Current issues and new directions in Psychology and Health: Introducing the NICE guidance on behaviour change interventions

In October 2007, the National Institute for Health and Clinical Excellence (NICE) published guidance on ‘Behaviour change at population, community and individual levels’. This guidance was developed over a period of 2 years by an interdisciplinary Programme Development Group, working with a NICE project team. The development process involved drawing on evidence reviews and theory, and consulting at every stage with stakeholders. In the UK, NICE guidance is intended to reflect consensus regarding best practice, and NICE publications are widely disseminated. NICE guidance therefore has the potential to strongly influence both policy and practice.

This important role for NICE guidance provides the motivation and context for the following editorials. We have (with permission from NICE) reproduced verbatim in the tables below the summary of the guidance, and the eight key principles, as summarised in the NICE Quick Reference Guide. Full details of the guidance and the process by which it was developed are given in the full report, which is freely available for download from the NICE website (www.nice.org.uk/PH006, NICE public health guidance 6). Our first editorial reflecting on the significance of the guidance provides a European health promotion perspective (Aro & Absetz, 2009). The second editorial (Kelly & Abraham, 2009) is a response from Mike Kelly, who led the NICE group that developed the guidelines, and Charles Abraham, who was part of the group. We hope that this series of editorials offers a stimulating variety of perspectives on the guidance, and its implications for health psychology.

Summary of NICE guidance

• Plan carefully interventions and programmes aimed at changing behaviour, taking into account the local and national context and working in partnership with recipients. Interventions and programmes should be based on a sound knowledge of community needs and should build upon the existing skills and resources within a community.

• Equip practitioners with the necessary competencies and skills to support behaviour change, using evidence-based tools. (Education providers should ensure courses for practitioners are based on theoretically informed, evidence-based best practice.)

• Evaluate all behaviour change interventions and programmes, either locally or as part of a larger project. Wherever possible, evaluation should include an economic component.

Principle 1: Planning interventions and programmes

• Work in partnership with individuals, communities, organisations and populations to plan interventions and programmes to change health-related behaviour. The plan should:

  		be based on a needs assessment or knowledge of the target audience
  		take account of the circumstances in which people live, especially the socioeconomic and cultural context
  		aim to develop–and build on–people's strengths or ‘assets’ (that is, their skills, talents and capacity)
  		set out how the target population, community or group will be involved in the development, evaluation and implementation of the intervention or programme
  		specify the theoretical link between the intervention or programme and its outcome
  		set out which specific behaviours are to be targeted (e.g. increasing levels of physical activity) and why
  		clearly justify any models that have been used to design and deliver an intervention or programme
  		assess potential barriers to change (e.g. lack of access to affordable opportunities for physical activity, domestic responsibilities, or lack of information or resources) and how these might be addressed
  		set out which interventions or programmes will be delivered and for how long
  		describe the content of each intervention or programme
  		set out which processes and outcomes (at individual, community or population level) will be measured, and how
  		include provision for evaluation.

• Prioritise interventions and programmes that:

  		are based on the best available evidence of efficacy and cost effectiveness
  		can be tailored to tackle the individual beliefs, attitudes, intentions, skills and knowledge associated with the target behaviours
  		are developed in collaboration with the target population, community or group and take account of lay wisdom about barriers and change (where possible)
  		are consistent with other local or national interventions and programmes (where they are based on the best available evidence)
  		use key life stages or times when people are more likely to be open to change (such as pregnancy, starting or leaving school and entering or leaving the workforce)
  		include provision for evaluation.

• Disinvest in interventions or programmes if there is good evidence to suggest they are not effective.

• Where there is poor or no evidence of effectiveness (or the evidence is mixed) ensure that interventions and programmes are properly evaluated whenever they are used.

• Help to develop social approval for health-enhancing behaviours, in local communities and whole populations.

Principle 2: Assessing social context

• Identify and attempt to remove social, financial and environmental barriers that prevent people from making positive changes in their lives, for example, by tackling local poverty, employment or education issues.

• Consider in detail the social and environmental context and how it could impact on the effectiveness of the intervention or programme.

• Support structural improvements to help people who find it difficult to change, or who are not motivated. These improvements could include changes to the physical environment or to service delivery, access and provision.

Principle 3: Education and training

• Provide training and support for those involved in changing people's health-related behaviour so that they can develop the full range of competencies required. These competencies include the ability to:

  		identify and assess evidence on behaviour change
  		understand the evidence on the psychological, social, economic and cultural determinants of behaviour
  		interpret relevant data on local or national needs and characteristics
  		design, implement and evaluate interventions and programmes
  		work in partnership with members of the target population(s) and those with local knowledge.

• Appropriate national organisations (e.g. the Faculty of Public Health, the British Psychological Society, the Chartered Institute of Environmental Health and the Nursing and Midwifery Council) should consider developing standards for these competencies and skills. The standards should take into account the different roles and responsibilities of practitioners working both within and outside the NHS.

• Ensure fair and equitable access to education and training, to enable practitioners and volunteers who help people to change their health-related behaviour to develop their skills and competencies.

• Review current education and training practice in this area, and disinvest in approaches that lack supporting evidence.

Principle 4: Individual-level interventions and programmes

• Select interventions that motivate and support people to:

  		understand the short, medium and longer term consequences of their health-related behaviours, for themselves and others
  		feel positive about the benefits of health-enhancing behaviours and changing their behaviour
  		plan their changes in terms of easy steps over time
  		recognise how their social contexts and relationships may affect their behaviour, and identify and plan for situations that might undermine the changes they are trying to make
  		plan explicit ‘if–then’ coping strategies to prevent relapse
  		make a personal commitment to adopt health-enhancing behaviours by setting (and recording) goals to undertake clearly defined behaviours, in particular contexts, over a specified time
  		share their behaviour change goals with others.

Principle 5: Community-level interventions and programmes

• Invest in interventions and programmes that identify and build on the strengths of individuals and communities and the relationships within communities. These include interventions and programmes to:

  		promote and develop positive parental skills and enhance relationships between children and their carers
  		improve self-efficacy
  		develop and maintain supportive social networks and nurturing relationships (e.g. extended kinship networks and other ties)
  		support organisations and institutions that offer opportunities for local people to take part in the planning and delivery of services
  		support organisations and institutions that promote participation in leisure and voluntary activities
  		promote resilience and build skills, by promoting positive social networks and helping to develop relationships
  		promote access to the financial and material resources needed to facilitate behaviour change.

Principle 6: Population-level interventions and programmes

• Deliver population-level policies interventions and programmes tailored to change specific, health-related behaviours. These should be based on information gathered about the context, needs and behaviours of the target population(s). They could include:

  		fiscal and legislative interventions
  		national and local advertising and mass media campaigns (e.g. information campaigns, promotion of positive role models and general promotion of health-enhancing behaviours)
  		point of sale promotions and interventions (e.g. working in partnership with private sector organisations to offer information, price reductions or other promotions).

• Ensure population-level interventions and programmes aiming to change behaviour are consistent with those delivered to individuals and communities.

• Ensure interventions and programmes are based on the best available evidence of effectiveness and cost effectiveness.

• Ensure the risks, costs and benefits have been assessed for all target groups.

Principle 7: Evaluating effectiveness

• Ensure funding applications and project plans for new interventions and programmes include specific provision for evaluation and monitoring.

• Ensure that, wherever possible, the following elements of behaviour change interventions and programmes are evaluated using appropriate process or outcome measures:

  		effectiveness
  		acceptability
  		feasibility
  		equity
  		safety.

Principle 8: Assessing cost effectiveness

• Collect data for cost-effectiveness analysis, including quality of life measures. Where practicable, estimate the cost savings (if any) when researching or evaluating behaviour change interventions and programmes. This is particularly pertinent for research:

  		on mid- to long-term behaviour change
  		comparing the effectiveness and efficiency of interventions and programmes delivered to different population groups (e.g. low- versus high-income groups, men versus women, young versus older people)
  		comparing the cost effectiveness of primary prevention versus clinical treatment for behaviour-related diseases.