Behaviour change: general approaches

This guideline covers a set of principles that can be used to help people change their behaviour. The aim is for practitioners to use these principles to encourage people to adopt a healthier lifestyle by, for example, stopping smoking, adopting a healthy diet and being more physically active.

# Introduction
The Department of Health asked NICE to produce public health guidance on the most appropriate generic and specific interventions to support attitude and behaviour change at population and community levels.
This guidance provides a set of generic principles that can be used as the basis for planning, delivering and evaluating public health activities aimed at changing health-related behaviours. The guidance should be read in conjunction with other topic-specific public health guidance issued by NICE. It does not replace any of this guidance.
Future NICE guidance that aims to change people's behaviour will be based on the principles outlined in this guidance.
The guidance is for NHS and non-NHS professionals and others who have a direct or indirect role in, and responsibility for, helping people change their health-related knowledge, attitudes and behaviour. This includes national policy makers in health and related sectors (including those with a responsibility for planning or commissioning media, marketing or other campaigns), and commissioners, providers and practitioners in the NHS, local government, the community and voluntary sectors. It is also relevant for the research community (including those who oversee research funding), social and behavioural scientists, and health economists working in the area of health-related knowledge, attitude and behaviour change.
The Programme Development Group (PDG) has considered a range of evidence, key theories, economic data, stakeholder comments and the results of fieldwork in developing these recommendations.
Details of membership of the PDG are given in appendix A. The methods used to develop the guidance are summarised in appendix B. Supporting documents used in the preparation of this document are listed in appendix E. Full details of the evidence collated, including fieldwork data and activities, are available, along with a list of the stakeholders involved and their comments.# Public health need and practice
There is overwhelming evidence that changing people's health-related behaviour can have a major impact on some of the largest causes of mortality and morbidity. The Wanless report (Wanless 2004) outlined a position in the future in which levels of public engagement with health are high, and the use of preventive and primary care services are optimised, helping people to stay healthy. This 'fully engaged' scenario, identified in the report as the best option for future organisation and delivery of NHS services, requires changes in behaviours and their social, economic and environmental context to be at the heart of all disease prevention strategies.
Behaviour plays an important role in people's health (for example, smoking, poor diet, lack of exercise and sexual risk-taking can cause a large number of diseases). In addition, the evidence shows that different patterns of behaviour are deeply embedded in people's social and material circumstances, and their cultural context.
Interventions to change behaviour have enormous potential to alter current patterns of disease. A genetic predisposition to disease is difficult to alter. Social circumstances can also be difficult to change, at least in the short to medium term. By comparison, people's behaviour  as individuals and collectively  may be easier to change. However, many attempts to do this have been unsuccessful, or only partially successful. Often, this has been because they fail to take account of the theories and principles of successful planning, delivery and evaluation. At present, there is no strategic approach to behaviour change across government, the NHS or other sectors, and many different models, methods and theories are being used in an uncoordinated way.
Identifying effective approaches and strategies that benefit the population as a whole will enable public health practitioners, volunteers and researchers to operate more effectively, and achieve more health benefits with the available resources.

# Health inequalities
Social and economic position is directly linked to health. In the UK, there is a health inequalities gradient, with the least advantaged experiencing the worst health. Social and economic conditions can prevent people from changing their behaviour to improve their health, and can also reinforce behaviours that damage it.
Health inequalities are the result of a set of complex interactions, including:
the long-term effects of a disadvantaged social position
differences in access to information, services and resources
differences in exposure to risk
lack of control over one's own life circumstances
a health system that may reinforce social and economic inequalities.
These factors all affect people's ability to withstand the stressors  biological, social, psychological and economic  that can trigger ill health. They also affect the capacity to change behaviour.

# Changing behaviour
Actions to bring about behaviour change may be delivered at individual, household, community or population levels using a variety of means or techniques. The outcomes do not necessarily occur at the same level as the intervention itself. For example, population-level interventions may affect individuals, and community- and family-level interventions may affect whole populations.
Significant events or transition points in people's lives present an important opportunity for intervening at some or all of the levels, because it is then that people often review their own behaviour and contact services. Typical transition points include: leaving school, entering the workforce, becoming a parent, becoming unemployed, retirement and bereavement.
This guidance provides a systematic, coherent and evidence-based approach, considering generic principles for changing people's health-related knowledge, attitudes and behaviour, at individual, community and population levels.
Strategies for reaching and working with disadvantaged groups are considered and the health equity implications assessed.# Considerations
The Programme Development Group (PDG) took account of a number of factors and issues in making the recommendations.

# Key theories
The PDG was influenced by a number of different theories, concepts and accounts of behaviour and behaviour change, drawn from the social and behavioural sciences. These include: resilience, coping, self-efficacy, planned behaviour, structure and agency, 'habitus' and social capital. (Ajzen 1991, 2001; Antonovsky 1985, 1987; Bandura 1997; Bourdieu 1977, 1986; Conner and Sparks 2005; Giddens 1979, 1982, 1984; Lazarus 1976, 1985; Lazarus and Folkman 1984; Morgan and Swann 2004; Putnam 2000; for more details, see appendix A.)
The PDG discussed efforts to use policy and legislation to change behaviour (although relatively little formal evidence on legislation was identified). Such measures tend to work through a combination of awareness-raising, compulsion and enforcement, providing legislative or environmental 'structure' to the decisions people make about their behaviour. It was noted that legislation can appear to be a simple and powerful tool, and the evidence suggests that introducing legislation, in conjunction with other interventions, can be effective at the individual, community and population levels. However, it also suggests that it can be subject to contingencies and side effects, including criminalisation, compensating or displaced behaviour, and lack of public support (Gostin 2000; Haw et al. 2006; WHO 2005).
The PDG observed that people's health behaviours may change, depending on their social and material circumstances and their time of life. It was also noted that many other factors (such as place of birth, parental income, education and employment opportunities, or the impact of prejudice and discrimination) can have both direct and indirect effects on health, and on people's ability to change, leading to a cumulative effect over the life course (Graham and Power 2004; Kuh et al. 1997). The PDG considered the concept of the life course and evidence was sought on the potential benefits of intervening at key life stages or transition points. Explicit, formal evidence (at the level searched) was scarce.
The PDG further noted that the knowledge and evidence from different disciplines are very different in the concepts they use, the assumptions they make about cause and explanation, and (sometimes) the methods that they favour. Consequently, combining knowledge and evidence from different levels  such as the social and the individual  is extremely difficult. To ensure that as broad a range as possible of knowledge and evidence was taken into account, the PDG adopted a pluralistic approach that acknowledged the value of different forms of evidence and research methods.
The psychological literature is extensive and provides a number of general models of health behaviour and behaviour change. However, the research literature evaluating the relevance and use of these models is inconsistent. For example, it includes multiple adaptations of particular models, poor study designs and studies that fail to take account of all the confounding factors. Having considered some of the more commonly used models of health behaviour, the PDG concluded that the evidence did not support any particular model (although some have more evidence of effectiveness than others). For this reason, it believes training should focus on generic competencies and skills, rather than on specific models. These include the ability to:
critically evaluate the evidence for different approaches to behaviour change
design valid and reliable interventions and programmes, that take account of the social, environmental and economic context of behaviours
Identify and use clear and appropriate outcome measures to assess changes in behaviour
employ a range of behaviour change methods and approaches, according to the best available evidence
regularly review the allocation of resources to interventions and programmes in light of current evidence.

# Definitions
For the purposes of this guidance, human behaviour is defined as: 'the product of individual or collective human actions, seen within and influenced by their structural, social and economic context'. These actions produce observable social, cultural and economic patterns which limit  or enable  what individuals can do. The recommendations in this guidance span the individual, social and group processes involved in human behaviour.
The PDG considered the psychological models showing relationships between knowledge, attitudes and behaviour, according to the various definitions outlined in the identified literature. The PDG noted that for some actions the links between intentions and behaviour can be described precisely. However, simple models do not capture more complex or population-level dynamics.
Although the evidence on psychological models was found to be limited, a number of concepts drawn from the psychological literature are helpful when planning work on behaviour change with individuals. When used in conjunction with recommendations here on planning and social context, these concepts could be used to structure and inform interventions. They include:
-utcome expectancies (helping people to develop accurate knowledge about the health consequences of their behaviours)
personal relevance (emphasising the personal salience of health behaviours)
positive attitude (promoting positive feelings towards the outcomes of behaviour change)
self-efficacy (enhancing people's belief in their ability to change)
descriptive norms (promoting the visibility of positive health behaviours in people's reference groups  that is, the groups they compare themselves to, or aspire to)
subjective norms (enhancing social approval for positive health behaviours in significant others and reference groups)
personal and moral norms (promoting personal and moral commitments to behaviour change)
intention formation and concrete plans (helping people to form plans and goals for changing behaviours, over time and in specific contexts)
behavioural contracts (asking people to share their plans and goals with others)
relapse prevention (helping people develop skills to cope with difficult situations and conflicting goals).
Coordinated attempts to promote or support behaviour change can take a number of forms. These activities can also be delivered at a number of levels, ranging from local, one-to-one interactions with individuals to national campaigns. Many terms are used to describe these activities and sometimes these are used interchangeably (see glossary). Broadly, interventions can be divided into 4 main categories:
policy  such as legislation, workplace policies or voluntary agreements with industry
education or communication  such as one-to-one advice, group teaching or media campaigns
technologies  such as the use of seat belts, breathalysers or child proof containers for toxic products
resources  such as leisure centre entry, free condoms or free nicotine replacement therapy.
This guidance adopts the NICE definitions for public health interventions and programmes, unless another specific term has been used in the literature (such as 'campaign' to refer to a media initiative). See 'The public health guidance development process: an overview for stakeholders including public health practitioners, policy makers and the public' (details in appendix E).
Whether an intervention or programme is delivered to individuals, in community or family settings, or at population level, the effects are rarely restricted to 1 level. For example, a brief primary care intervention aimed at reducing alcohol consumption among individuals could have an impact:
-n the individual's behaviour (for example, level of alcohol consumption, individual health outcomes, or incidence of domestic violence)
-n the local community (for example, local alcohol sales, alcohol-related crime or accident and emergency  events)
at population level (for example, national alcohol sales and consumption, national statistics on alcohol-related crime and A&E events, or demographic patterns of liver cirrhosis).

# Planning and design
The PDG noted that it is important to specify 3 things with respect to any intervention that aims to change behaviour. First, be as specific as possible about its content. Second, spell out what is done, to whom, in what social and economic context, and in what way. Third, make it clear which underlying theories will help make explicit the key causal links between actions and outcomes (Davidson et al. 2003; Pawson 2006; Weiss 1995). The PDG noted that the evidence is often very weak in these respects.
It is important for those planning health improvement interventions to be clear about the behaviours that need to be changed, any relevant contextual changes that also need to be made, and the level at which the intervention will be delivered (individual, community or population). The following questions should be used as a guide:
Whose health are you seeking to improve (target population/s)?
What behaviour are you seeking to change (behavioural target)?
What contextual factors need to be taken into account (what are the barriers to and opportunities for change and what are the strengths/potential of the people you are working with)?
How will you know if you have succeeded in changing behaviour (what are your intended outcomes and outcome measures)?
Which social factors may directly affect the behaviour, and can they be tackled?
What assumptions have been made about the theoretical links between the intervention and outcome?
A range of resources provide access to good quality, up-to-date evidence on the effectiveness of interventions and programmes aimed at changing behaviour. These include: NICE public health guidance, research and review databases (for example, the Database of Abstracts of Reviews of Effectiveness, the Cochrane Library, Medline, and the Social Science Citation Index), and current texts on behaviour change (for example, Conner and Norman 2005). When drawing up plans to change people's behaviour, enough time needs to be set aside to consult these resources to establish which interventions and programmes will be most appropriate.
Time and resources should be set aside for evaluation. The size and nature of the intervention, its aims and objectives and the underlying theory of change used should determine the form of evaluation (see below).
Attempts to change behaviour have not always led to universal improvements in the population's health. For example, different groups (measured by age, socioeconomic position, ethnicity or gender) react differently to incentives and disincentives, or 'fear' messages. Effective interventions target specific groups and are tailored to meet their needs. This is particularly important where health equity is 1 of the goals. Service user views may be helpful when planning interventions.
The cultural acceptability and value of different forms of behaviour varies according to age, ethnicity, gender and socioeconomic position. It is important not to stereotype or stigmatise groups or individuals because of these variations. This can be avoided by working closely with communities over time, by tackling prejudice and discrimination in professional practice, and by using needs assessments to gather local and cultural information to ensure interventions are tailored appropriately.
Changing behaviour may not be a priority for the individuals being targeted. People do not necessarily make their own long-term health a priority and may want to focus on other, more immediate needs and goals (for example, relieving stress, or complying with peer pressure).
Some damaging and, therefore, apparently negative health behaviours may provide positive psychological, social or physical benefits for individuals in certain social and cultural contexts. For example, smoking cigarettes may provide 'time out' for people in difficult circumstances. Effective interventions take account of the social, cultural and economic acceptability of the intervention and the target group's attitudes toward the behaviour. They recognise diversity in the values people use to guide their lives and behaviour.
Interventions may have unintended and negative consequences. When planning an intervention, it is often helpful to conduct a prospective health and equity impact assessment.
No single method can be universally applied to influence all behaviour and all people. Universal interventions do not invariably have uniform effects, and may be more effective among some population groups, or in some settings, than others.
An intervention aimed at changing 1 behaviour may inadvertently lead to other changes. For example, someone who gives up smoking may start eating more food to compensate, leading to other health risks.
Motivated individuals actively seeking to make changes in their behaviour require a different approach from those who are unmotivated. The latter may need more information about the benefits of change, as well a realistic plan of action. Equally, different methods may be required at different times and to reach different people. This guidance identifies the broad principles.
Enabling individuals and communities to develop more control (or enhancing their perception of control) over their lives can act as a buffer against the effects of disadvantage, facilitating positive behaviour change.
A range of cognitive, social and environmental resources can help to boost the resilience of people living in difficult circumstances. These resources can help promote their health and protect them against illness and other negative outcomes. They include a positive attitude to health (leading to positive, health-related behaviours), coping skills and 'social capital', the relationships of trust and reciprocity built up through, for example, friendship, family and faith networks.
Action taken earlier, rather than later, in an individual's life can sometimes be more effective at preventing health-damaging behaviours. Consequently, interventions that focus on children and young people (and usually, their carers too) are important. However, interventions with other population groups can be highly effective and cost effective. An example is action to prevent falls among older people.
All interventions need to be developed and evaluated in stages, using an established approach such as the Medical Research Council's framework for the development and evaluation of complex interventions (Campbell et al. 2000; see also Campbell et al. 2007; Flay 1986; Nutbeam 1998). Such an approach will help ensure interventions are based on the best available evidence of feasibility, acceptability, safety, effectiveness, efficiency or equity.

# Delivery
As well as focusing on individual factors, it is important that policy makers and commissioners take steps to address the social, environmental, economic and legislative factors that affect people's ability to change their behaviour.
A large number of mechanisms could be used to influence behaviour but the amount of evidence varies. Generally, there is far more evidence on activities aimed at individuals than on policies and other activities aimed at tackling the wider determinants of health. The evidence on efficacy and equity is also variable. The PDG could not review all the possibilities, but noted that the following mechanisms were successful in some circumstances:
legislation and taxation
mass media campaigns
social marketing
community programmes
point of sale promotions.
Population-level interventions have the greatest potential, however, if supported by government and implemented effectively. (Legislation making it compulsory to wear seatbelts in the front seats of cars is an example of a highly effective, population-level intervention.)
Epidemiological theory suggests that even small degrees of change, over time, can result in significant improvements in population-level health (Rose 1985). Population-level interventions could be an effective and cost-effective way of changing behaviour.
The PDG noted that a wide range of policies and the actions of a range of government and non-governmental organisations impact directly and indirectly on health. (Relevant policies and actions include those related to taxation, the licensing laws and the benefits system.) This could be explicitly acknowledged by carrying out routine health impact assessments on how a policy, law or system affects people's health-related behaviour. It could also be acknowledged through partnership and cross-government working.
The level of skills, knowledge and the competencies required by those providing health-related interventions will differ, according to their specific role. However, some are central to most public health activity. These include: knowledge of the full range of difference approaches to behaviour change, competence in planning and evaluation, understanding the principles of non-discriminatory practice; and the ability to use evidence from research and practice.
The PDG noted that the capacity of the public health workforce requires assessment. An education and training strategy to support the development needs of those involved in helping to change people's behaviour (within both NHS and non-NHS settings) could improve effectiveness. National training standards to reflect the skills and competencies described in the recommendations would support their implementation.

# Evaluation
The distinction between monitoring and evaluation is important. Monitoring involves routinely collecting information on a day-to-day basis and using shared information resources and statistics to keep local and national health activity under surveillance. It is part of quality and safety assurance. Evaluation, on the other hand, is the formal assessment of the process and impact of a programme or intervention. Where an intervention is employed that has already been rigorously evaluated (for example, in NICE public health guidance) and demonstrated to be effective in equivalent conditions, then monitoring, rather than a full evaluation, is likely to be sufficient.
Complex public health interventions can be systematically evaluated, based on the relevant theory and evidence, if they use a well-planned, 'staged' approach to evaluation.
Formal outcome and process evaluation can be challenging, but it is an important way of assessing efforts to change behaviour. An effective evaluation is based on clearly defined outcome measures  at individual, community and population levels, as appropriate. Qualitative research looking at the experience, meaning and value of changes to individuals may also be appropriate. Methods and outcome measures are identified during the planning phase. In addition, effective interventions specify their 'programme theory' (or reason why particular actions are expected to have particular outcomes). They also use a framework of 'action  reason  outcome' to guide evaluation (Campbell et al. 2000; Campbell et al. 2007; Flay 1986; Nutbeam 1998; Pawson 2006; Weiss 1995).# Recommendations
This document is the Institute's formal guidance on generic principles that should be used as the basis of initiatives to support attitude and behaviour change. When developing the principles the Programme Development Group (PDG; see appendix A) considered the evidence of effectiveness (including cost effectiveness), relevant theory, fieldwork data and comments from stakeholders.
The reviews that informed this guidance are listed in appendix B. The evidence reviews, supporting evidence statements and economic appraisal are available.
Key theories, concepts, and other evidence that informed this guidance are listed in appendix C.
On the basis of the evidence considered, the PDG believes that where interventions and programmes are applied appropriately, according to the principles outlined in this guidance and in conjunction with other topic-specific NICE guidance, then they are likely be cost effective. In some circumstances, they will save money.
See also the recommendations for research and other gaps in the evidence.
The guidance highlights the need to:
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.

# Planning

## Principle 1: planning interventions and programmes
See recommendations 1 to 6 in NICE's guideline on behaviour change: individual approaches for guidance on developing local strategies and commissioning and planning behaviour change programmes.

## Principle 2: assessing social context
NHS and non-NHS policy makers and commissioners planning behaviour change interventions or programmes for communities or populations, especially disadvantaged or excluded groups.
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
Policy makers, commissioners, trainers, service providers, curriculum developers and practitioners.
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 populations and those with local knowledge.
Appropriate national organisations (for example, 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.

# Delivery

## Principle 4: individual-level interventions and programmes
Commissioners, service providers and practitioners working with individuals.
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 'ifthen' 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.
Also see recommendation 7 in NICE's guideline on behaviour change: individual approaches for practical guidance on designing interventions.

## Principle 5: community-level interventions and programmes
NHS and non-NHS policy makers and commissioners planning behaviour change interventions and programmes for communities or subgroups in the population.
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 (for example, 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
National policy makers, commissioners and others whose work impacts on population-level health-related behaviour.
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 populations. They could include:
fiscal and legislative interventions
national and local advertising and mass media campaigns (for example, information campaigns, promotion of positive role models and general promotion of health-enhancing behaviours)
point of sale promotions and interventions (for example, 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.

# Evaluation

## Principle 7: evaluating effectiveness
Researchers, policy makers, commissioners, service providers and practitioners whose work impacts on, or who wish to change, people's health-related behaviour.
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.
For practical guidance on evaluating interventions, see recommendation 16 in NICE's guideline on behaviour change: individual approaches, and the Medical Research Council's guidance on natural experiments to evaluate population health interventions.

## Principle 8: assessing cost effectiveness
Policy makers, research funders, researchers and health economists.
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:
-n mid- to long-term behaviour change
comparing the effectiveness and efficiency of interventions and programmes delivered to different population groups (for example, 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.

# Recommendations for research
The Programme Development Group (PDG) has made the following recommendations to plug the most important gaps in the evidence.

# Recommendation 1

## Who should take action?
Research councils, national and local research commissioners and funders, research workers and journal editors.

## What action should they take?
Include as standard in research reports:
a description of what was delivered, over what period, to whom and in what setting
information on the impact on health
clear definitions of the 'health outcomes' measured
a report of differences in access, recruitment, and (where relevant data are available) uptake, according to socio-economic and cultural variables such as social class, education, gender, income or ethnicity
a description and rationale of the research methods and forms of interpretation used, and where relevant the reliability and validity of the measures of behaviour change adopted.
Ensure research studies on behaviour change always:
identify and account for the different components of change among different social groups
pay attention to minority ethnic and religious groups
include social variables wherever possible (for example, social class or education) in every study
consider the impact of age and gender on the effectiveness of interventions and programmes.
Promote the inclusion of process as well as outcome data.
Encourage those in charge of randomised controlled trials on health-related behaviour change to register with a trial register.

# Recommendation 2

## Who should take action?
Research commissioners and funders.

## What action should they take?
Encourage research that takes into account the social and cultural contexts in which people adapt or change their behaviour and the factors that encourage or inhibit change. These include:
the role of support networks, neighbourhood resources and community action
the relationships that help protect and build people's resilience
the way people adapt positively to adverse socio-structural conditions
social processes that strengthen the mutual support provided by families and other forms of households
the clustering of health behaviours
the material circumstances in which people live, including income levels, environmental characteristics of neighbourhoods and work-related factors.
Use embedded process evaluations that include the perspectives of recipients.
When studying the mechanisms of adaptation and change, use mixed method ethnographic research, longitudinal studies and qualitative approaches, as well as multivariate and interactive statistical models.
Support development of new methods for collating and synthesising a range of evidence on effectiveness. These methods should meet the highest scientific standards.

# Recommendation 3

## Who should take action?
Policy makers, research commissioners and local service providers.

## What action should they take?
Collect baseline data at the outset of interventions or policy changes and allow for an adequate length of time for evaluation.
Develop evaluative approaches which can accommodate the complexities inherent in community and population-level interventions or programmes, including multiple and confounding factors.
Develop methods for synthesising and interpreting results across studies conducted in different localities, policy environments and population groups.
Formulate rigorous and transparent methods for assessing external validity and for translating evidence into practice.

# Recommendation 4

## Who should take action?
Policy makers, research funders and health economists.

## What action should they take?
As a matter of urgency, commission research on the cost-effectiveness of behaviour change interventions. This should cover:
interventions over the mid to long term
interventions aimed at specific population groups (for example, low-income groups, men versus women, young people versus older people)
primary prevention versus clinical treatment for behaviour-related disease.
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Weiss CH (1995) Nothing as practical as good theory: exploring theory-based evaluation for comprehensive community initiatives for children and families. In Connell JP, Kubisch A, Schorr LB et al. editors. New approaches to evaluating community initiatives: concepts, methods and context. Washington DC: Aspen Institute.
WHO (2005) Seventh futures forum on unpopular decisions in public health. Regional office for Europe# Glossary

# Assets
Assets are the skills, talents and capacity that individuals, associations and organisations can share to improve the life of a community. An assets approach focuses on the strengths rather than the weaknesses (or deficiencies) found in groups or communities.

# Communities
For the purposes of this guidance, communities are defined as social or family groups linked by networks, geographical location or another common factor.

# Determinants of health
The wide range of personal, social, economic and environmental factors which determine the health status of people or communities. These include health behaviours and lifestyles, income, education, employment, working conditions, access to health services, housing and living conditions and the wider general material and social environment.

# Health inequalities
The gap or gradient in health, usually measured by mortality and morbidity, between population groups identified by social characteristics, including different social classes, ethnic groups, wealth and income groups, genders, educational groups, housing and geographical areas.

# Interventions
Clearly circumscribed actions that help promote or maintain a healthy lifestyle.

# Life course
The life course is a term used in social epidemiology to describe the accumulation of material, social and biological advantages and disadvantages during a lifetime.

# Population
The aggregate of individuals defined by membership of a social, geographic, political or economic unit (for example, members of a state, a region, a city or a cultural group).

# Programmes
Multi-agency, multi-packages and/or a series of related policies, services and interventions or other actions focused on broad strategic issues. They can involve a suite of activities that may be topic, setting or population based  and may involve changes to organisational infrastructures.

# Promoting and supporting behaviour change
A number of terms are used to describe attempts to promote or support behaviour change and sometimes these are used interchangeably. They include: initiative, scheme, action, activity, campaign, policy, strategy, procedure, programme, intervention and project.

# Resilience
The ability to withstand or even respond positively to stressors, crises or difficulties.

# Self-efficacy
Self-efficacy is a person's estimate or personal judgment of his or her own ability to succeed in reaching a specific goal.

# Social capital
Social capital is commonly defined as those features of a society, such as networks, social trust and cohesion, that facilitate cooperation among people for mutual benefit.

# Socioeconomic status
A person's position in society, as determined by criteria such as income, level of education achieved, occupation and value of property owned.

# Transition points
Points of change during a lifetime or the life course (for a definition of life course, see above). Examples include: leaving school, entering or leaving a significant relationship, starting work, becoming a parent or retiring from work.# Appendix B: summary of the methods used to develop this guidance

# Introduction
The reports of the reviews and economic appraisal include full details of the methods used to select the evidence (including search strategies), assess its quality and summarise it.
The minutes of the Programme Development Group (PDG) meetings provide further detail about the Group's interpretation of the evidence and development of the recommendations.
All supporting documents are listed in appendix E.

# Key questions
The key questions were established as part of the scope. Initially they formed the starting point for the reviews of evidence and facilitated the development of recommendations by the PDG. The overarching question was: What are the most appropriate generic and specific interventions to support attitude and behaviour change at population and community levels? The subsidiary questions were:
. What is the aim/objective of the intervention?
. How does the content of the intervention influence effectiveness?
. How does the way that the intervention is carried out influence effectiveness?
. Does effectiveness depend on the job title/position of the deliverer (leader)? What are the significant features of an effective deliverer (leader)?
. Does the site/setting of delivery of the intervention influence effectiveness?
. Does the intensity (or length) of the intervention influence effectiveness/duration of effect?
. Does the effectiveness of the intervention vary with different characteristics within the target population such as age, sex, class and ethnicity?
. How much does the intervention cost (in terms of money, people and time)? What evidence is there on cost effectiveness?
. Implementation: what are the barriers to implementing effective interventions?
These questions were refined further in relation to the topic of each review (see reviews for further details).

# Reviewing the evidence of effectiveness
Six reviews of the evidence, 1 cost-effectiveness review and 1 economic modelling report were conducted. In addition, a number of important theoretical and methodological principles were taken into account.
The empirical evidence about behaviour change is very varied and methodologically diverse. Areas of focus can include 1 or more of the following:
the individual, including the psychological processes affecting individuals
social factors
large-scale policy and legislative arrangements
empirical investigations and observations
propositional and modelling approaches.

## Identifying the evidence
It is not always appropriate  or even possible  to carry out controlled trials or gather experimental evidence for public health interventions, including those covering legislation or policy. The search process initially followed standard NICE processes. However, as relatively little evidence on behaviour change addresses effectiveness or cost effectiveness, the review of the literature was extended to cover theoretical, descriptive and empirical studies of a type not normally reviewed for NICE guidance.
The goal of the primary studies varied and included efficacy, effectiveness, the theoretical elegance of models, implementation and programme evaluation. Some studies included all or some of these elements. The economic modelling for this guidance reflected the state of the literature.
There are few evidenced-based reviews on the effect of behaviour change interventions on social and health inequalities. There is evidence that the uptake of interventions or response to health education messages differs by social circumstances, and this has historically, widened the health inequalities gap. Evidence about interventions intended to narrow the health inequalities gap had to be drawn from the outcomes and methods described in other sorts of literature.
Databases were searched to identify the evidence relevant for each review. Since very different types of evidence were being gathered for each review, no common core set of databases was searched.
Further details of the databases, search terms and strategies used are included in the individual review reports.

## Selection criteria
Details of inclusion and exclusion criteria for each review are in the individual reviews on the guideline's webpage.

## Summary of reviews
Review 1 included systematic reviews and meta-analyses which focused on public health, health promotion or primary care-led interventions which contained an educational or behavioural component.
Review 2 (part 1) included reviews of intervention studies that evaluated the effectiveness of road safety interventions. Part 2 included reviews of intervention studies that evaluated the effectiveness of 'pro-environmental behaviour'.
Review 3 (part 1) included reviews that provided an overview of conceptual, theoretical or research issues in relation to resilience, coping and salutogenesis. It also included reviews of interventions explicitly linked to 1 of these theories. Part 2 included reviews of empirical evidence on positive adaptation in conditions of socio-structural adversity.
Review 4 included reviews of 4 behaviour change models.
Review 5 included reviews of empirical data on the effectiveness of interventions designed to change knowledge, attitude, intention and behaviour with respect to smoking, physical activity and healthy eating. Specific attention was focused on whether or not effectiveness was influenced by the individual's position in the life course, the intervention's mode of delivery or the social and cultural context.
Review 6 included reports on the strategies used by marketeers to influence low-income consumers and any evidence of effectiveness.

## Quality appraisal
Papers included in the reviews and additional empirical and theoretical data were assessed where appropriate for methodological rigour and quality using the NICE methodology checklist. This is set out in the NICE technical manual 'Methods for development of NICE public health guidance' (see appendix E). Each study or paper was described by study type and graded (++, +, -) to reflect the risk of potential bias arising from its design and execution.
Meta-analyses, systematic reviews of randomised controlled trials (RCTs) or RCTs (including cluster RCTs).
Systematic reviews of, or individual, non-randomised controlled trials, case-control studies, cohort studies, controlled before-and-after (CBA) studies, interrupted time series (ITS) studies, correlation studies.
Non-analytical studies (for example, case reports, case series).
Expert opinion, formal consensus, theoretical articles.
++  All or most of the checklist criteria have been fulfilled. Where they have not been fulfilled the conclusions are thought very unlikely to alter.
-  Some of the checklist criteria have been fulfilled. Those criteria that have not been fulfilled or not adequately described are thought unlikely to alter the conclusions.
-  Few or no checklist criteria have been fulfilled. The conclusions of the study are thought likely or very likely to alter.
The studies or papers were also assessed for their applicability to the UK where this was possible and the evidence statements were graded as follows:
A. Relevant  review makes direct reference to a UK population.
B. Probably relevant  review from outside UK but most likely equally applicable to UK settings.
C. Possibly relevant  review from outside UK and needs interpreting with caution for a UK setting.
D. Not relevant  review is from outside UK and is not relevant to a UK setting.

## Summarising the evidence and making evidence statements
The review data were summarised in evidence tables (see full reviews). The findings from the reviews were synthesised and used as the basis for a number of evidence statements relating to each key question. The evidence statements reflect the strength (quantity, type and quality) of evidence and its applicability to the populations and settings in the scope.

# Economic appraisal
The economic appraisal consisted of a review of economic evaluations and a model of cost effectiveness.

## Review of economic evaluations
A systematic search of Medline, Embase, NHS EED, OHE HEED, NCCHTA, CEA Registry (Harvard University) was undertaken in June 2006, using a specified set of search terms, as well as inclusion and exclusion criteria. Following a review of 4,122 abstracts and 225 papers, 26 papers were retained for full review, using a standard set of piloted questions. The data extracted included: background, population characteristics, interventions and alternatives, main features and findings and 3 sets of quality review criteria.

## Cost-effectiveness analysis
An economic model was constructed to incorporate data from the reviews of effectiveness and cost effectiveness. The results are reported in: 'The cost-effectiveness of population level interventions to lower cholesterol and prevent coronary heart disease: extrapolation and modelling results on promoting healthy eating habits from Norway to the UK'. The economic model and results are both available.

# Fieldwork
Fieldwork was carried out to evaluate the relevance and usefulness of NICE guidance and the feasibility of implementation. It was conducted with policy makers, commissioners, service providers and practitioners whose work involves changing people's health behaviour. They included those working in local and national government, the NHS and in charitable organisations.
The fieldwork comprised:
Qualitative interviews carried out by Dr Foster Intelligence with 97 individuals, either in small groups or individually, across 30 sites. Participants included: representatives from the DH, other government departments and arm's length bodies; directors of public health in PCTs and strategic health authorities; public health advisers, health promotion staff and NHS practitioners (including GPs, practice nurses, community midwives, health visitors and health advisers); community-based school nurses; health trainers; and commissioners, service providers and practitioners working in local and national charities.
The fieldwork was conducted in London, Greater Manchester and the West Midlands to ensure there was ample geographical coverage. Grid analysis was used to determine common ground and differences of opinion.
The main issues arising from the fieldwork are set out in appendix C under 'Fieldwork findings'. The full fieldwork report is available.

# How the PDG formulated the recommendations
At its meetings held between July 2006 and February 2007, the PDG considered the evidence of effectiveness and cost effectiveness and theoretical and methodological evidence. Initially, discussions focused on the evidence outlined in the reviews (see appendix B). The PDG also considered evidence on cost effectiveness, evidence from fieldwork, additional review material and a range of theoretical and methodological approaches (see appendix C).
In addition, at its meeting in May 2007 it considered comments from stakeholders and the results from fieldwork to determine:
whether there was sufficient evidence (in terms of quantity, quality and applicability) to form a judgement
whether, on balance, the evidence demonstrates that the intervention is effective or ineffective, or whether it is equivocal
where there is an effect, the typical size of effect.
The PDG developed draft recommendations through informal consensus, based on the theoretical ideas that informed its view of behaviour, and the degree to which the available effectiveness evidence could support these ideas.
The draft guidance, including the recommendations, was released for consultation in April 2007. The guidance was signed off by the NICE Guidance Executive in September 2007.# Appendix C: the evidence
This appendix sets out a summary of the key behaviour change theories (empirical, theoretical and methodological) and other, additional evidence used to inform the recommendations. It also sets out a brief summary of findings from the economic appraisal and the fieldwork.
The reviews, economic appraisal and fieldwork report are available.

# Key theories
The reviews were unable to capture all material related to behaviour change. This is because the evidence is broad, the methods used are diverse and the assumptions made about science, knowledge and explanation vary considerably. Some evidence focuses on particular components of human actions, much is theoretical, and some consists of models of human behaviour (see also appendix B). The Programme Development Group (PDG) has also, therefore, drawn on a range of theoretical and methodological evidence. This evidence is briefly outlined below.

## Resilience and coping: Antonovsky (1985, 1987) and Lazarus (1976, 1985; Lazarus and Folkman 1984)
Antonovsky argued that there are 'health-giving' or 'health-generating' factors in many situations. These 'salutogenic' factors can help people withstand or respond positively to stressors, crises or difficulties. They help to protect against vulnerability and disease and may help maintain good mental and physical health. Lazarus argued that people develop habitual ways of coping with life. However, although they may be highly effective from the individual's point of view, some coping mechanisms (like smoking or excessive alcohol consumption) may damage their health and the health of others. Behaviour change and readiness to change behaviour takes place in this context.

## 'Habitus': Bourdieu (1977)
Bourdieu argued that many of the things that people do and believe are so familiar and habitual that they go largely unnoticed (because they are part of their 'habitus'). This makes changing them very difficult.

## Social capital (Bourdieu 1986; Putnam 2000; Morgan and Swann 2004)
Social capital is commonly defined as those features of a society, such as networks, social trust and cohesion, which facilitate cooperation among people for mutual benefit. It was of interest because of the way these factors might influence health behaviours and people's ability to change.

## Society: Giddens (1979, 1982, 1984)
Giddens argued that society was the product of interaction between individual human behaviour and the social structure. He argued that the human actions or agency produce societal patterns. The patterns repeat themselves to such a degree that structures emerge. Although those structures change, sometimes gradually, sometimes rapidly, individuals are aware of them and orient their actions in line with them (and are constrained by them).

## The Theory of Planned Behaviour: (Ajzen 1991) and Bandura's construct of self-efficacy (1997)
The Theory of Planned Behaviour (TPB) is the most widely applied model of beliefs, attitudes and intentions that precede action (Ajzen 2001; Conner and Sparks 2005). TPB proposes that intention is the main determinant of action and is predicted by attitude, subjective norms and perceived behavioural control (PBC). PBC is a person's perception of whether or not they can control their actions and is closely related to Bandura's construct of self-efficacy (1997). Both PBC and self-efficacy are likely to bolster intentions and sustain action because people are more likely to attempt actions that are controllable and easy to perform.

# Additional evidence
The PDG drew on other sources for a general understanding of wider public health issues. These included:
The former Health Development Agency's evidence base.
Conner M, Norman P (2005) editors. Predicting health behaviour: research and practice with social cognition models. Maidenhead: Open University Press.

# Cost-effectiveness evidence
The health economic analysis compared and contrasted the cost-effectiveness of behaviour change interventions aimed at reducing coronary heart disease (CHD) and delivered across the life course. Two phases were completed. The first involved a review of the cost-effectiveness of interventions designed to promote healthier lifestyles and to reduce the risk of developing CHD. In the second phase, a model was developed to determine the cost effectiveness of a population-based behaviour change intervention.

## Phase 1: comparing the cost-effectiveness of behaviour change strategies to reduce the risk of CHD
Many interventions aimed at tackling multiple risk factors fell into the 'likely to be very cost effective' category (0 to 20,000/per cost per quality adjusted life year ). These included a mix of population-level and individual interventions for adults over the age of 30.
Interventions aimed at changing the behaviour of adults with specific CHD risk factors (such as smoking, poor diet and low levels of physical activity) fell into the 'likely to be very cost effective' category. Two non-advisory interventions (labelling of foods containing trans-fatty acid and a population-based programme promoting a healthier diet) also fell into the 'likely to be very cost effective' group.
Significant gaps in the evidence were noted. There was little evidence on the cost-effectiveness of using behaviour change interventions with specified sub-groups (for example, 19- to 30-year-olds, low-income groups, pregnant women, and particular ethnic or disadvantaged groups). The quality of evidence was also a cause for concern. For example, there was a lack of reliable data from which to extrapolate the long-term health outcomes. In addition, only a limited number of economic evaluations had been conducted alongside RCTs of behaviour change interventions to reduce CHD.

## Phase 2: modelling
In the second phase, a deterministic Markov chain simulation model was developed of a population-wide intervention to lower cholesterol and prevent CHD. The intervention was carried out in Norway in 1990. It included a mass media campaign and information delivered to a range of sectors including academia, the agricultural sector and schools. The model extrapolated the results to England and Wales in the first decade of 2000.
In the base case, an incremental cost-effectiveness ratio (ICER) of 87 per QALY (116 per life year) was estimated. However, it was noted that the health benefits were underestimated, as this model only reported those related to CHD. Sensitivity analysis estimated that the intervention would be highly cost effective in a wide range of situations.

# Fieldwork findings
Fieldwork aimed to test the relevance, usefulness and the feasibility of implementing the recommendations, and the findings were considered by the PDG in developing the final recommendations. The fieldwork was conducted with commissioners, service providers and practitioners involved in a wide range of services and activities relevant to health-related behaviour change. For details, see the fieldwork report on generic and specific interventions to support attitude and behaviour change at population and community levels.
Fieldwork participants were fairly positive about the recommendations and their potential to support attitude and behaviour change at the individual, community and population levels.
The recommendations were seen to reinforce aspects of a range of government policies and initiatives, including providing support to achieve certain public service agreement (PSA) targets (for example, to reduce teenage pregnancies and to reduce health inequalities).
While participants did not view the recommendations as offering a new approach, the principles they are based on have not been implemented universally. They indicated that wider and more systematic implementation would be achieved if there was:
clarity about how the recommendations apply to people in different roles
more information about how to implement some of the recommendations
further information on how compliance with the recommendations will be determined.# Appendix D: gaps in the evidence
The Programme Development Group (PDG) identified a number of gaps in the evidence related to behaviour change interventions and programmes, based on an assessment of the evidence. These gaps are set out below.
. Evidence about the cost-effectiveness of behaviour change evaluations is lacking, in particular, in relation to specific sub-groups (for example, 19- to 30year-olds, low-income groups and particular ethnic and disadvantaged groups).
. Evaluations of behaviour change interventions frequently fail to make a satisfactory link to health outcomes. Clear, consistent outcome measures need developing.
. Evaluations of interventions based on specific psychological models tend not to relate the outcome measures to the model. As a result, it is difficult to assess the appropriateness of using the model as a means of describing behaviour change.
. Few studies explicitly address the comparative effect that behaviour change interventions can have on health inequalities, particularly in relation to cultural differences.
. There is a need for more information on the links between knowledge, attitudes and behaviour. Conflation between them should be avoided.
. There is a lack of reliable data from which to extrapolate the long-term health outcomes of behaviour change interventions.
The Group made 4 recommendations for research.# Appendix E: supporting documents
Supporting documents are available. These include the following.
Reviews of effectiveness
Review 1: 'A review of the effectiveness of interventions, approaches and models at individual, community and population level that are aimed at changing health outcomes through changing knowledge, attitudes or behaviour'
Review 2: 'Review of the effectiveness of road-safety and pro-environmental interventions'
Review 3: 'Resilience, coping and salutogenic approaches to maintaining and generating health: a review'
Review 4: 'A review of the use of the health belief model (HBM), the theory of reasoned action (TRA), the theory of planned behaviour (TPB), and the trans-theoretical model (TTM) to study and predict health-related behaviour change'
Review 5: 'The influence of social and cultural context on the effectiveness of health behaviour change interventions in relation to diet, exercise and smoking cessation'
Review 6: 'Social Marketing: a review'.
Expert report
'Evidence for the effect on inequalities in health of interventions designed to change behaviour'.
Evidence briefings and other reviews and toolkits published by the former Health Development Agency
Economic analysis:
'The cost-effectiveness of behaviour change interventions designed to reduce coronary heart disease: a thorough review of existing literature'
'The cost-effectiveness of population level interventions to lower cholesterol and prevent coronary heart disease: extrapolation and modelling results on promoting healthy eating habits from Norway to the UK'.