Importance of behaviour in health outcomes Flashcards
Two domains to health behaviour
1 Preventative
2 Remedial Rehabilitation Mitigative
Preventative
- individual lifestyles
- health screening
- vaccination
- epidemic control
- other structural dynamics in society affecting population health i.e environmental issues
Remedial
- rehabilitation / pre-habilitation
-lifestyle interventions
- adherence to medication or advice
- healthcare delivery practices
Preventative individual lifestyles
Impact of health behaviours on life expectancy
Example: (see slides n10)
Observational study of 487,209 participants in China. Examined the combined impact of 5 risk factors on life expectancy:
- Smoking
- Alcohol intake
- Physical activity
- Diet (fruit, veg, red meat, legumes, fish)
- Body shape (BMI & waist circumference)
Outcome: Deaths from cardiovascular diseases, cancer, chronic respiratory diseases –> Cox proportional hazards regression models
Projected gained/ lost life expectancy –> Ariaga’s decomposition method
Health screenings
Factors influencing vaccination uptake (preventative)
- physical availability
- ease of access/ convenience
- knowledge, attitudes and beliefs
- recommendation/ cue of action
Vaccination ( a behavioural case study):
the COM-B model (based on capability, motivation, opportunity)
Reflective motivation
Based on available information, does the person think getting the vaccine is a reasonably good idea, or a reasonably bad idea?
Automatic motivation
How does the person feel when they think about the vaccine?
What does the person reflexively or unconsciously associate vaccination with?
Epidemic control (preventative)
- treatment of an infectious disease is a medical issue
- control of the spread of an infectious disease is a psychological and social issue
- Social stigma can thwart preventative behaviours (e.g. Vrinten et al., 2019)
- (Mis)information spread via social media can influence epidemic dynamics – often positively (Kumar et al.; 2021) but also negatively (Du et al., 2021)
- Mistrust of government or health institutions hinders society’s ability to control an epidemic (Claude, Underschultz & Hawkes, 2019)
Example: Social resistance drives persistent transmission of Ebola virus disease in Eastern Democratic Republic of Congo: A mixed-methods study
Levels of behavioural intervention
Social -ecological framework:
-individual
-interpersonal
-community, organisations, institutions
-policies
-culture
Structural dynamics in society affecting population health
The climate and environment crisis:
food scarcity
Proliferation or emergence of infectious diseases
Air pollution
Conflict
Heatwaves
Displacement
—>
Malnutrition
Infectious disease burden
Respiratory diseases
Destruction of health infrastructure
Heat stress
Psychological stress and trauma
Practical solutions are required that address the complexity of our societies
The necessary emissions and environmental impact reductions require changes to individuals’ behaviour
Behavioural, cultural, technological, economic, and policy factors all interact, influencing one another (Centre for Climate Change and Social Transformations, 2023)
It has been argued that we are witnessing merely the symptoms of a collective ‘behavioural crisis’ driven by excessive consumption (Merz et al., 2023)
Medical adherence (remedial)
Patients with chronic conditions may have several reasons for not adhering to medication regimens
WHO identified five main categories of factors affecting this behaviour:
- Patient factors
Beliefs, health literacy, cognitive ability - Socioeconomic influences
Medication costs, access to healthcare - Structure of the healthcare system
Poor communication between healthcare teams, leading to poor communication with patients - Therapy factors
Unwanted side-effects, reminder of illness, complicated dosing regimes - Illness factors
Complex comorbidity, ‘the work of being a patient’
Impact of medication adherence on hospitalisation risk and healthcare costs example
Observational study of 137,277 participants on the register of the medical benefit plan of a large employer
Each participant assigned to four cohorts based on four medical conditions:
Diabetes
Hypertension
Hypercholesterolemia
Congestive heart failure
Medication adherence score stratified into five bins: 1–19%, 20–39%, 40–59%, 60–79%, or 80–100%
Outcome measures:
Medical costs (sum of health service costs and drug costs)
Hospitalisation risk (defined as the probability of 1 or more hospitalisations during a 12m period)
Kini and Ho (2018) reviewed 49 RCTs which studied medication adherence interventions
Six categories were found:
Patient education
Medication regimen management
Clinical pharmacist consultation for disease co-management
Cognitive behavioural therapies
Medication-taking reminders
Incentives to promote adherence
All were found to be potentially effective (with various qualifiers)
Incentives have shown mixed results
Methods vary in their availability and feasibility of implementation
Some methods of improving adherence have been shown to be effective
App or SMS based reminders are effective (but only if the cause for non-adherence is forgetfulness)
Methods influencing motivation and cognition show inconsistent results – possibly best reserved for patients whose primary barrier is motivation
Modifying drug delivery protocols to make them simpler and more streamlined appears to be effective and is cost-efficient
Effects are heterogenous and probably vary depending on the cause of the patient’s behaviour
Qualitative data can assist in identifying the mechanics of complex behaviours
Lifestyle interventions and (p)rehab (remedial)
Cancer
Exercise post-cancer diagnosis has been convincingly shown to confer survival benefits for some cancers – in particular breast, prostate, and colorectal cancer (Cormie et al., 2017)
Breast cancer
Meta-analytic review: 10 studies (combined N=23,041) showed post-diagnosis moderate-to-vigorous physical activity to be associated with a 45% lower risk of death from breast cancer (HR 0.55 [95% CI 0.36–0.84]) (Spei et al., 2019)
Colorectal cancer
Meta-analytic review: 13 studies (combined N=19,135) showed high intensity exercise was associated with cancer survival, with death from colorectal cancer reduced by almost a third (HR 0.69 [95% CI 0.57–0.84]) (Choy, Lam & Kong, 2022)
Prostate cancer
Prospective cohort study: 830 men with prostate cancer showed post-diagnosis physical activity to be associated with a 44% lower risk of death from prostate cancer (HR 0.56 [95% CI 0.35–0.90]) (Friedenreich et al., 2016) which is consistent with other studies
Exercise post-cancer diagnosis is beneficial to health-related quality of life, including in advanced settings (Burke et al., 2017; Chen et al., 2020)
Fewer side effects from treatments, systemic anti-cancer treatments are better tolerated (and, possibly, more efficacious)
Better surgical outcomes
Alleviates fatigue
Improves sleep quality
Helps maintain functionality and mobility
Provides patients with an enhanced psychological sense of self-determination, which enhances resilience
Type II diabetes
Recent advancements in understanding have shown that remission from type II diabetes can be feasibly achieved via lifestyle intervention (Kelly, Karlsen & Steinke, 2020)
Reviewed studies of lifestyle interventions reporting both therapeutic (n=5) and subtherapeutic (n=4) results
Findings “support[ed] the feasibility of T2D remission in diabetic patient populations using lifestyle as a primary means of treatment” (p408)
Remission success rate found to be comparable to other treatment modalities – while less invasive and lower risk
Evidence supports diet over exercise as a means of achieving remission
Low energy diets (reduction of 600-1100kcal/day) appear to be far more effective (49.4% remission rate) than moderate caloric restrictions (reduction of 500-600 kcal/day) (6.9% remission rate)
Healthcare delivery practices
Optimal clinical practices are not always delivered, for institutional and behavioural reasons
Greene and Wilson (2022) scoping review on infection control behaviours amongst healthcare workers:
n=11 studies identified which used COM-B, TDF, or Behaviour Change Wheel (all related frameworks) to study behaviour
Studies covered hand hygiene, antimicrobial stewardship, and MRSA screening
Three behavioural domains were identified as relevant across all included studies:
Beliefs about consequences
Environmental context and resources
Social/professional role and identity
Often, behaviours of personnel within healthcare systems are a both function of their individual psychology and their physical and social environment
Kennedy et al. (2022) scoping review on barriers to the implementation of exercise provision in oncology services, using an ecological framework
Reviewed n=50 studies which described 243 barriers to implementation, operating at all levels of the healthcare system
40% of barriers existed at the organisational level
The two most commonly reported barriers were:
Inadequate structures to support the inclusion of exercise into care
A lack of staff and/or resources to build exercise into care
There were also individual barriers, e.g.:
A lack of knowledge among HCPs regarding exercise for cancer patients
A perception that patients are uninterested in exercise as a therapy, or unsuitable
Being unsure of the quality of local exercise programmes
Perception of exercise as an “auxiliary” issue
However, individual- and system-level factors were found to be “interrelated … solving one on its own will not be enough to create meaningful progress” (p876)
Again – qualitative data can help to identify and characterise complex behaviours:
Oakley et al. (2016) did a qualitative study on delays to reporting of neutropenic sepsis in patients receiving chemotherapy:
13h of observations of chemotherapy consults
31 in-depth interviews with patients, partners/family/friends, and clinicians
Analysis of the QUAL data revealed a complex social dynamic in which clinicians, patient and carers “subconsciously conspired to underplay the seriousness and possibility of NS occurring”, leading to delays in presentation
Summary
Human behaviour can be integral to health outcomes, both before and after the onset of disease
Qualitative analyses are often key to understanding behaviour, because they allow for mechanistic insights to emerge
An understanding of behaviour should accommodate the levels of influence on behaviour – from the individual, up to communities, organisations, policy, and wider culture in society (i.e. an ecological framework)
The role of behaviour in health outcomes is not simply limited to patients and the public – it can also include the behaviour of health care professionals
Models of behaviour can help us to design interventions by understanding the key behavioural drivers of a particular outcome, and how/where to intervene
