Changing behaviours: Local authorities will need to understand how they cluster

Published on Thursday, 23 August 2012 09:06
Written by David Buck

From April next year local government is taking on the mantle of behaviour change from the NHS.Our report The Clustering of unhealthy behaviours over time: implications for policy and practice for the King's Fund, published today, outlines what's been happening to clusters of health behaviours over time in England

This government has been as active as any other releasing updated strategy documents on a raft of health improvement strategies including  tobacco, alcohol and obesity. Yet we all intuitively know that behaviours tend to go together and can often see it in the experience of ourselves, families or the communities in which we live.  Despite this, there has been little research into whether and how this might be occurring. Given that, a colleague at The King's Fund, Francesca  Frosini,  and I have looked at just how clustered four important health behaviours - whether we smoke, get our fruit and veg, exercise as we should, or drink beyond government limits - are in the English population and how that's changed over time. These behaviours account for about half the disease burden in the developed world.

We looked at two waves of the national Health Survey for England between 2003 and 2008 and found some really good news.  The proportion of the population who had three or four of these unhealthy behaviours fell significantly from around one in three adults to around one in four.  The bad news is that the large majority of the improvements have come from people from high socio-economic groups and with higher education levels. Although there did not seem to be any worsening over time, the poorest and least educated saw no improvement over the five years between Health Surveys.  This means that relative inequalities have increased and are becoming more polarised. For example, the chances of someone with no qualifications having four unhealthy behaviours compared to those with higher education increased from three-fold to five-fold over the period.

This will be disappointing news given the government's commitment to increase the health of the poorest, fastest, although it does give important insights that can help with designing health improvement initiatives.  This is especially relevant to local authorities and health and wellbeing boards as they think through their priorities for behaviour change.

Another finding from the study is that despite the progress, around England 70% of adults have 2 or more of the four behaviours.  It's therefore likely that the majority of adults in virtually all local authorities have more than one poor health behaviour but the specific patterns could be quite different.  Understanding local patterning of clusters through re-analysing local health and wellbeing surveys along the lines above is a pre-requisite for doing this.  Informed by that, each area will be better armed to make the right decisions on how to intervene and where to direct its actions, and the mix of targeted interventions on specific clusters versus more traditional single issue approaches.

To be successful in the longer term, local authorities will need much more support from Public Health England and NICE in understanding the dynamics of sustained multiple behaviour change, and what methods are cost-effective, especially in poorer and less educated groups.  For instance, we know that social capital and norms are important in explaining why some communities continue to have very high smoking rates, but how does this work for multiple behaviours and what are the solutions?   One important source may lie in the existing Health Trainer workforce and Community Champions, already embedded in many local communities.  Whatever the answers locally, we believe that if local authorities are to be successful in improving the health of the poorest fastest in their communities, looking at how behaviours cluster should be an important part of the mix.

The Clustering of unhealthy behaviours over time: implications for policy and practice

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