
Behavioural insights and NHS Health Check Historically, the two teams in Public Health England have worked closely together to explore different elements of the NHS Health Check programme, for example looking at: - Invitation letters - Risk messaging - Branding - Telephone invitations - Marketing campaigns 32
Digital Exemplar ➔ To Understand the NHS Health Check service from an end user, provider and commissioner viewpoint blending service design and behavioural insights research principles. ➔ The project vision is to understand what service changes both digital and non-digital could improve the health check service focusing but not limited to ○ Increasing uptake of the service ○ Increasing the impact of the service ➔ Conceptualise and prioritise possible service improvements as candidates for an Alpha. 33
Multidisciplinary team Behavioural CVD prevention Digital insights Andrea Hewins- Dr Chryssa Eleanor Wilkinson- Manisha Mistry- Dellis Roberts- Prof. Jamie Product Manager Stefanidou- CVD Subject Matter Delivery Manager User Researcher Waterall- Service Behavioural Expert Owner Scientist Kate Burn Megan Roger Callum Bates Vicki Litherland Iain Cooper Senior Service Senior Interaction User Researcher Content Designer Senior Content Designer Designer Designer 34
Behaviour change in a digital service ⮚ Currently Behavioural Insights are not embedded in the agile service design process as a mandatory step ⮚ Public Health England are commissioning the development and implementation of a digital service with a Behavioural Insights Advisor as part of the multidisciplinary team 7
Intro to digital 8
Behaviour change in discovery Identify target behaviours associated with the uptake and follow up of the NHS Health Check from an end user, provider and commissioner viewpoint Identify evidence base for the research questions from high-quality systematic reviews Consult with experts to identify needs of the target population Recruitment of participants according to socio-economic, behavioural and cognitive characteristics in order to reflect a diverse range of participants COM-B model of behaviour change for designing and analysing the interviews Comprehensive analysis for all identified user needs using COM-B and TDF (explore barriers and need for a digital intervention) 9
Develop recruitment screeners using psychological models and theories Recruitment of participants according to socio-economic, behavioural and cognitive characteristics in order to reflect a diverse range of participants Diary study to Health Digital Inclusion Assessing monitor Confidence Scale Scale to people’s people’s to monitor consider the people’s lifestyle readiness to different levels behaviours change their confidence in of digital (smoking, their unhealthy literacy for exercising, behaviours ability to manage individuals drinking etc.) their own health 10
Identify user needs through qualitative semi-structured interviews The COM-B model informed the development of discussion guides to identify the barriers and facilitators of behaviours relevant to NHS Health Check Behaviour : Start Action Plan (end users) Capability Do you think you have the skills to start the action plan? Capability Do you understand the next steps? Opportunity Do you have the support of your friends and family? Opportunity Do you have the time required to do it? Is there something to follow your progress (tools)? Motivation Do you believe that it would be a good thing to do? Motivation How important is it for you to be able to develop a better and clearer plan for doing it? 11
Understanding user needs through Behavioural analysis Target Behaviour: Start action plan Attend referral (end users) COM-B Theoretical Facilitators Barriers Domains Framework A lack of knowledge about next Psychological Knowledge steps/action plan both in terms of Capability what could do and how to do it Encouragement from people around Social Opportunity Social Influences them (partner, family, friends) Access to technology; Significant life Perception that time and location Physical Environmental, Context changes like moving home; can be a barrier - finding the correct Opportunity and Resources Monetary incentive (ex. not wanting time; Perception that lifestyle to waste a paid gym membership) services are not easy to access; Time limit on lifestyle service provision; Data privacy Identification of risk and early Potential challenges of changing Reflective Beliefs about detection of disease (ex. lifestyles if visible symptoms don't Motivation consequences “prediabetes”) exist Digital reminders/prompts; Seeing Automatic Reinforcement other people's progress and Motivation achievements 12
NHS Health Check User Journey Target Behaviours • End User • Provider • Commissioner Facilitators + Highlights Barriers + Pain points 13
Moving on to the alpha phase Identify intervention content which targets the influences on behaviours Provide a preliminary list of intervention functions and Behaviour Change Techniques Work closely with the service design team to translate this knowledge into engaging digital content and designs Test prototypes with embedded behaviour change techniques 14
Key learnings ⮚ We need to collaborate in multidisciplinary approaches to develop a service that is viable, desirable and feasible. ⮚ Behavioural science provides robust, validated frameworks that increase the likelihood for intervention effectiveness and can enhance the governmental digital service process. ⮚ Embedding behavioural science into the service design process can help overcome subjective bias (e.g. small sample sizes). ⮚ Cross-government stakeholders should increasingly interact with and draw upon behavioural insights expertise to optimise public health services. 15
Questions? Chryssa.Stefanidou@phe.gov.uk Eleanor.Wilkinson@phe.gov.uk
Appendix
A Behavioural Approach Stage 1: Understand the behaviour Capability 1.Define the problem in Motivation Behaviour behavioural terms 2.Select the target behaviour Opportunity 3.Specify the target behaviour 4.Identify what needs to change
A Behavioural Approach Stage 2: Identify Intervention Options 5. Intervention functions 6. Policy categories
A Behavioural Approach Stage 3: Identify content & implementation options 7. Behaviour change techniques 8. Mechanisms of action 9. Modes of delivery
11:40 – 12:00 Cheshire & Merseyside MECC approach, Dave Sweeney, Executive Implementation Lead, C&M Health & Care Partnership & Louise Vernon , C&M MECC Implementation Lead Q&A (5 mins)
Population Behaviour Change in Cheshire & Merseyside Louise Vernon Cheshire & Merseyside MECC Programme Lead Champs Public Health Collaborative Dave Sweeney Executive Implementation Lead Cheshire & Merseyside Health & Care Partnership
Vision in C&M for Making Every Contact Count (MECC) at scale • MECC is a behaviour change approach that supports positive health and well being choices, signposting the public to further information and support • We want to see MECC flourish in every place, building on great existing local and sub-regional work and creating innovative approaches • The aim is to create a culture shift and focus on prevention • Every front line contact can add up to a huge impact on population health and wellbeing in C&M
Our approach in Cheshire & Merseyside
1. Systems Leadership • C&M has 2.5 million people , nine local authorities, 12 CCGs, nine trusts, one STP and two fire and police authorities • In Aug 17 C&M DsPH Board agreed to help drive the delivery of MECC at scale using a systems leadership approach with partners • The Champs Public Health Collaborative are working with those key partners (PHE, HEE, NHSE, LA’s, STP and voluntary sector) to create a new innovative and large scale approach • Jan 2018 Scoping exercise report – assets and variation in practice • NICE Behaviour Change Guidelines PH6 and principles underpin the programme - including planning, assessment, training, programme delivery and evaluation
2. Co-production of the vision/strategic framework In April 2018 partners from across C&M met to establish a shared vision/ strategic framework. Key recommendations included: 1. Create a consistent and standardised approach to MECC , with an online portal to share resources 2. Establish a culture focused on prevention , this was seen as critical to enable staff to fully utilise MECC training 3. Produce an effective Communication and Engagement Strategy and ensure senior leadership ownership 4. Establish a Partnership Board to oversee the work on behalf of the broader MECC network. 5. Develop robust and standardised evaluation methods
3. Distributed Leadership – Partnership Board • Established Partnership Board co-chaired by Dave Sweeney, Executive Implementation Lead, C&M Health & Care Partnership and Dr Charlotte Simpson, Healthcare Public Health Consultant , PHE NW and NHSE. • Essential representation from groups across the sub region • 3 active partnership working groups supporting the board in; a) Training and Education b) Communications and engagement c) Evaluation • DsPH and the SCN co-fund a programme lead post
4. Workforce Development • C&M ambition to create a focus on prevention and embed a sustainable model • An accredited face to face training programme is one of a suite of learning opportunities available to everyone • Development of a train the trainer model by September to strengthen the approach at scale • Suite of resources co-created and available to increase awareness and knowledge • Creation of a network of MECC leads and champions
5. Communications & Engagement • www.mecc-moments.co.uk launched today for colleagues to view containing tools and support for local implementation • Communications and engagement strategy developed from insight through 1:1 interviews with senior leaders, MECC leads and frontline staff in all public and voluntary sector organisations • Raising awareness and build understanding of behaviour change and a shift in culture to focus on prevention, stimulating action • Co-produced with focus and test groups across C&M MECC campaign, tools and resources to support behaviour change, including an on-line services signposting portal • Implementation leads and a new network of colleagues will be supported to become MECC ambassadors
6. Evaluating impact • Guide - C&M How to Evaluate for MECC guide developed • Training evaluation process including impact on practice/confidence • Communications framework - Pre, mid and post developed to evaluate activity using a set of key indicators • Leadership Insight project by PHE on how to support system wide implementation of MECC
Lessons Learnt – Perceived barriers from insight work Early indications from PHE led organisational/system insight highlights; • Pressure/capacity • Commissioners need to be engaged; commissioning for full impact • Low priority in comparison to other challenges • Benefits realisation not understood • Simple and clear definitions needed • Public ask and vice versa
Innovative opportunities in C&M • Fire and Rescue safe and well checks • PHE Insight work shared with key senior leaders ( DoN’s, HRD’s) • STP NHS Prevention Pledge to include MECC • Pharmacy Network and Healthy Living Pharmacies • Primary Care Network pilots development with NHSE (2019) • PHE Dental Programme – Mouth Care Matters programme (2019-20) • DWP potential collaboration • Cancer Alliance collaboration on early detection
Thank you www.mecc-moments.co.uk #meccmoments Louisevernon@wirral.gov.uk
12:00 – 12:30 Workshop One - Exploring the 8 key themes in the behavioural science strategy Mari Davis
8 key themes in the behavioural science strategy
Workshop One Questions on your tables – please use the booklet 1. Why is this theme a priority? 2. Where and in what way are we already doing this? 3. What are we not doing? 4. What further actions might we take?
Tables 1 and 9 ……….. start with priority theme 1.. then 2 etc Tables 2 and 10 ………..start with priority theme 2.. then 3 etc Tables 3 and 11 ………..start with priority theme 3..then 4 etc Tables 4 and 12 ……….. start with priority theme 4..then 5 etc Table 5 ……….. start with priority theme 5.. then 6 etc Table 6 ……….. start with priority theme 6..then 7 etc Table 7 ……….. start with priority theme 7..then 8 etc Table 8 ……….. start with priority theme 8..then 9 etc
12.30 – 12.45 Workshop One plenary session Mari Davis & Chairs
12.45 – 12.50 Social Marketing Campaigns in the North West Paula Hawley Evans, Health and Well Being Programme Lead/Public Health Specialist, (PHE North West) introducing a Showcase film on behalf of Claire Troughton , Regional Marketing Manager (PHE North West) https://campaignresources.phe.gov.uk/resources/
12:50 – 13:30 Lunch & Networking: 13:15 – 13:30 - Optional pop-up presentation - MECC launch Cheshire & Merseyside Tweet us on @nwphpn using #BhSci2019
13.30 Introduction to the afternoon session:
13:30 – 13:50 Case Studies – Behavioural Sciences in Action The power of combining behavioural science and social marketing, Sue Cumming, Liverpool City Council, Head of Behavioural Insight & Change Q&A (5 mins)
The power of combining Behavioural Science and Social Marketing Sue Cumming, Head of Behavioural Insight & Change, Public Health Liverpool, Liverpool City Council Public Health Liverpool
This Session… Much of the global burden of BUT….. We still struggle to change behaviours disease arises from unhealthy behaviours BUT….. Habitual and unconscious Our behaviour is often not deliberate and considered AND ….. In line with how we perceive other people to behave By understanding drivers of behaviour including attitudes, motivations, barriers and psychology we can create shortcuts in the brain to change behaviour
BEH EHAVIOUR MOTIVATION AUTOMATIC REFLECTIVE
REFLECTIVE AUTOMATIC Problem Habit Solving Impulses Effortful Emotional Logical Automatic Planning Fast Slow
Behaviour occurs as an interaction between three necessary conditions
REFLECTIVE AUTOMATIC AUTOMATIC Behavioural Insights Insight and Social Nudge Theory Marketing BI uses routine data, literature, psychology and qualitative SM uses market research and commissions research, then tests interventions BI preference for Randomised Controlled Trials SM uses marketing channels at scale
AUTOMATIC REFLECTIVE Insight and Social Behavioural Insights Marketing Nudge Theory
Tools for Nudge MINDSPACE M essenger I ncentives N orms D efaults S alience P riming A ffect C ommitments E go
AUTOMATIC REFLECTIVE Reducing Obesity in Children Campaign to reduce sugar consumption in 4 – 11 year olds
38.8% of 11 year olds are obese or overweight 34.6% of 5 year olds have decayed teeth 2 children a day (on average) under age 10 have to be admitted to hospital to have teeth removed
INSIGHTS REFLECTIVE Parents simply don’t know how much sugar their children are consuming. Food labels are bewildering and parents find it hard to understand how much sugar is in their children’s food Single items e.g. breakfast cereals don't appear to be high in sugar Parents of under 18s are more likely to believe that if a sugary cereal has other nutritional benefits, its ok to have for breakfast Parents are not aware of the Maximum Daily Amount of sugar
AUTOMATIC Much of sugar consumption is through ‘mindless consumption’ – dependent on the environment
The Liverpool sugar reduction journey
EVAL ALUATION - Obese or ove verweight ht prevalence – year 6 childr dren Source: PHE, NCMP profile
EV EVALUATION • Over 85,000 visits to our website www.savekidsfromsugar.co.uk since launch 19/6/17 2500 Save Kids from Sugar web hits 2019 2000 1500 1000 500 0 Jan-19 Feb-19 Mar-19 April • 16,500 completion of our online sugar checker that shows the total amount of sugar a child has each day from a cereal, snack and drink. • In November 2017 a representative population survey was conducted with parents of children aged 4 -11 to evaluate the campaign. Total number of interviews 310: • 65% of parents recalled seeing the campaign • 67% of parents who recognised the campaign said they did make a change as a result of the campaign • 9 in 10 parents say the campaign will have an impact on them.
AUTOMATIC REFLECTIVE USING NUDGE, INSIGHTS AND SOCIAL MARKETING Campaign to motivate higher risk drinkers to drink less
Liverpool data • 1 in 3 people in Liverpool are drinking above the national alcohol guidelines of 14 units per week. This is above the national average for England of 1 in 4 • For those aged 40 – 64 Liverpool has higher than national figures for the number of hospital admissions related to alcohol - 1945 people per 100k people compared to 877 for England
INSIGHTS Limits often see as ‘scaremongering’. Some feel that REFLECTIVE they are set artificially low “14 really means 28” People disengage with info on ‘Units’ Most people don’t realise how much they are drinking People disassociate with the long term health risks of drinking People are motivated with the short term effects such as effects on appearance
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