Guidance for professionals in health promotion: Keeping it simple–but not too simple

The NICE Public Health Guidance has taken on a tremendous challenge in presenting combined recommendations in the format of generic principles for behavioural change on the levels of population, community and individual. While it is important to acknowledge the need for multi-level approaches, covering the different levels that require different forms of action means that the guidance is at risk of losing specificity and practical applicability. This Editorial examines the NICE guidance on behaviour change from the health promotion perspective in general and, more specifically, in the light of Finnish experiences of health promotion research in ‘real-life’ settings. Based on these experiences, the Editorial presents theoretical approaches, which may be valuable tools for guidance in behaviour change from the health promotion perspective.

Trends in health promotion

Health promotion has heavily advocated that individual behaviour change becomes possible and easier when the surroundings support it, resources are provided and environmental, policy and political changes are concomitantly made. One of the key terms, empowering people, means that a will to change is not sufficient but individuals must also have skills and resources, and a supportive environment for the change. Without a bicycle (and a helmet if you are in Finland), skills for riding it, bicycle lanes, and a safe neighbourhood, biking as a physical activity may not be attractive or sustainable. The 1986 Ottawa Charter for health promotion emphasised (individual or social) empowerment and participation, whereas the 2005 WHO Bangkok Charter for health promotion in a globalised world focuses on societal and organisational solutions to promote well-being and health. This development resulted from a participatory approach applied in the preparation for Bangkok, where increasing number of representatives from developing countries brought insights from situations where social turmoil or even war, poor infrastructure and lack of resources call for societal, political and environmental action instead of individualistic approaches.

However, simultaneously with recognition of the importance of upstream approaches, a renewed interest in individuals’ behaviour can be found among health professionals and health policy makers. This is due to major trends in population health such as the global epidemic of obesity and obesity-related non-communicable diseases, and to evidence that these can be overcome by changes in everyday behaviours (Knowler et al., 2002).

A part of the NICE Public Health Guidance, the Behaviour Change Guidance reflects these parallel and recent developments in advancing health promotion and the role of individual behaviour change therein. Operating at multiple levels, it acknowledges the importance of individual, community and population/societal approaches in promoting sustainable behaviour change. However, the body of evidence on how to combine these different levels is limited, a problem pointed out in the evidence reviewed in the guidance. One explanation might be that the traditional evidence hierarchy paradigm that values randomised controlled trials as the gold standard fits poorly with both individual behaviour change and structural health promotion actions (Fisher 2008; Skovgaard, Nielsen, & Aro, 2008) which are both context-dependent or context-focused. We agree with Fisher (2008) that comprehensive, creative and dynamic multi-level strategies (also to be used in evaluation) are vital for a thorough understanding of behaviour change, as well as for promoting the change and thereby also health.

Can the NICE guidance meet the needs of professionals?

In the NICE guidance, the target audience is broadly defined–from policy makers and commissioners to service providers to individual health professionals aiming at behaviour change. Different target audiences have different needs for guidelines and it is difficult to fulfil them all. Policy makers want to get information on the most cost-effective and sustainable ways to promote public health in the society and in different target groups; service providers are also interested in these factors but in addition use guidelines for other purposes such as quality control. Instead of giving easy answers the NICE guidance sends these groups off to do the work themselves, with a checklist of items that they need to pay attention to along the way.

What are health professionals seeking in different guidelines? First, we claim, reassurance that their current practices are on the right track rather than ways of changing them. Supporting this view, a finding from the preparation and testing phase of the NICE guidance shows that professionals who were best able to understand what the guidance was about were the ones who already reported compliance with most of the recommendations (Jackson, 2007). Second, professionals want practical tools that help them solve specific problems as effectively and quickly as possible–the lack of specificity was also one of the major criticisms of the NICE guidance during its preparation (Jackson, 2007). Research on the use of Current Care clinical guidelines on prevention and treatment of lifestyle-related diseases in Finland, shows that only 10% of physicians found guidelines useful when the major target was changing patients’ behaviour, in comparison to 20–30% when the major target was medication (Kuronen, Jallinoja, Ilvesmäki, & Patja, 2006). This implies that our existing guidelines do not provide sufficient guidance for promoting behaviour change.

However, when the question is about changing behaviour, there may not be any answers or tools specific enough to satisfy the professionals’ needs. This might be due to the complex nature of any behaviour and its change, and the resulting inadequacy of models used in practice. When working with health professionals in the GOAL Programme (Absetz et al., 2007, 2008), we witnessed a discrepancy between a medical treatment model and a health behaviour change model. The medical model progresses in a straightforward manner from identification of symptoms to setting a provisional diagnosis to testing treatment options to eventual cure. Unsuccessful treatment results in redefinition of the diagnosis and changes in the treatment protocol. Still, both the target outcome and the path leading to it can usually be sufficiently defined by the professional (who also tends to be responsible for the main actions involved).

Lifestyle change, on the other hand, is anything but straightforward. Rather, it is teetering from one small change to another–with lapses and relapses, and shorter and longer time intervals with no apparent changes in between. The main responsible actor is the individual, not the professional, but neither one of them can usually point to the target or clearly define ways to get at it. This kind of a behaviour change model is only a provisional model that the existing, mainly cognitive-rational–and rather static–theories have not been able to fully tap but it has resemblance to the chaos theoretical approach to behaviour change promoted by Resnicow Page (2008).

The health promotion approach takes a broader perspective on individuals and their behaviour as embedded into the material, social, cultural and political environment. Individuals are seen primarily as members of their communities, influenced by community needs values, priorities and resources together with societal policies and political realities. That is why the health promotion paradigm functions on multiple levels. All phases from planning to implementing and evaluating health promotion programmes need to recognise existing strategies, initiatives, structures and channels in the communities (Aro, van den Broucke, & Räty, 2005; Mullen et al., 1995), and use them in a participatory, empowering manner that gives ownership to the people.

Frameworks for intervention planning and evaluation

To promote practical applicability, the NICE guidance has taken the following strategy: Keep it simple. The guidance outlines only three phases–planning, delivery and evaluation–then states major principles for each phase, and finally gives a shopping list of recommended actions for each principle. However, keeping it overly simple on the highest level–phases–compromises practicability on the intermediate level–principles–and leads to a mixture of numerous overly generic versus very specific action recommendations that are not distinct to the phases.

When outlining the different phases, principles and actions, some existing frameworks for programme planning and evaluation would have clarified the guidance. Intervention mapping (Bartholomew, Parcel, Kok, & Gottlieb, 2001) is a framework for designing and evaluating behavioural interventions based on empirical evidence and theoretical considerations. It provides clearly defined, detailed guidance for six phases or steps: (1) needs assessment including capacities and problems, (2) definition of evidence-based intervention objectives ranging from the most proximal behavioural targets to health and quality of life outcomes, (3) theoretically informed selection of determinants of behaviour at different levels of influence as well as methods for addressing them, (4) planning and producing practical program components and materials, (5) planning for program adoption, implementation and sustainability and (6) developing framework for process and impact evaluation. By defining the first three steps in their own right the IM not only emphasises their importance but also overcomes some of the problems we pointed out in the NICE guidance, i.e. unnecessary overlap of recommendations across the phases and practical inapplicability. As with the NICE guidance, throughout the steps, IM emphasises the health promotion relevant broad collaboration and linkages between all invested partners, including the target population.

Another useful way to look at interventions is the Reach, Efficacy/Adoption, Implementation, Maintenance (RE-AIM) framework (Glasgow, McKay, Piette, & Reynolds, 2001). Although developed for evaluation purposes, it also serves as a guide for designing interventions that (1) will reach the intended population, (2) can be demonstrated to have high efficacy/effectiveness, (3) are adopted by the programme users and implemented with high treatment fidelity and (4) will be maintained–as programmes but also, preferably, as long-term changes in the target behaviours (Dzewaltowski, Glasgow, Klesges, Estabrooks, & Brock, 2004). Both the IM and the RE-AIM have ample empirical evidence of their applicability and hopefully we will see their influence in the further development of the NICE guidance.

To tackle the issue of behaviour change theories and models, the NICE guidance has taken an eclectic view: it explicitly states that no single theory deserves to be recommended as such–instead, some individual, theory-driven constructs or theoretically informed techniques are promoted, as well as the general need for using at least some theoretical considerations in the planning phase. Theoretical eclecticism is also shared by IM approach and probably applies to most professionals working in the field of health promotion. Our own research with theory-based interventions suggest that to sufficiently (or even remotely) understand and to be able to promote sustained behaviour change, different theories are needed (Absetz et al., 2007, 2008).

The view expressed by the NICE guidance towards behaviour change theories carries an important message for health psychologists working on this field: We do not have adequate evidence for determining what really works. Partly this may be due to inadequate study designs, partly to problems with existing theories which cannot be effectively solved without interaction between theory-development and theory-testing in intervention settings (Rothman, 2004). One clear take-home message for us is that we need to put more effort into showing what works best for whom, with different target groups and settings, and with different timeframes included in our analyses. In addition, and most importantly, we need to plan, function and evaluate on multiple levels and in partnership to make a sustainable change and to make a difference in health on longer term. Otherwise, we will lose the window of opportunity that we now have for integrating knowledge from the behavioural sciences with the health sciences in a joint effort to promote public health.