Improving People's Health: Applying behavioural and social sciences to improve population health and well-being in England

This is an abridged version of Public Health England's national strategy document. Download the complete strategy: Improving people’s health: Applying behavioural and social sciences to improve population health and wellbeing in England.

Foreword

We live in a time when our population faces complex health and wellbeing challenges that stem from biological, psychological, economic, environmental, and social causes. The rising burden of long-term conditions and health inequalities poses a challenge for the whole public health system, and to deal with this we need to address the social, cultural and behavioural aspects of health and its determinants at a population level.

The behavioural and social sciences are the future of public health. Evidence from behavioural science suggests that simple and easy ways of helping people to change their behaviour are the most effective. Whether it’s encouraging smokers to quit, increasing uptake of the NHS Health Check, making healthier food choices easier, or reducing the number of inappropriate antibiotic prescriptions, this evidence can help in understanding and therefore influencing behaviour change that promotes health, prevents disease, and reduces health inequalities. We must reach and be meaningful to people in the lives that they are leading.

It is time for the public health system to advance the use of behavioural and social sciences, and for this purpose, PHE’s Behavioural Insights experts, working with many partners, have led the collaborative development of this comprehensive strategy – the first of its kind in the field.

Improving People’s Health: Applying behavioural and social sciences to improve population health and wellbeing in England aims to enable public health professionals to engage with and apply the insights, methodologies and knowledge of behavioural and social sciences to their work on protecting and improving the health of the people. As a high-level guide, it provides a framework and consolidates a suite of relevant resources to help achieve this.

The strategy was developed in partnership with the Association of Directors of Public Health, Faculty of Public Health, Behavioural Science and Public Health Network, and the Local Government Association. This is the start of the process, not the conclusion, and PHE joins all stakeholders in our commitment to use this strategy to create and encourage further collaboration across the sector. We owe all partners involved in its development a debt of gratitude for freely giving their time, energy and expertise for the good of the health of our population.

Duncan Selbie
Chief Executive
Public Health England

Executive summary

Aim, vision and mission of this strategy

The aim of this strategy is to better enable the broad public health system to use behavioural and social sciences to benefit the health of the population. We want all public health organisations in England to make the most of the contribution of behavioural and social sciences to the protection and improvement of the public’s health and wellbeing. We have a vision of a strong and vibrant behavioural and social science community that champions best practice to deliver these improvements.

Our mission is to improve health and wellbeing outcomes for the population, reduce health inequalities, and improve value to the public purse. This strategy provides high-level guidance on how to do this, applying the insights and riches from behavioural and social science to public health practice. The stakeholders, learned societies, and agencies that contributed to this strategy identified eight priority themes to work on for the future and a number of related actions to be taken (Table 1).

The behavioural and social sciences are still underutilised in practice and insufficiently integrated when applied to public health, and the workforce that is qualified to provide this behavioural and social science input remains small. Complex social phenomena and the pressures and challenges imposed on individuals by the contemporary world, as well as digital innovation and system restructuring, mean that we need to enlist and learn from these sciences more thoroughly, and strengthen transdisciplinary approaches (which are problem-based and ‘person-centred’), to deliver effective and efficient change.

Five key principles for good practice

Since this strategy brings together a variety of stakeholders, including people coming from different disciplinary traditions that may have different terminologies, we agreed in a stakeholder workshop on five key principles to govern our common approach:

1. We should all use inclusive language that does not alienate.
2. We should all think outside of our disciplinary boundaries and cooperate across disciplines in order to ensure a multi-disciplinary approach.
3. We should promote our common focus on improving public health and reducing health inequalities.
4. We should involve end users in the development and implementation of behavioural and social sciences to benefit the public’s health.
5. Our approach should be reflective and critical, informed by the evidence, and involve the highest possible standard of evaluation.

Although in this strategy we highlight different disciplines and the contributions they can make to public health, we seek to build policies and interventions in a transdisciplinary manner. We envisage a future where analyses of issues and their aetiology are not discipline-specific, but draw on insights from across the behavioural and social sciences.

National and local context

The field of public health currently faces a variety of significant challenges including tackling obesity, reducing smoking, increasing physical activity, improving mental health, increasing uptake of screening and immunisation, reducing inappropriate antibiotic use in order to address antimicrobial resistance, and improving air quality. Progress on these challenges will rely on changing behaviours (individual, professional, and organisational) as well as understanding and changing systems. A systems approach is needed because the complexity of public health means that change often needs to happen at multiple levels simultaneously.

Traditionally, public health professionals have worked to change behaviour by informing and educating people (health education and health promotion), as well as making structural changes. In more recent years we have recognised that many of the behaviours targeted by information and education campaigns are more effectively changed by also addressing psycho-social and structural issues (e.g., food environments) and other wider determinants of health, These can shift systems towards healthier states, can create new healthier practices, and can encourage ‘making the healthier choice the easier choice’. The focus on the individual and the focus on the social and structural therefore need to be integrated.

The use of behavioural and social sciences in public health can be traced back a long way. For instance, Dr John Snow used geography to trace a cholera outbreak to a water pump in Soho in 1854 and Dr Joseph Goldberger drew on sociology when arguing that pellagra was caused by dietary deficiencies in 1914. More recently, evidence from the social sciences was influential in changing legislation, such as securing tobacco advertising bans and introducing mandatory wearing of seat belts, which has then affected cultural norms. However, to date, the behavioural and social sciences have often not been applied in a systematic way.

The behavioural and social sciences include a range of disciplines that study individual behaviour and social systems. ‘Behavioural insights’ and behaviour change methodologies have been gaining recognition over the last ten years. These approaches combine findings from fields such as cognitive psychology, behavioural economics, social psychology and health psychology to understand human behaviour and decision making. Behavioural insights can be used to develop and evaluate behaviour change interventions and the approach has now gained support from key leaders (11). To demonstrate leadership in this area, the Department of Health and Social Care (DHSC) launched ‘DHSC Collaborate’ in 2018. This stepwise initiative to further develop open policy making was established with an initial focus on behavioural science. Public Health England (PHE) has embedded the behavioural insights approach into recent strategies including ‘From evidence into action: opportunities to protect and improve the nation’s health’ (12) and ‘Strategic plan for the next four years: better outcomes by 2020’ (13). These state that the behavioural insights approach is a game changer for PHE and the wider system because it delivers high value for money and return on investment, and uses a systematic approach based on evidence and theory.

A range of developments is also happening at a local level. Since local authorities have become responsible for public health in England, the increasing use of behavioural and social science approaches is evident. The Local Government Association (LGA) produced two briefings for public health professionals on behaviour change in 2013 and 2016 including local examples of good practice (14, 15). In 2015/16, the LGA initiated a behavioural insights grant funding programme that was subsequently re-run in the next two years. The most recent wave was hugely oversubscribed, despite the requirement of matched funding. Across a number of areas, local authorities have been working to enhance capability for applying the behavioural and social sciences to public health practice. This has been achieved in a variety of ways including employment of a behaviour change lead (such as in Solihull and Croydon), setting up a behaviour change hub (Croydon), and collaboration between academic experts and councils (such as in Coventry and Warwickshire). As a result, behavioural science expertise has been applied to external funding applications, rapid literature reviews and service redesigns. It has also led to the embedding of behavioural science in specific interventions and the provision of ad-hoc advice across organisations. This work has also extended to the upskilling of frontline staff through a range of behaviour change and communication skills training courses, led by behavioural and social scientists. Competency frameworks have also been developed in some areas to ensure that staff gain the appropriate skills and that these skills are embedded into practice.

Although there have been many gains in terms of behavioural science being better taken up by local public health functions, there have been fewer initiatives for building similar capacity for other social sciences. Many local authorities do commission from, work with, and learn from psychologists, sociologists, geographers, and anthropologists working on public health, but there are fewer resources to provide guidance about where insights from these disciplines could have greatest impact, or how best to work with social scientists. There needs to be a step change in these areas following publication of this strategy.

There is an important role for Health Education England (HEE) in developing competencies, and identifying opportunities for training and capacity building. Some professions already include behavioural science in their core curriculum; professional bodies should encourage and build upon this.

This strategy for incorporating the behavioural and social sciences into public health builds on recent work by the Academy of Medical Sciences, the British Academy, and the Campaign for Social Science, which has highlighted some of the current and future needs across the public health system for the behavioural and social sciences. The roles of behavioural and social science in public health practice have gained momentum in recent years. Some of the key developments include:

• British Journal of Health Psychology special issue on links between public health and psychology (1998)
• European University Studies Monograph on Health Behaviour and Health Promotion in a Public Health Psychology by Thomas von Lengerke (16) (2001)
• American Psychological Association book on Integrating Behavioural and Social Sciences with public health (2001)(17)
• Secondment of two Health Psychologists to the government’s Division of Public Health (2003)
• National Consumer Council review of health-related campaigns and social marketing, ‘It’s Our Health!’ (2006)(18)
• NICE Guidance on behaviour change: general approaches (2007)(19)
• Funded places for Health Psychology training (stage 2) through the Scottish Health Boards and National Health Service (NHS) (2008).
• Evidence based public health: a review of the experience of NICE in developing public health guidance (20)
• Behavioural and Social Sciences Teaching in Medicine published “A Core Curriculum for Psychology in UK Undergraduate Medical Education” (2010)(21)
• House of Lords Science and Technology Select Committee on Behaviour Change (2011)
• Public Health England created with a specific Behavioural Insights function (2013)
• Behavioural Science in Public Health Network (BSPHN) founded (2013)
• Local Government Association briefing on ‘Changing Behaviours in Public Health’ (2013)(14)
• NICE Guidance on behaviour change: individual approaches (2014)(22)
• Behavioural Experiments in Health Network founded (2015)
• PHE and British Psychology Society’s Division of Health Psychology briefing on ‘Why Directors of Public Health need to know a Health Psychologist’ (2015)(23)
• Behavioural Experiments in Health Network (BEH-net) launched its international workshop, now in its fifth edition (2015)
• European Health Psychology Society monograph on Health Psychology (2016)
• Behavioural and Social Sciences Teaching in Medicine published “A Core Curriculum for Sociology in UK Undergraduate Medical Education” (2016)(24)
• Local Government Association’s briefing on ‘Behavioural insights and health’ (2016)(14)
• Academy of Medical Sciences launch “Health of the Public 2040” (2016)(25)
• National Academy of Social Sciences Campaign for Social Science launches “The Health of People: How the Social Sciences can improve population health” (2017)(26)
• London School of Economics launched the first Executive MSc course in “Behavioural Science for Health” (2017)
• Competencies developed and applied to lifestyle services in Hertfordshire (2017) and Solihull, based on the Dixon and Johnston behaviour change competency framework
• Behavioural Experiments in Health Network and three universities launch the first PhD Summer School in Behavioural and Experimental Health Economics (2018)
• Social science evidence used in development of NICE guidelines on topics such as Active Travel and Environmental Interventions

What can behavioural and social sciences contribute to public health?

Behavioural sciences bring rigour and discipline to intervention design, development, and evaluation. They use explicit theories and models, which can underpin interventions, and provide a cumulative evidence base of what works. Behavioural and social scientists have valuable research and methodological skills, in some cases these can lead to new avenues for public health, such as the ability to use large datasets to inform practice. They can contribute quantitative and qualitative skills for evaluation, to understand what works, how it works, why, and for whom. As noted earlier, we recommend that public health simultaneously draws on multiple skills and expertise from the behavioural and social sciences in a transdisciplinary approach.

In this section we demonstrate how the behavioural and social sciences have contributed to improving the public’s health and the opportunities they present to build on current practice and improve the effectiveness of interventions with two examples: tobacco control and tackling obesity.

Tobacco control

The biggest public health success story of the 21st century may very well be the reduction in tobacco use and smoking-related diseases. It also demonstrates how the behavioural and social sciences can be usefully applied to public health issues.

A broad range of insights and evidence from behavioural and social sciences have been used to understand and develop a range of interventions to address this significant public health issue. The interventions have been implemented at various levels, from the political, to the environmental, to the individual, and include informing the population of the risks associated with smoking, so that they would understand the problem, and then: providing evidence-based stop smoking services to support people attempting to go smoke free, providing a national accessible training programme for practitioners, increasing tobacco taxes, banning advertising, banning smoking in public places, and requiring plain packaging.

The greatest benefits to health are likely to result when social structural changes are combined with more targeted interventions. For example, in the case of tobacco control, raising tobacco taxes has clearly played an important role but when it was used as the only tobacco control measure in the 1990s there was no corresponding reduction in prevalence. The ban on smoking in indoor public spaces has been a huge success in protecting the health of non-smokers, but its effect on smoking prevalence remains uncertain. Social marketing campaigns, including No Smoking Day and Stoptober, have shown good evidence of being effective and highly cost-effective. Targeted clinical interventions, in the form of brief opportunistic advice from physicians and pharmacists, and provision of stop-smoking support, have led to a substantial increase in quitting. (26)

Tobacco control has also tackled health inequalities, when done in a targeted way. For example, Stop Smoking Services reduced health inequalities when they were well targeted to certain groups, such as the sick and disabled, manual workers, and those with mental health problems (29, 30, 31). The Marmot Review concluded that “Tobacco Control is central to any strategy to tackle health inequalities, as smoking accounts for approximately half the difference in life expectancy between the lowest and highest income groups” (2).

Upstream interventions

Downstream interventions

Tackling obesity across the life course

Obesity is a complex contemporary public health problem that involves a range of social, environmental, individual, physiological, biological and cultural components. Halting (and ultimately reversing) the current obesity epidemic requires systemic change by taking a holistic view that addresses the individual, social, environmental, and fiscal influences over the long term.

Strategies to tackle obesity, at a national and local level, include a mix of preventative population level approaches (e.g., the soft drinks industry levy, improving the nutrient content of food and drink at the point of purchase); curative secondary prevention services (e.g., family and adult weight management services); and targeted community asset based approaches. Alongside this, it is imperative to create local places that promote healthier defaults through our built, active, and food environment. Applying behavioural and social sciences and building behavioural insights into the design of these approaches is key, and is already contributing to the delivery of both population approaches at a systems level and targeted individual interventions.

What are behavioural and social sciences?

The richness and diversity of behavioural and social scientific disciplines is impossible to encompass in a strategy document, and there are many more than we have chosen to represent in brief here. Those summarised in the sections below are chosen purposefully as examples of disciplines where there has been, or currently is, fruitful engagement with public health disciplines, and where there are insights which are valuable. It is not any indication or suggestion that those not included here are not valuable or important. Figure 3 shows how a larger, though still not comprehensive, list of disciplines can inform different aspects of public health, taking a systems approach with both upstream and downstream factors.

Although we set out illustrative examples of the contributions of different disciplines, our aim is to support the interdisciplinary application of the behavioural and social sciences. Indeed, it is sometimes difficult to say which discipline is responsible for a particular approach or framework, so our classification is necessarily somewhat imprecise. This simply highlights our broader point that exemplar applications of behavioural and social sciences do not follow disciplinary boundaries and that our application of behavioural and social science to public health needs to be transdisciplinary and issue-based.

In what follows, we focus on the contribution of behavioural and social sciences to understanding behaviour and behaviour change, but all of these disciplines can also contribute quantitive and qualitative methods for evaluation, in order to answer such questions as what is happening and why, what interventions work and why, and for whom.

A. Anthropology

Anthropology is the study of human cultures and societies. Anthropology has made important methodological contributions to public health, in particular through the use of ethnography (explained below) to better understand the spread of infection and adopting healthier practices. Anthropological approaches can also contribute to the translation of scientific knowledge into effective practice at the community level.

Key concepts and theories

The focus on cultures, societies and communities can be applied to digital projects (e.g., in the discovery phase, when research is done on whether users need the service that it is proposed to build and what other services exist).

Tools and frameworks

Ethnography: a form of qualitative inquiry used to gain insight into the lived experience of individuals and groups, where the researcher is embedded in the society or group that is being studied and observes behaviour in order to develop insights. ‘Focused ethnography’, which studies specific beliefs and practices of a particular group of people, has been adopted for work in health (56).

B. Economics

Behavioural economics

Behavioural economics takes into account theories, insights, and methods from economics, psychology, and other disciplines (sociology, anthropology, philosophy, but also biology, neuroscience, medicine) to improve the descriptive power of economic models of decision making. Traditional economics is based on a model of rational decision making. The behavioural economics approach builds on, and departs from, traditional economics by acknowledging that human decision making and behaviour are not always fully rational and optimal, and may be subject to biases and heuristics. It discovers and diagnoses biases through testing the assumptions of the rational choice model, and it implements psychological insights into standard economic models. Behavioural economics can contribute to public health by enhancing our understanding of how humans behave and make decisions (in contrast with how they should behave and make decisions), thus informing the design of effective policy interventions.

Key concepts and theories

Non-standard beliefs: while traditional economics assumes that people’s beliefs are formed in a rational manner based on all available evidence, behavioural economics allows that people may have systematically incorrect beliefs because of biases in the way beliefs are formed.

Non-standard preferences: traditional economics assumes that people are time-consistent (that they have the same preferences about future plans at different points in time), that they only care about their final outcomes, and that they are rationally self-interested; behavioural economics allows that people are time-inconsistent, that they care about whether an outcome is a gain or a loss and may be particularly averse to losses, and that they may also care about other people’s wellbeing.

Non-standard decision making and behaviour: traditional economics assumes that decisions are consistent and optimal, given a person’s preferences; behavioural economics allows, for instance, that people may use suboptimal heuristics, that they may have limited attention, that they may be affected by the framing of the decision, or that their choices may be affected by their emotional state.

Key frameworks and tools for public health practitioners

Nudge (57): we can change behaviour through ‘nudges’, altering the way choices are presented without restricting any options.

MINDSPACE (58): a framework to develop behaviourally informed interventions, including insights from psychology and behavioural economics.

EAST (59): a framework to support the application of behavioural insights to public policy, including insights from psychology and behavioural economics.

What is Really ‘Behavioural’ in Behavioural Health Policy? (60): a conceptual framework for preference-based policies, information-based policies, incentives, nudges, regulation, taxation, and ‘behaviourally super-charged’ health policies.

Behavioural Insights in Healthcare (61): an quick scoping review, summarising the evidence of the application of nudge-type interventions in health care and considering opportunities for reducing inefficiency and waste in health care using nudge-type interventions.

The Behavioural Experiments in Health Economics checklist (62): an Oxford Research Encyclopaedia toolbox to navigate 10 key areas of potential challenge/debate about applying behavioural economics experiments to health.

Test, Learn, and Adapt (63): a guide to using Randomized Controlled Trials (RCTs) to evaluate policy interventions.

Public and health economics

Public and health economics have contributed to the design of public interventions and incentive frameworks in public and health-related sectors and organisations. In particular, public economics has proposed a fundamental tri-partition of public finance functions into (i) economic stabilization, (ii) income redistribution, and (iii) resource allocation. Economic stabilization is achieved through both fiscal and monetary policies. Income redistribution is achieved through taxation and provision of subsidies, public goods, and social services, including healthcare. Resource allocation is achieved through direct public provision of public goods and social services, and through regulation of private markets, including price regulation.

Building on the public economics framework, health economics has proposed a rationale for public intervention in the health and healthcare sectors in all the instances where those sectors are characterised by market failures, namely: public goods, externalities, asymmetric information, and monopoly. Health economics has contributed to informing the design and implementations of behavioural interventions embedded within health systems and to evaluating their macro-level impact, including also any unintended spillover effects across different stakeholders. Health economic modelling can further help to identify cost-effective interventions and potential return on investment, which is necessary when presenting invest-to-save under the preventative agenda.

Key concepts and theories

Market failures: Any time the health and healthcare sectors are characterised by the presence of public goods, externalities, asymmetric information, or monopoly, there is a rationale for public intervention in health.

C. Behavioural operational research

Operational research uses modelling to find optimal solutions to complex decisions; behavioural operation research is a sub-field that studies behavioural factors affecting model-based problem solving and decision making processes. It evaluates three aspects of model-based problem solving and decision making processes (64): (i) behaviour in models (how human behaviour is represented in models and how variations in behaviour impact model outcomes); (ii) behaviour with models (how decision makers use models to inform their decisions); and (iii) behaviour beyond models (how models impact upon organisational processes and behaviour). Behavioural operational research can help with the improvement of screening campaigns, policy making in the management of long-term conditions, workforce planning, optimisation of resources in organisational units (e.g. hospital, A&E areas, bed utilisation), and facilitation of organisational change programmes, to name a few examples (65).

Key frameworks and tools for public health practitioners

Behavioral Operational Research, Theory, Methodology and Practice (64): an overview that connects together theory, methodology and practice and offers the “state of the art” on Behavioral Operational Research theory and practice.

Special Issue “Healthcare Behavioural OR” to be published by the Journal of the Operational Research Society (forthcoming in 2018/9), including a review of implementation of behavioural aspects in the application of OR in healthcare (65).

D. Psychology

Psychology is a broad set of disciplines and perspectives, which range from the study of individual cognition to the study of group behaviours and many more aspects besides. For example, the psychology of leadership and diversity is of increasing importance to public health practice.

The aspiration underlying this strategy is to integrate the use of science and disciplines but here we discuss just three disciplines – health psychology, cognitive psychology, and social psychology – as starting points for public health’s engagement with the broad spectrum of psychologies.

Health psychology

Health Psychology uses the biopsychosocial model to promote and maintain health, enhance the wellbeing of those affected by illness and disease, and improve the health care system and support health policy formation. Behaviour is complex and often people are unaware that they are engaging in detrimental behaviours, or feel unmotivated or unable to make a change. Understanding how people think, feel and learn can help us to understand and predict how they will act, and to understand how to change behaviours for better health. Within public health, health psychology can be used to identify target behaviours for change, create a behavioural diagnosis of key determinants of behaviour, identify behaviour change techniques and ways to effectively deliver them (e.g. education, incentivisation, restructuring the environment), develop and evaluate services, suggest low-cost changes to existing interventions and identify how best to communicate risk.

Key concepts and theories

Behaviour change theories and models, such as COM-B (Capability, Opportunity, Motivation – Behaviour) (29, 30) take into consideration the dual-process of motivation via conscious (reflective) and less conscious (automatic) decision-making processes including habits, impulses and drives.

The Health Action Process Approach (65): introduces the distinction between motivation to change behaviour and the enactment of this motivation, integrating a range of self-regulation processes.

Key frameworks and tools for public health practitioners

Intervention development frameworks:

• Intervention Mapping (66), a step-by-step approach to intervention development;
• the Person-Based Approach (67), a ‘person-centred’ approach to developing digital health interventions which combines ongoing qualitative research at all stages of development with the identification of guiding principles that highlight the ways the intervention will address behavioural issues;
• the Experimental Medicine Model (68) a programmatic approach which emphasises experimental testing of targets or mechanisms of change;
• Multiphase Optimization Strategy (MOST) (69), a three stage process for digital design in which intervention components are screened, refined and confirmed.

Combining psychological theories: the Theoretical Domains Framework (70).

Building intervention content:

• the Behaviour Change Technique (BCT) Taxonomy (71), with free BCT Online training;
• Oxford Food and Activity Behaviors (OxFAB) taxonomy and questionnaire to explore the cognitive and behavioral strategies used by individuals during weight management attempts (72).

The TIPPME (Typology of Interventions in Proximal Physical Micro-Environments) intervention typology for changing environments to change behaviour (73).

Delivery approaches: Motivational interviewing, an approach used to increase motivation to change behaviours (74).

Networks to support intervention developers:

• the Behavioural Science and Public Health Network (BSPHN) (formerly the Health Psychology in Public Health Network) for practitioners and academics, a community of practice for those working within the behavioural and social sciences and public health to come together to share best practice both virtually and physically at regular events;
• the Division of Health Psychology, a society membership for health psychologists trained in intervention design, delivery and evaluation.

Manchester Implementation Science Collaboration open access elearning website about behaviour change for health professionals.

Division of Health Psychology’s specialist knowledge database (available from September 2018).

Cognitive psychology

Cognitive psychology is the study of internal mental processes such as attention, language use, memory, perception, problem solving, and thinking.

Key concepts and theories

Dual-process theories (75): propose that human cognition can be conceptualised as two types of processes: System 1 (automatic, fast, and non-conscious) and System 2 (slow, deliberative and conscious). The idea that people often use mental shortcuts and rules of thumb to speed up decision making can inform interventions to support positive health decision making (76).

Key frameworks and tools for public health practitioners

Review of cognitive biases and heuristics in medical decision making (77).

Review of how cognitive biases affect clinicians (78).

Social psychology

Social psychology is the scientific study of how people's thoughts, feelings, and behaviours are influenced by the actual, imagined, or implied presence of others (79). Social psychology is an interdisciplinary domain that bridges the gap between psychology and sociology.

Key concepts and theories

Social norms: these are implicit rules about behaviours and standards that are socially acceptable and/or commonly enacted by relevant others. Social norms can be descriptive (what others do) or injunctive (what others approve of).

Social comparison theory (80): this theory proposes that individuals are motivated to compare themselves with others when evaluating their behaviours, attitudes and opinions, and to adjust behaviour accordingly.

Social learning theory (81): this theory suggests that individuals learn behaviours via observational learning of others performing the behaviour.

Theory of reasoned action (82, 83): this theory sees intention as the main determinant of behaviour and, in turn, intention is determined by a person's attitudes towards that behaviour and the subjective norms of influential people and groups that could influence those attitudes.

Theory of planned behaviour (84): this theory builds on the theory of reasoned action by including the individual’s perceived behavioural control over the outcome as a factor influencing the probability of undertaking a behaviour.

Key frameworks and tools for public health practitioners

Behaviour-centred design (85): unites the latest findings about how brains learn with a practical set of steps and tools to design successful behaviour change programmes.

E. Sociology

Sociology examines the individual’s social action (agency) and the community’s social and physical context (structure). The focus lies predominantly on the context in which people live, interact, work, and play (rather than on the individual, which is the focus of psychological disciplines).The influence of social class on health status, health behaviour, and access to and use of health services, is one of the earliest and most examined social influences on health.

Key concepts and theories

Social determinants approach to public health (86): public health programmes that intend to address social determinants and to have a great impact on health equity.

Social practice theory (87): the study of social practices and how they change over time, incorporating an understanding of both individual human agency and the social structures that individuals act within.

Normalisation process theory (88): this theory is concerned with factors that promote or inhibit the implementation of complex interventions, from early implementation up to the complete integration (or normalisation) of the intervention into everyday practice. It can be useful for developing and evaluating interventions.

Social model of health (89): this model depicts the relationship between the individual, the contexts in which they live (i.e., from social communities to wider socioeconomic and structural factors), and their health.

Key frameworks and tools for public health practitioners

ISM Model (90, 91): a practical tool for designing effective policy interventions, bringing together Individual, Social, and Material factors that affect behaviour..

Social Model of Health (92): this model depicts the relationship between the individual, the contexts in which they live (i.e., from social communities to wider socioeconomic and structural factors), and their health.

F. Other useful public health tools

• The Behaviour Change Wheel (32, 33) is a synthesis of 19 frameworks from multiple domains, sectors and disciplines. It includes COM-B at the hub (capability, opportunity, motivation as influencing factors in a model of behaviour), surrounded by ‘intervention functions’ to deliver behaviour change techniques (BCTs) and ‘policy categories’ as the outer layer.
• EPOC taxonomy
• TIDieR for reporting of interventions: template, checklist and guide
• PARiHS framework for implementing research into practice
• Health Behaviour Change Competency framework
• Lifeguide for creation of interactive web-based interventions
• NIHR/CIHR Guidance on taking context into account in population health research (forthcoming)

Evaluation

• MRC Guidance on developing and evaluating complex interventions
• MRC Guidance on process evaluation of complex interventions
• MRC Guidance on natural experimental evaluations
• The Magenta Book – HM Treasury guidance on evaluation
• PHE Resources for Evaluation in Health and Wellbeing
• Frameworks for evaluability assessment

Leadership and delivery organisations

Leadership is vital to enhance the delivery of the behavioural and social sciences in the public health system and to embed transdisciplinary approaches. Without a concerted and systematic drive, strengthening practitioners’ capability within the system is likely to be patchy and sporadic. As an initial step, this strategy focuses on the national public sector players, but we recognise that many others – voluntary and community organisations, employers, private sector agencies, faith communities, and more – have a very important part to play. The key stakeholders that contributed to discussions about this strategy, who are acknowledged in the appendix, are grouped as follows:

• National policy and delivery organisations
• National professional societies, learned bodies, and networks
• Research funders, thought leaders, and think tanks
• Royal Colleges and Academies

The infographic below proposes a systems map of these stakeholders and their primary role in delivering or enabling the use of the behavioural and social sciences in public health (Figure 4).

The first steps to implementation and a road map

Leadership of our organisations

Make available knowledge and skills from the behavioural and social sciences mainstream within all organisations that commission, research, design, deliver or evaluate public health services:

1. Key stakeholders develop implementation plans to deliver on their functions of this strategy
2. Senior leadership of stakeholders subscribe to the strategy and provide support to staff who are leading on behavioural and social sciences
3. Promote the employment of people with behavioural and social science training directly within public health teams, to support public health organisations in developing this specialised skill set

Wider system leadership

System leaders commit to a systems thinking approach, to work collaboratively across organisations, to be aware of how complexities affect the impact of their work, and to use transdisciplinary approaches where appropriate:

1. Acknowledge the value added from behavioural and social sciences, advocate for them, and celebrate success
2. Encourage synergistic approaches to change behaviour across individual, group and population levels (where appropriate)
3. Provide topic-based leadership for various public health functions (e.g., Making Every Contact Count, health literacy, self care, tobacco, obesity, physical activity, alcohol, occupational health, immunisation, screening etc.)
4. Promote evaluation of behavioural and social science interventions and behavioural and social science approaches
5. Facilitate coordination of activities and resources across the system
6. Encourage systematic investigation of the cost-effectiveness of interventions
7. Use a comprehensive approach to identify key behaviours that need to change

Access to expertise

Assist policy makers and decision makers to understand and apply evidence and approaches from behavioural and social sciences to public health problems:

1. Increase opportunities and resources for behavioural and social science experts to work with policy-makers and practitioners
2. Map and increase opportunities for fellowships, placements, and internships for behavioural and social science academics into non-academic organisations
3. Signpost to centres of excellence for behavioural and social science

Tools and resources

Support the development, continuous improvement, and implementation of a coherent and systematic framework for a behavioural and social science approach through the provision of a range of tools and resources:

1. Develop and promote tools to enable practitioners, policy makers and commissioners to use behavioural and social sciences
2. Produce and update intervention design, practice, and commissioning guidelines
3. Develop and optimise access to behavioural and social science tools and frameworks (e.g. quality standards, evaluation frameworks, commissioning templates)
4. Agree a quality framework and processes for how and when to apply existing tools

Capacity building

Build a public health workforce that is appropriately skilled and competent to commission and deliver behavioural, social and structural interventions:

1. Conduct a needs assessment of the level of behavioural and social science knowledge and skills required by segments of the workforce
2. Strengthen behavioural and social sciences (knowledge, skills, use) in pre- and post-service training, and focus on practice change
3. Leverage financial incentives for the workforce to develop capability, opportunity, and motivation
4. Develop training pathways at all levels of expertise
5. Ensure that behavioural and social sciences in professional competencies and standards are implemented and assessed effectively
6. Regulate and support professional requirements where appropriate
7. Consider an accreditation system for behavioural and social science providers to give quality assurance
8. Provide online training and development resources
9. Facilitate workshops and scientific meetings

Research and translation

Advocate for behavioural and social science research funding streams in public health and the development of collaborative and multidisciplinary research capacity (with a focus on applied approaches):

1. Strengthen the portfolio of health research with increased support for research involving behavioural and/or social science
2. Encourage representation of behavioural and social scientists on funding panels
3. Develop new funding streams for implementation science, which may include the use of behavioural and social sciences, to promote the uptake of behavioural and social science research findings into clinical, organisation and policy contexts
4. Encourage research funders to collaborate in the funding of multi-disciplinary research
5. Encourage funding of knowledge exchange and impact generation capacity, capability, and activity, to make best use of high quality evidence that is fit for purpose and enable academics to work with policy makers and practitioners
6. Continue to judge behavioural and social science funding applications based on pathways to impact plans and engagement with end users
7. Encourage collation and funding of datasets that collect behavioural and social science data that can inform public health research and policy
8. Encourage funders to support multi-disciplinary training for researchers from MSc studentships to post-doctoral research posts, including new training avenues to support multi-disciplinarity
9. Support the development, uptake and adoption of behavioural and social science innovations in the health and social care system

Communities of practice

Strengthen or establish vibrant networks/communities of practice, improve quality of service, and promote exchanges of scientific information and professional experience:

1. Facilitate knowledge of resources available across the system
2. Map and strengthen liaison between organisations
3. Support early career networks
4. Strengthen collaboration across disciplines and between different functions of the public health system
5. Strengthen links and knowledge transfer between behavioural and social science research centres that produce high value evidence, and the public health professionals that use it

Key stakeholder acronyms

This section describes the key organisations involved in the planning, delivery and evaluation of behavioural sciences and their application to public health.

National policy and delivery organisations

Association of Directors of Public Health (ADPH)

Represents and supports the practice of Directors of Public Health (DsPH). Captures and disseminates the views of DsPH, identifies and engages with the training needs of individuals holding the role and seeks to influence public health policy in line with the views of membership.

Department for Health and Social Care (DHSC)

Responsible for government policy on health and adult social care. Supports and advises ministers to develop policy, sets direction in terms of domestic and international health, operates in oversight of health and care framework and of arm’s length bodies.

Faculty of Public Health of the Royal College of Physicians of the United Kingdom (FPH)

Drives the training and ongoing professional standards of public health professionals, promotes research and understanding of public health and partners at a local and national level to improve public health policy practice.

General Medical Council (GMC)

Ensures that newly qualified doctors are able to apply social science principles, methods and knowledge to medical practice and integrate these into patient care. It provides quality assurance for the delivery of education and training and promotes the pursuit of evidence-based improvement in the quality of care.

Health Education England (HEE)

Leads on the development of the core PH workforce including specialists, practitioners, and the wider PH workforce. It commissions education and training in line with its mandate from Government.

Local Government Association (LGA)

The national voice of local government. We work with councils to support, promote and improve local government. We are a politically - led, cross party organisation which works on behalf of councils to ensure local government has a strong, credible voice with national government. We aim to influence and set the political agenda on the issues that matter to councils so they are able to deliver local solutions to national problems.

National Institute for Health and Care Excellence (NICE)

Non-departmental public body providing national evidence-based guidance and advice to improve health and social care. Provides guidance for public health, health has social care practitioner and information services for commissioners, practitioner and managers and develops quality standards and performance metrics for commissioners and providers of public health, health and social care.

NHS England (NHSE)

Responsible for arranging the provision of health services in England. Sets priorities and direction for the NHS, commissions healthcare services and assesses and supports clinical commissioning groups in accordance with its government mandate.

NHS Improvement (NHSI)

Responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. We offer the support these providers need to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. By holding providers to account and, where necessary, intervening, we help the NHS to meet its short-term challenges and secure its future.

Public Health England (PHE)

Brings together public health professionals, scientists and researchers to provide evidence-based professional, scientific expertise and support focused on improving health and wellbeing and reducing health inequalities. It delivers specialist public health services, provides practical advice to LGAs and partnership with the NHS and NHS Improvement. Behavioural science is embedded in teams and directorates and through specialist teams which strengthen the behavioural science component of projects and trials and shares knowledge and expertise.

National professional societies and networks

Behavioural Experiments in Health Network (BEH-net)

An international network of researchers and practitioners whose mission is to foster the use of experimental methods and behavioural insights in health economics, policy, management, and practice, and to inform policy and management interventions in the area of health and healthcare.

Behavioural Science and Public Health Network (BSPHN, formally the Health Psychology in Public Health Network)

Brings together and provides a forum for behavioural and social scientists, health psychologists and public health specialists to increase the synthesis between behavioural science and public health.

British Psychological Society Division of Health Psychology

Applies its science to the prevention, promotion and maintenance of health and wellbeing and the analysis and improvement of the healthcare system and health policy formation. It also works to develop professional skills in research, consultancy, teaching and training.

British Psychological Society Division of Occupational Psychology

Undertakes activities to support well-being within the work environment.

British Society of Criminology (BCS)

A network of academics and professionals who are engaged with research, teaching or practice related to crime, criminal behaviour and the justice systems in the UK.

British Sociological Association (BSA)

Has the primary objective of promoting sociology through events, journals, a professional network and special interest groups, and representation on key bodies both nationally and internationally to influence policies.

European Health Psychology Society (EHPS)

Brings together an international network of health psychologists to promote research and application of health psychology across Europe. Promotes interchange of information with other professional psychological societies and has formal association with the UN.

Operational Research Society (OR)

Supports the application of appropriate analytical methods to help those who run organisations make better decisions. Its focus is on improving the complex social and technical systems and processes that underpin everybody’s daily lives. Operational Research is the 'science of better'.

Society of Social Medicine (SSM)

Aims to promote the development of scientific knowledge in social medicine through multi-disciplinary scientific meetings, networking, communications and input to policy consultations.

UK Society for Behavioural Medicine (UKBSM)

Helps to build capacity in the behavioural sciences by promoting exchange of scientific knowledge and professional experience, formal meetings and collaborative undertakings, and raising the profile of behavioural medicine in science and health policy.

Research funders, thought leaders and think tanks

Economic and Social Research Council (ESRC)

A member of UK Research and Innovation; funds high quality social science research, collection of social and biosocial datasets, knowledge exchange, and impact generation to make the best use of social science evidence for impact on policy and practice.

Medical Research Council (MRC)

A member of UK Research and Innovation; supports research in universities and hospitals, and its own units, centres and institutes in the UK, and in its units in Africa.  The MRC supports research across the entire spectrum of medical sciences, including infections and immunity, molecular and cellular medicine, neuroscience and mental health, population and systems medicine, global health and translational research.

National Institute for Health Research (NIHR)

Funds health and care research, and translates discoveries into practical products, treatments, devices and procedures, involving patients and the public in all its work. The NIHR ensures that the NHS is able to support the research of other funders to encourage broader investment in, and economic growth from, health research. It works with charities and the life sciences industry to help patients gain earlier access to breakthrough treatments and it trains and develop researchers to keep the nation at the forefront of international research. The NIHR is funded by the Department of Health and Social Care to improve the health and wealth of the nation through research.

UK Research and Innovation (UKRI)

A body which works in partnership with universities, research organisations, businesses, charities, and government to create the best possible environment for research and innovation. Operating across the whole of the UK with a combined budget of more than £6 billion, UKRI brings together the seven Research Councils, Innovate UK and Research England. Supported and challenged by an independent chair and board, UKRI is principally funded through the Science Budget by the Department for Business, Energy and Industrial Strategy (BEIS).

Wellcome

Funds a broad spectrum of high quality research across science and humanities and social science disciplines. Schemes support researchers at all stages of the career spectrum and fund the highest calibre collaborative research projects. Population Health at Wellcome has a strategic focus on understanding health and disease, the design of effective interventions and using knowledge more effectively. Wellcome currently supports the “Human Behaviour Change Project” and the “Behaviour Change By Design” research programmes amongst others relevant to this space.

Royal Colleges and Academies

Academy of Medical Sciences

Comprising elected fellows drawn from biological sciences, clinical academic medicine, public and population health, technology implementation, veterinary, dentistry medical and nursing care and underpinning disciplines. Celebrates excellence amongst medical science research, draws upon membership and evidence-base to provide advice and support, identifies and addresses support needs in the medical science community and fosters collaboration between academics, the NHS and industry and with international partners.

Academy of Royal Medical Colleges

Coordinating body for the UK and Ireland’s medical Royal Colleges which provide development or training in one or more medical speciality. Supports consistency in training and practice, contributes to training and ongoing development for postgraduate, qualified and international doctors.

Academy of Social Sciences

Comprising individual Fellows composed of academics and practitioners from academia, the public and private sectors, learned societies and affiliates. It produces and disseminates theoretical and applied social sciences research, provides training and events and operates as a bridge between the social science community and governments.

Royal College of General Practitioners (RCGP)

Provides education and training for over 50,000 GPs in the UK to understand how behavioural and social sciences can be implemented to support the delivery of high levels of care and address the challenges facing primary care and receive continued professional development.

Royal College of Nursing (RCN)

Supports the education, professional development and professional practice of nurses – to enable them develop the skills to support people with behaviour change through their understanding of local issues and communities.

Royal College of Physicians (RCP)

Supports and provides education and training to physicians in the UK including the provision of training curricula and exams for physicians and guidelines for care. Develops evidence-based policy focused on person-centred care, public health challenges and academic medicine and research.

Royal Pharmaceutical Society (RPS)

Represents pharmacists in Great Britain. Provides professional development and accreditation to members and the industry, provides medicines information and advice and promotes and commissions research to improve practice and patient care and safety.

References