Improving the health of the public: what is the role of health psychologists?

Abstract

Changes in human behaviour are at the heart of any response to the current epidemic of chronic disease. Health psychologists are in a unique position to address these major public health challenges, but need to focus efforts on maximising the scale of our impact. Training frontline health and social care practitioners of every type to deliver evidence-based behaviour change support to patients and clients is an approach with great potential in this regard.

Editorial

The number of people in the world with type 2 diabetes is expected to rise from 366 million at the present time to 552 million in 2030 (Chen et al. 2012); and whereas around 17 million people died from cardiovascular disease in 2008, some 23 million are expected to do so in 2030 (Laslett et al. 2012). Though this epidemic is clearly the result of a multiplicity of influences (Butland et al. 2007), any response to it has, at its heart, change in human behaviour. In order to make any real impact, however, these behaviour changes have to be made at a population level and there is clearly a role for health psychologists in making this happen. Health psychology has made significant progress in identifying what it takes to change health behaviour (Michie and West 2013;Olander et al. 2013), which begs the question why there are not more of us involved in applying our knowledge at scale to address this public health crisis.

Health psychologists seeking to tackle public health issues sit somewhere on a continuum. At one end they work as specialists, operating as highly trained practitioners with a specific skill set and expertise whose role it is to use behaviour change techniques of proven effectiveness such as self-monitoring, feedback and goal-setting in supporting relatively small numbers of individuals to improve their health and well-being. This can be viewed as a clinical model of working. At the other end of the continuum, they function more as disseminators of knowledge and expertise, whose role it is to provide support and training for the health and social care workforce who use the skills they learn in their contacts with patients and clients. Though this approach results in dilution of expertise and skills it also achieves a reach into the community that would not be possible by the limited number of health psychologists currently employed within public health.

The work of most health psychologists will, of course, contain elements from a number of points on this spectrum. Our argument, however, is that to address the major epidemic of chronic disease now facing us we need to focus our efforts on maximising the scale of our impact; and that training frontline health and social care practitioners of every type to deliver evidence-based behaviour change support is an approach with great potential in this regard. Our paper, published in this issue, describes the delivery and evaluation of a programme of training for health and social care staff in skills to empower and support behaviour change (Lawrence et al. 2014). The training is in skills proven to support behaviour change and adopts an empowerment approach to supporting patients and clients to identify their own problems and solutions, and to set goals for achieving change. Our paper describes the impact on the practice of a range of professionals from play workers and community development workers to highly qualified oral health workers and experienced nursery nurses. We demonstrate that the training leads to changes in the way staff work both in the short and long term. From this, we conclude that it is possible to train staff with a wide range of backgrounds and qualifications in skills to support behaviour change. We have previously shown that the training increases staff confidence in addressing difficult lifestyle problems with their clients (Black et al. 2012;Tinati et al. 2012). The significance of these findings from our point of view is that these professionals have an unparalleled reach into disadvantaged communities, and regular contact with young families. If they are equipped with and use their skills to support behaviour change in these communities, then the potential for improvements in public health is huge (Barker et al. 2013).

There are, undoubtedly, many other groups like us, excited about the value of training health professionals in brief intervention techniques to improve public health. The work of the PRE-EMPT team based in Cardiff highlights the potential impact of opportunistic engagement by health professionals trained in behaviour change skills (Butler et al. 2013;Phillips et al. 2012). Work in Manchester suggests that inclusion of behaviour change education in the medical curriculum could help medical practitioners make the best use of the regular opportunities they have to discuss lifestyle changes with patients (Chisholm et al. 2012). The ‘Very Brief Intervention’ study team based in Cambridge is exploring the potential of using practice nurses and health care assistants to deliver a range of brief motivational and action-based interventions to increase physical activity opportunistically as part of the standard NHS health check (Lamming et al. 2012). So far, their findings suggest this is both feasible and acceptable in the context of a standard primary care consultation. Internationally, the WIC programme in the USA has seen the value of training nutritionists to recognise opportunities to implement obesity prevention counselling techniques (Marley et al. 2011), and maternity services in parts of Central Asia have been transformed by training staff to incorporate empowerment strategies within routine care (de Haan 2010).

All this exciting work implicates health psychologists in the future for public health and disease prevention, and the majority of it is through developing the skills of the public health and primary care workforce. What’s more, there are many in public health who already realise this. The February issue of ‘The Psychologist’ contained a plea from the director of public health in Hertfordshire for health psychologists to take more of a prominent role in public health, suggesting there is a need for psychological as well as biomedical interventions to combat the public health challenges facing us, and that there is “much untapped potential” (McManus 2014). Previous calls from around the world for greater engagement of psychologists in public health have pointed out the potential of our discipline for empowering both practitioners and the public but only if we take seriously the structural determinants of health and leave behind some of our focus on the individual (Hepworth 2006). Our opinion is that, if we are committed to improving public health, health psychologists must move on from the development of small-scale, programmatic interventions to becoming more involved in designing, delivering, monitoring and evaluating population-level, sustainable, cost-effective interventions, of which workforce training in behaviour change skills is one obvious example.

Most of us do not work as front-line staff. What we can do, however, is support front-line health and social care practitioners to ‘make every contact count’. This NHS initiative recognises the opportunity that practitioners have to improve public health through supporting behaviour change in the millions of people with whom they come into contact (NHS Future Forum 2012). It makes perfect sense within this context for us not necessarily to “do”, but to train and to teach the workforce that needs behaviour change skills. Where this approach is criticised because of the relatively small effect size of such interventions, it can be countered by reference to arguments for the value of modest reduction in risk across large populations (Rose 1985). Even a small effect at a population level would still produce significant health gains.

Health psychologists have a huge opportunity to improve population health. One way they can achieve this is by training the health and social care workforce in the strategies and skills that our discipline has shown to be effective in supporting behaviour change. We think the time is right to take that opportunity and make the best use of it.