As new figures show rising levels of diabetes and obesity in England , NICE has published guidance on helping people change their health-related behaviour. Nerys Hairon reports
Hairon, N. (2007) Nice public health guidance promote lifestyle changes. Nursing Times; 103: 44, 21-22.
The Department of Health has recently published a report on the overall health of the population in England (DH, 2007). Health Profile of England 2007 details improvements in some areas, such as health outcomes in cancer and circulatory diseases, but increasing levels of diabetes and obesity.
This follows a government-sponsored report predicting soaring levels of obesity over the coming decades if current trends continue (Foresight, 2007). The Foresight report outlines the complexity of the obesity problem. We now live in an 'obesogenic' environment, it concludes, for which our biology is not adapted. It argues that preventing obesity will require major changes in the environment, individual behaviour, organisations, communities and families.
Meanwhile, NICE has launched public health guidance aimed at helping healthcare professionals to bring about changes in people's lifestyle (NICE, 2007a). The guidance is aimed at NHS healthcare professionals and others with direct or indirect responsibility for helping people to change their health-related knowledge, attitudes and behaviour.
The DH report found a general improvement in health outcomes (DH, 2007). It details recent improvements in a number of critical areas, for example:
- Declining mortality rates in cancers, all circulatory diseases and suicides;
- Increasing life expectancy, which is now at its highest level ever;
- Declining infant mortality, which is now at its lowest level ever.
However, the report points out that to sustain progress challenges remain to be overcome in some areas, such as rising rates of diabetes. Similarly, the DH states that although there have been improvements in some important health determinants, such as the number of smokers and the quality of housing stock, there remain areas of concern, for example increasing levels of obesity in adults and children.
The report points out that even where improvements have been seen, health inequalities are often present. It finds that there is a consistent 'north-south divide', with poorer health in the north of England compared with the south. There is a distinct north-south divide for female life expectancy, for example. The average life expectancy of women in the north east and north west of England is over two years shorter than that in the south east and south west, while the life expectancy of men in the same northern regions is over 2.5 years shorter than for those in the southern regions.
The DH data also compares progress in England to that in all other countries of the EU, and to the 15 countries that were members of the EU before 2004 (EU-15). These comparisons demonstrate that:
- Premature mortality rates from the two biggest killers (circulatory disease and cancer) are falling faster in England than the average for the EU;
The prevalence of obesity in England is the highest in the EU;
- Overall death rates for chronic liver disease and cirrhosis have risen markedly in England , particularly since the mid-1990s, and the latest data shows that the death rate among women has risen above the average for EU-15 countries;
- The percentage of all live births to mothers under 20 in the UK remains the highest of all the EU-15 countries.
This new public health guidance seeks to help healthcare professionals bring about behavioural change in their patients (NICE, 2007a). The recommendations comprise 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 at the population, community and individual levels.
The institute says it has long been accepted that interventions to change people's health-related behaviour have 'enormous potential to alter current patterns of disease' (NICE, 2007b). For example, encouraging people to give up smoking reduces rates of lung cancer and other smoking-related illness, and getting people to eat a healthier diet and increase levels of physical activity can help to reduce obesity.
However, NICE argues that because there has been no unified approach to behaviour change across different public sectors, such interventions have enjoyed only limited success to date (NICE, 2007b). The institute states that its guidance is based on a comprehensive assessment of the evidence on what approaches and strategies are effective in bringing about health-related benefits for the population as a whole.
It advises that the guidance should be read in conjunction with other topic-specific public health guidance from NICE but it does not replace any of this guidance. Future NICE guidance that aims to encourage people to change their behaviour will be based on the principles outlined in this document.
The guidance contains eight principles covering planning, delivery and evaluation (see box below for the principles).
Actions for nurses
In change principle 4, NICE recommends that nurses and healthcare professionals 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;
Plan their changes in easy steps over time;
Recognise how their social contexts and relationships may affect their behaviour, and plan for situations that might undermine the changes they are trying to make;
Plan explicit 'if-then' 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 goals for changing their behaviour with others.
For recommendations on interventions at community level and population level, see www.nice.org.uk.
Principle 1, which is focused on planning interventions and programmes, outlines recommendations for service providers and practitioners whose work impacts on - or who wish to change - people's health-related behaviour. Specifically, NICE recommends prioritising interventions and programmes that:
Are based on the best available evidence of efficacy and cost-effectiveness;
Are developed in collaboration with the target population and take account of lay wisdom about barriers to change;
Use key life stages or times when people are more likely to be open to change (such as pregnancy, starting or leaving school and entering or leaving the workforce).
In addition, practitioners should disinvest in interventions or programmes if there is good evidence to suggest they are not effective. Where evidence of effectiveness is poor or absent (or the evidence is mixed), professionals should ensure that programmes are properly evaluated whenever they are used.
In the fields of education and training (principle 3), NICE advises trainers, service providers and practitioners to provide training and support for those involved in changing health-related behaviour so they can develop the full range of competencies. The guidance states that appropriate national organisations (such as the NMC) should consider developing standards for these competencies and skills. For recommendations on evaluation, see www.nice.org.uk.
The DH report on public health in England suggests that improvements need to be made in diabetes, obesity, alcohol-related conditions and teenage pregnancy. This new NICE guidance offers some practical advice on how nurses can help to bring about health-related behavioural change at different levels.
EIGHT BEHAVIOUR CHANGE PRINCIPLES
1. Planning interventions and programmes.
2. Assessing social context.
3. Education and training.
4. Individual-level interventions and programmes.
5. Community-level interventions and programmes.
6. Population-level interventions and programmes.
7. Evaluating effectiveness.
Department of Health (2007) Health Profile of England 2007. London: DH. www.dh.gov.uk
Foresight (2007) Tackling Obesities: Future Choices - Project Report. London : Foresight. www.foresight.gov.uk
NICE (2007a) Behaviour Change - Quick Reference Guide. London : NICE. www.nice.org.uk
NICE (2007b) NICE Public Health Guidance Aims to Help People Change their Behaviour so that they can Enjoy Healthier Lives. Press release, October 2007. London: NICE