Behaviour change: The NICE perspective on the NICE guidance

The National Institute of Health and Clinical Excellence (NICE) is an independent, government-funded body. Its role is to produce evidence-based guidance on the prevention and treatment of disease and the promotion of good health. In 2006, NICE was commissioned by the UK government to produce general, cross-disciplinary guidance on behaviour change and its implications for health inequalities The independent, ‘programme development group’ (PDG) appointed by NICE to review relevant evidence included psychologists, economists, sociologists, public health experts and lay stakeholders. The PDG also included a range of relevant professional and research expertise. The guidance (NICE, 2007) was developed for use by a range of professionals including teachers, doctors, nurses, town planners, as well as researchers and, consequently, presents a broad set of overarching principles which can be used to assess and guide behaviour change practice. Forthcoming NICE guidance on the prevention of cardiovascular disease, smoking, alcohol misuse, obesity and accidental injury, which involve behaviour change, will build a more detailed guidance framework. The 2007 guidance will itself be reviewed and if necessary revised in due course.

Aro and Absetz (2009) provide an interesting commentary on the NICE guidance. We agree much with what they say, but refute some of their claims. They endorse key principles articulated in the guidance. For example, the guidance emphasises the importance of empowerment and participation and the integration of population, community and individual-level interventions. The guidance also highlights the incomplete nature of current research evidence on behaviour change and makes specific recommendations on research priorities.

Aro and Absetz appear to criticise the guidance by saying that it ‘sends these (various professional) groups off to do the work themselves, with a checklist of items that they need to pay attention to along the way’ (p. 126). The guidance offers more than ‘a checklist’ but it does not attempt to specify what particular professional groups should do on particular occasions when they employ behaviour change interventions. Rather, the guidance specifies essential competencies required by teams attempting to induce behaviour change and key issues that they should address. It is the role of competent educational bodies for relevant professionals, such as the British Psychological Society and the UK Health Professionals Council, to develop profession-specific competencies that will equip multi-disciplinary teams with prerequisite skills.

Aro and Absetz suggest that the guidance is ‘overly simple on the highest level [which] … compromises practicability’ (p. 127). Einstein entreated us to ‘make everything as simple as possible, but not simpler’ and simplicity is a virtue in professional guidance. Does the simplicity achieved by the NICE guidance compromise its relevance to practical application? The reviews conducted and considered by the PDG clarified that the following features blighted otherwise well-intentioned attempts to change health related behaviours: (i) poor planning and lack of specificity concerning target behaviours and intended outcomes; (ii) selective application of models without reference to evidence demonstrating the importance of model-specified causal processes to the target behaviour; (iii) failure to articulate the nature of hypothesised causal links between the use of particular intervention techniques and intended outcomes; (iv) confusion about the level at which interventions and outcomes operated–individual, group, community or population; (v) an absence of systematic evaluation linked to the specificity of the behaviour and the causal chain and (vi) a failure to use evidence-based and validated psychological approaches. So, while the principles articulated in the NICE guidance are simple–e.g. assess needs and barriers, be specific about change processes, plan carefully, implement accurately and evaluate properly–they are not widely applied. The vast amount of money channelled into behaviour change projects could be spent more cost effectively if researchers and practitioners adopted such ‘simple’ principles.

Aro and Absetz recommend application of ‘intervention mapping’ (IM) (Bartholomew, Parcel, Kok, & Gottlieb, 2006), with its focus on detailed preparation and planning of interventions. The PDG considered this approach and found much to commend it. Key principles included in the guidance are addressed by IM and IM provides an excellent framework within which to plan health promotion. However, IM is not quintessentially ‘simple’. IM uses terminology that is not self-evident across behavioural scientists or professions, is based on a core text of more than 750 pages and involves training courses that last up to 5 days. We also agree that ensuring the external validity of evaluations of behaviour change interventions is critical to enhanced routine practice, as is emphasised by the RE-AIM model (Glasgow, Bull, Gillette, Klesges, & Dzewaltowski, 2002; Glasgow, Klesges, Dzewaltowski, Bull, & Estabrooks, 2004). Both these approaches make important contributions to improved behaviour change practice, but neither provides overarching guidance. They complement rather than substitute the NICE guidance.

Aro and Absetz are right to note that ‘professionals want practical tools that help them solve specific problems as effectively and quickly as possible’ (p. 126). Providing useful tools requires a clear and specific understanding of the causal processes contributing to change. Recommending particular models or tools without this understanding may lead to ineffective or even harmful practice. We strongly agree with Aro and Absetz that the guidance emphasises ‘an important message for health psychologists … we do not have adequate evidence for determining what really works …. 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’ (p. 127) (see Abraham, Kelly, West & Michie, 2009).

An important idea underpinning the guidance is specification of causal processes. In public health behaviour change practice, it is important to specify a series of linked but analytically separate causal pathways. These include: (i) causation of the patterning of mortality and morbidity at the population level (ii) causation of disease at the individual level (iii) the causal impact of individual behaviour on individual disease and (iv) the causal connections between interventions at various levels and changes in individual behaviour. These important distinctions are not infrequently elided in public health. The work done on the behaviour change guidance in articulating the causal mechanisms illustrates the importance of such distinctions and some of the ways in which gaps between psychological, social and economic approaches may be connected (Kelly et al. 2008).