WHO report on Behavioral Change Strategies in Health: the Role of Health Systems

Behavioural risk factors are the leading cause of morbidity and mortality. With an increase in quality of care combined with longer lifespans there will be higher levels of behavioural-related illnesses requiring continuous and complex care. Evidence shows that healthy behaviour leads to increased lifespan and quality of life.

To ensure this healthy behaviour, increased awareness and education are important but "seldom sufficient," this must be complemented by "implementing a mix of legislative and regulatory instruments" to "change from unhealthy to healthy behaviours for the good of the individual or society as a whole." Therefore the role of the state is to change behaviour.

So how to change behaviour? Various models have been tried and tested. This paper, as well as discussing the theory behind behavioural change interventions, compares examples that have both worked and failed, and provides reasons for this. The models for behavioural change interventions:
 One to one - Health counselling and advice
 Community - Community development and health outreach projects
 Population - Mass media, targeted campaigns, awareness programmes

All of these models have been proven to work in theory but the practical difficulties cannot be avoided.

Interventions that are robust and rigorous tend to be difficult to generalise or replicate as they are targeted to a niche audience.

Variation in interventions is essential, as what works in one place may not work in another. The coverage is dependent on the remit of the programme and it is essential that the project be sensitive to the local context.

The report then gives several examples of cases where lessons were learned from behavioural change programmes, and suggestions on how to improve them in the future.

 Combining general educational material with tailored messages can bring about sufficient awareness to effect a change in behaviour.
 The potential for the success of initiatives which directly involve patients and health care professionals, along with educational programmes is highlighted.
 Even small-scale initiatives may not be flexible enough to overcome insufficient planning and a lack of clear delineation of responsibilities based on clear and shared targets from the outset.
 Participatory needs assessment and training in the means to tackle behaviours, which are to a large extent dictated by the environment, can be effective where there is recognition and a shared view of the problem, and interest in changing behaviour.
 Suggests that appropriately targeted and implemented programmes for communities who are most often at risk or affected in developed countries, may be successful in instigating community-led behaviour change.

The study also shows that targeting interventions well is of the utmost importance to ensure success.

Provider compliance is an important issue - if the providers of the project, e.g. health professionals, are not properly incentivised, trained and monitored then the project will not be sustainable in the long term. Motivation of the providers is essential to assist compliance.

Those benefiting from the programme need support networks to ensure maintenance and promotion of behavioural change. Education is necessary but seldom sufficient.

What can the Health System do? In order to ensure effective behavioural change, health systems must intervene, not just on an educational level but on a legislative level. Awareness campaigns and programmes for behavioural change must be used in conjunction with legislation.

An example of the combination between education and legislation: "The growing acceptance of legislation designating smoke-free public places, with penalties to enforce breaches of such regulations, testifies to the fact that

(i) government has a legitimate role to play in using legislative instruments to promote health where the mandate is clear, the solution is effective and the public has sufficient information to be able fully to grasp the issue, and

(ii) the impact of public health interventions is enhanced when supported by robust legislation. Responsibility for taking actions to bring about behaviour change in health is often divided between different levels of government and public health agencies."

Six key characteristics were observed for successful interventions in health and the role the health system can play:
 Strong Leadership
 Multi-pronged intervention
 Multi-level intervention
 Timing, or a ’window of opportunity’
 Adequate financing
 Assessment of (dis)incentives

"Evidence that either the ministry of health, if it is the main programme implementer, or the State, through its various ministries and institutions, has the wherewithal and capacity to implement the programme through a mix of policies, institutional and organizational arrangements (e.g. inter-ministerial steering committee, task forces, etc.), proper planning and adequate financing, involvement of civil society organizations and the private sector, training of staff and establishment of proper incentive schemes (the implementation hypothesis)."

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To read the full report click here