580921 research-article2015
RSH0010.1177/1757913915580921Guest editorialGuest editorial
Guest editorial
Behaviour change. Change behaviour Whichever way you write it, it is the popular way to solve the nation’s ills or the last hope to save us from a noncommunicable disease-ridden future. Whether it be putting your recycling in the right boxes, washing at 30 degrees, turning out the lights or putting less salt on those chips, wherever you look, there is a plan in place to make you and I behave differently. ‘Behaviour change’ is an overarching term that covers a myriad of methods to make us do stuff differently – whether it be legislation to stop us smoking in cars with children, remodelling the environment to make the cycle/walk to work or school safer or nudging us to buy more fruits and vegetables with cardboard cutouts in the supermarket. The methods in play are varied and admired/feared by the population in equal parts depending on who or what is trying to make us change and whether you want to change. Government – good that they want to protect children in cars from smoke, or nanny state restricting yet again the rights of a smoker to enjoy a cigarette? Big business – helpfully reducing salt and sugar content to make healthier choices easier or finding a new way to market products to a gullible audience? When it comes to behaviours, the first place to start is with the knowledge that all our behaviour is influenced or altered by someone or something else. No man is an island, so we are influenced by those who surround us – and even that man on his island altered his behaviour; I bet he developed a liking for fish and a little shade at midday. So if we are always being influenced, surely it is admirable to alter behaviour to make us happier and healthier. Most would agree that this is okay, but how far do you take it and who is going to influence us? Well that is the rub… when a South West Clinical Commissioning Group decided to ration healthcare for those who are obese to encourage change in behaviour (as well as save money), they soon backtracked as this behaviour change seemed more like coercion than a nudge.
So, how I would describe the current status of behaviour change is that we can demonstrate that it works, it is ‘good’ to change behaviour for the benefit of those whose behaviour is being changed, but we don’t quite know how far we think we should go to change that behaviour. Additionally, if the change of health behaviour is in any way linked to saving money, we find ourselves morally challenged. The free at the point of need status of the National Health Service means we can’t quite be happy to nudge, persuade, trick or coerce the population to better health – particularly if it sounds like rationing. Add to this our fear of a big brother Orwellian future where we are controlled by the state, the business of behaviour change becomes tricky to manage. To add to this internal debate about whose behaviour we change and how we change it, we have a revolution in technology unfolding (whatever health technologists like to tell us, we are not there yet) that may help us alter our own behaviour and have it altered by others. Technology has vastly changed our behaviour already, the smartphone is ubiquitous and organisations are using it to specifically alter our behaviour – how many of us now scan, pack and pay for our groceries because technology has meant supermarkets can dispense with the cashier, even going as far as to converse with these machines. Some of the technology will be life changing – diabetics will be wearing a constant patch that talks to a device/ smartphone and lets them and others know when blood glucose levels are low/high and they can alter their diet/ medication to sort it. This is rather than taking daily blood tests and not knowing that a hyperglycaemic attack is around the corner; parents can manage children, doctors can manage patients and more patients can manage their own condition. So with the debate both in our consciences and in public health teams and others, the tools available operating on a scale of behaviour change from legislation for nudging
120 Perspectives in Public Health l May 2015 Vol 135 No 3 Downloaded from rsh.sagepub.com by guest on November 15, 2015
and the desire for a liberal society with the ability to make choices about our lives and how we live them – the field of behaviour change is one that is growing rapidly and from the external view looks slightly confused. So what do we do? First, we acknowledge the drivers of ill health and behaviours that lead to ill health. Without understanding what causes behaviour, we will never be able to change it, certainly not in a sustainable manner. Once we understand behaviour, we need to test our understanding and any potential interventions we may believe will alter this; start small and figure out what works first. So once we believe we have found interventions and solutions that work, are sustainable and are cost effective – we live in the real world – we need the confidence and support to implement them. What does this mean to public health in the future? Well the ills of society will not wait for us to naval gaze for too long; the size of the problem will lead us to some uncomfortable decisions in the future. We may not like the idea of legislating on sugar – but the growth of childhood obesity will not wait for us to try and work with and nudge both the affected and the industry that supplies the product. We may dislike the idea of our phones tracking and advising us, providing nudges and influencing us, but in order to overcome well-developed habits, long-term behaviours and the knowledge that our current behaviour is impacting negatively on our health, we will need all the tools at our disposal to attempt to avoid a future where the 40% of cancers that can be avoided aren’t and where children are regularly diagnosed with fatty liver disease and type 2 diabetes; and obesity becomes the social norm that end our lives prematurely. So look up from the naval, the future is exciting and there is a lot of behaviour to change. Claire McDonald Behaviour Change Specialist and RSPH Fellow
RSH0010.1177/1757913915580921Guest editorialGuest editorial
Guest editorial
Behaviour change. Change behaviour Whichever way you write it, it is the popular way to solve the nation’s ills or the last hope to save us from a noncommunicable disease-ridden future. Whether it be putting your recycling in the right boxes, washing at 30 degrees, turning out the lights or putting less salt on those chips, wherever you look, there is a plan in place to make you and I behave differently. ‘Behaviour change’ is an overarching term that covers a myriad of methods to make us do stuff differently – whether it be legislation to stop us smoking in cars with children, remodelling the environment to make the cycle/walk to work or school safer or nudging us to buy more fruits and vegetables with cardboard cutouts in the supermarket. The methods in play are varied and admired/feared by the population in equal parts depending on who or what is trying to make us change and whether you want to change. Government – good that they want to protect children in cars from smoke, or nanny state restricting yet again the rights of a smoker to enjoy a cigarette? Big business – helpfully reducing salt and sugar content to make healthier choices easier or finding a new way to market products to a gullible audience? When it comes to behaviours, the first place to start is with the knowledge that all our behaviour is influenced or altered by someone or something else. No man is an island, so we are influenced by those who surround us – and even that man on his island altered his behaviour; I bet he developed a liking for fish and a little shade at midday. So if we are always being influenced, surely it is admirable to alter behaviour to make us happier and healthier. Most would agree that this is okay, but how far do you take it and who is going to influence us? Well that is the rub… when a South West Clinical Commissioning Group decided to ration healthcare for those who are obese to encourage change in behaviour (as well as save money), they soon backtracked as this behaviour change seemed more like coercion than a nudge.
So, how I would describe the current status of behaviour change is that we can demonstrate that it works, it is ‘good’ to change behaviour for the benefit of those whose behaviour is being changed, but we don’t quite know how far we think we should go to change that behaviour. Additionally, if the change of health behaviour is in any way linked to saving money, we find ourselves morally challenged. The free at the point of need status of the National Health Service means we can’t quite be happy to nudge, persuade, trick or coerce the population to better health – particularly if it sounds like rationing. Add to this our fear of a big brother Orwellian future where we are controlled by the state, the business of behaviour change becomes tricky to manage. To add to this internal debate about whose behaviour we change and how we change it, we have a revolution in technology unfolding (whatever health technologists like to tell us, we are not there yet) that may help us alter our own behaviour and have it altered by others. Technology has vastly changed our behaviour already, the smartphone is ubiquitous and organisations are using it to specifically alter our behaviour – how many of us now scan, pack and pay for our groceries because technology has meant supermarkets can dispense with the cashier, even going as far as to converse with these machines. Some of the technology will be life changing – diabetics will be wearing a constant patch that talks to a device/ smartphone and lets them and others know when blood glucose levels are low/high and they can alter their diet/ medication to sort it. This is rather than taking daily blood tests and not knowing that a hyperglycaemic attack is around the corner; parents can manage children, doctors can manage patients and more patients can manage their own condition. So with the debate both in our consciences and in public health teams and others, the tools available operating on a scale of behaviour change from legislation for nudging
120 Perspectives in Public Health l May 2015 Vol 135 No 3 Downloaded from rsh.sagepub.com by guest on November 15, 2015
and the desire for a liberal society with the ability to make choices about our lives and how we live them – the field of behaviour change is one that is growing rapidly and from the external view looks slightly confused. So what do we do? First, we acknowledge the drivers of ill health and behaviours that lead to ill health. Without understanding what causes behaviour, we will never be able to change it, certainly not in a sustainable manner. Once we understand behaviour, we need to test our understanding and any potential interventions we may believe will alter this; start small and figure out what works first. So once we believe we have found interventions and solutions that work, are sustainable and are cost effective – we live in the real world – we need the confidence and support to implement them. What does this mean to public health in the future? Well the ills of society will not wait for us to naval gaze for too long; the size of the problem will lead us to some uncomfortable decisions in the future. We may not like the idea of legislating on sugar – but the growth of childhood obesity will not wait for us to try and work with and nudge both the affected and the industry that supplies the product. We may dislike the idea of our phones tracking and advising us, providing nudges and influencing us, but in order to overcome well-developed habits, long-term behaviours and the knowledge that our current behaviour is impacting negatively on our health, we will need all the tools at our disposal to attempt to avoid a future where the 40% of cancers that can be avoided aren’t and where children are regularly diagnosed with fatty liver disease and type 2 diabetes; and obesity becomes the social norm that end our lives prematurely. So look up from the naval, the future is exciting and there is a lot of behaviour to change. Claire McDonald Behaviour Change Specialist and RSPH Fellow
