Public health overview: Change for the better
“There is an important difference between our country and many other countries around the world: our country is a freedom-loving country. If we look at the history of this country over the past 300 years, virtually every advance, from free speech to democracy, has come from this country. It is very difficult to ask the British population uniformly to obey guidelines in the way that is necessary.”
So said the Prime Minister, Boris Johnson, last September, as a way of explaining why the levels of COVID in the UK were higher than in most other countries. And it had been something of a narrative since the days before lockdown, when the plan was still herd immunity: British people don’t do restrictions, they don’t accept being told what to do, they don’t change their behaviour to order unlike those biddable Continentals or East Asians. You can’t do here what they have done.
Fortunately, it turned out not to be true. A year ago last week, the whole country went into lockdown. It was a dramatic solution to a dramatic and acute public health problem. And it turns out that Brits are not so ‘freedom loving’ that they aren’t willing to make changes in response to a serious and potentially fatal disease. In fact, the changes have been significant and unexpected, with the majority of people in this country adhering to some very restrictive rules for a year.
Over the past 12 months people have been willing to make quite dramatic changes in lifestyle and behaviour, whether that’s staying at home, self-isolating, social distancing, wearing face masks, washing hands; it’s the kind of behaviour that a year ago the government believed no one in this country would adhere to. And some of it may be here to stay, if, for example, the increased focus on hand hygiene makes people more aware of spreading germs in general.
It shows change is possible, even when improbable, which is what is needed to tackle many other, more endemic public health issues. For years Scotland has been struggling with a range of health problems such as poor diet, overweight and obesity (65 per cent of adults are overweight and 29 per cent obese), lack of physical activity, smoking, high alcohol consumption (Scots drink on average 36 per cent more than the maximum recommended weekly units) and drug use (the highest rate of drugs deaths in Europe). And shifting behaviours can be very challenging. So are there lessons that can be learned?
Clearly, this isn’t comparing like with like, the emergency response to a deadly pandemic and a series of long-term, ingrained health issues, but Professor Diane Dixon, chair in health psychology at the University of Aberdeen, believes there are lessons to be taken from it.
Dixon led a team of researchers on the CHARIS (Covid Health and Adherence Research in Scotland) project, funded by the Chief Scientist Office, looking at compliance with COVID guidelines such as physical distancing, wearing a face mask, hand washing and avoiding crowded places. This started when lockdown began easing at the beginning of June – when breaking the rules became more of a possibility, once people were no longer confined to their own homes – and continued until November.
The research looked at both people’s perception of the risk from the illness and at their attitudes towards the preventive behaviours, and it found that people’s beliefs about their behaviour predicted compliance for every group at every data wave for every behaviour. They asked people questions about what they thought other people were doing (norms), how confident they were at being able to follow the behaviour (ability) and whether they intended to do it (motivation).
“And people’s confidence in their ability to do something, which we call self-efficacy … and their motivation to do it were the two things that predicted for everybody. And we embedded in the study a little experiment, where we read out to people a little message that we’d designed to boost this concept of self-efficacy, to boost people’s confidence, did that impact on their confidence and their intention? And it did.
We know about social patterning and health, but oh my goodness, have we not seen it in the past year? Have we not seen it in levels of poor mental health, COVID cases and deaths?
“So you can move these beliefs. You can support people to feel confident about doing something. I think … we weren’t surprised that they predicted [the response], but we were surprised that they’re predicted it so universally and so consistently.”
It is this that Dixon believes can be transferred onto other public health issues, the idea that people will make change if they feel they are able to do it and if they feel part of a group doing it.
“If we’re thinking about what can we learn about health-related behaviour, I think there’s something about the way that collectively communities have done things. I think there’s some learning in that. So from what we’ve done, from looking at what individuals are telling us, how can we support a collective confidence in being able to engage in more positive behaviours?
“Recent surveys are telling us that four out of 10 people want to lose weight, eat more healthily, reduce their drinking, have a go at quitting smoking, increasing their physical activity, so there is a level of motivation, I think, in the population about wanting to do things that support their health. So how can we think, not about the individual, but how can we support communities to do that?”
Dixon notes that there has been clear social patterning in the effects of COVID on particular socio-economic groups of people, which relates to this point.
“We’ve all seen that social patterning, we know about social patterning and health, but oh my goodness, have we not seen it in the past year? Have we not seen it in levels of poor mental health, COVID cases and deaths? It’s just been so stark. So you know, there’s something about the collective and community and how we think about these things as public health rather than individual health and individual choices. It’s trying to think in a more public health perspective, a more community-level perspective, I think.”
Some of the negative health behaviours resulting from lockdown are well known, such as increased alcohol intake and inactivity, but Dixon suggests on those points people should give themselves a break and not worry too much. “These things can be reversed. If you’ve overdone the crisps and the chocolate and the odd glass of wine or a beer over the last year, that’s reversible. And, you know, I think people are telling us that they’re motivated to do things.”
There have been positive behavioural changes made during lockdown too. But another study, carried out by the University of Strathclyde, found social patterning in positive behaviour changes, such as taking up exercise, with women, younger people, those who were in married or in a partnership, employed and in better health most likely to have made positive changes, which again highlights the community nature of positive and negative health.
But Dixon also points out that some of the COVID communications included positive health messages within them that went wider than COVID.
“I thought it was interesting that when we were in that really tight lockdown, the thing that the government was telling us every day was you can go out for an hour to exercise, because physical activity is really important. That’s a massive public health intervention right there, isn’t it? Today we’re being told to go out to exercise for an hour.
“I think people’s minds are there, people’s motivations are there, so how do we enable that? And you know, that happens at different levels of intervention, doesn’t it? So if you think about how over the years, millions and millions of people have stopped smoking, what does that look like? Well, there’s legislation and then there’s individual smoking cessation support.
“If you’re thinking about physical activity, you’re probably not legislating, but you might be thinking about how do we build towns, what does architecture look like, what does town planning look like, can we make bikes more affordable, all sorts of things that you can do at that higher level down to how do we support communities, families and individuals.”
Dixon considers that the communication in Scotland around COVID was very good and that would have helped compliance, which is also a lesson that can be applied elsewhere in public health.
There’s lots of evidence in behavioural science, if you’re very clear and explain to people in behavioural terms what exactly is it that they have to do, in this case to protect themselves, and why that’s necessary, people will largely do their very best to do that.
“I will say that the clarity of the communication that’s come out of Holyrood has been – speaking as a behavioural scientist and not in a political way at all – has been exceptionally good. Very consistent, very clear, repeated it, you know, repetitious, which if you want to support people in behaviour change, doing the same thing again and again in the same environment is the way that you develop habits and is the way [it becomes] automatic.
“So, I’ve been hugely impressed by the communication from the First Minister, people like Jason Leitch … just extremely good with a behavioural scientist ear listening to that. Very clear, explaining what people need to do, why they’re being asked to do it and always going back to, ‘Well, let’s just go back to why we’re being asked to do this’.
“And if you treat people like adults, people behave like adults. There’s lots of evidence in behavioural science, if you’re very clear and explain to people in behavioural terms what exactly is it that they have to do, in this case to protect themselves, and why that’s necessary, people will largely do their very best to do that. So the communication has been good.
“The communication from academics has been great. So Linda Bauld in Edinburgh has been, again, extremely clear in all her communications, Devi Sridhar, very clear in their communications, so, you know, I think Scotland has benefited a lot from that. So with my behavioural science ear on, listening to people that have been in the public sphere, I think they’ve done very well.”
Obviously, talking about public health every single day has put health at the forefront of everyone’s minds, and we now know that there are links, for example, between obesity and susceptibility to COVID, so will this raised health awareness change behaviour in the long-term?
“The honest answer to that is I don’t think we know,” replies Dixon. “I think that’s the honest answer. I don’t think we know how long this will last.” She and her team are undertaking further research on whether some of pandemic preventative behaviours will be maintained going forward.
But she adds: “I think some things will be enduring. So I think the discourse around mental health, which was changing anyway, again, that message around it’s absolutely okay to speak about mental health… if you’re feeling down, if you’re feeling distressed, that’s an okay thing to speak about. I think the communication around that has been great … but from a broader mental health perspective, I think that’s enduring. I think that will that will go on.”
There is also increased awareness of the economic impact on health: “I think the socio-economic disparities now are just so [obvious]. We always knew that, but we’ve just seen it in front of our eyes every day. And these things aren’t easy to change.”
Dixon points out that it’s not all about communications, there is also high-level structural change needed as well. She points to the work Professor Linda Bauld normally does, outside of COVID times, in public health at the University of Edinburgh around smoking and diet, in particular sugar, and how other, practical changes, for example, around pricing, advertising and ingredients, are needed to address health inequalities.
“It’s incredibly complex, because you’re then in the food industry and the agricultural industry, so to move the primary health behaviours at a population level, and to do that in a way that actually tries to even out the disparity – because the danger with public health interventions is that people like you and I who are articulate and have resources, we benefit more than people that don’t have the resources that we do, so you’re very mindful of that – what you want to do is move everybody to a better place, but you want to do that more rapidly to the people that are currently struggling.
“So I think that comes from that more global, that higher-level approach that Linda has taken, and all power to it, because, you know, working in the area of tobacco and working in the area of sugar, there are vested interests and lots of money going on. But as a health psychologist, and I work mainly at the level of the individual, I absolutely recognise that if you really want to shift behaviour, then that higher level, more structural restructuring is incredibly important.”
But in terms of the communications around behaviour change that we’ve seen during COVID, Dixon is clear: “If you want to take people with you, and you want people to do these things that quite honestly have been quite extreme … you treat people like adults, you speak clearly to them, you tell them why, and what to do.”