In rude health

Inevitably, at an in-person conference in a Covid world – and a health conference at that – the pandemic was prominent throughout proceedings. Covid-19 had delayed or halted research, or in some cases afforded or accelerated it. Health Psychologists had mobilised rapidly to respond to the virus, and in many ways the Division and discipline appear to be in rude health because of it.

In his closing keynote, Marijn de Bruin (Radboud UMC, Chief Scientist, Behavioural Unit, RIVM) urged: 'If we further organise and up our game, this can be a step change in the relevance and impact of behavioural science'. In wrapping up, the ever-incisive Marie Johnston mused that 'it's a shame people had to suffer for our discipline… but the quality of the science has made it a step change'.

Chair of the Division Lucie Byrne-Davis (University of Manchester) told me: 'I feel like we're at a tipping point. Covid has made communicable disease a big issue again globally, and behavioural aspects have come under the spotlight. I do a lot of work in other countries and that has never gone away, but it's been interesting to see that in high income countries and in the UK.

'That has shown how important our research and practice is, particularly around behaviour change but also adaptation to long-term conditions and illness, and around staff wellbeing and pressures on our systems. These are huge areas of work we've been beavering away at, and people are now realising they need solutions. We need to stay ahead of that, so those roles are not filled by other people.'

Targeting interventions

I've never been to a conference where one person loomed so large – Susan Michie, herself a prominent and influential voice throughout the pandemic. Her COM-B model of behaviour change was everywhere, with Lucie Byrne-Davis telling me, 'the people we work with literally love health psychology, and it's because of COM-B'.

Chris Armitage (University of Manchester) presented work on COM-B and hearing health – hearing loss is a major contributor to disability, social isolation and dementia, he pointed out, and is 'deserving of more attention from health psychologists'. Numerous qualitative studies have assessed Capability, Opportunity and Motivation to identify what needs to change as part of the process of Behaviour change intervention.

The model features in UK government policy guidelines. Yet, Armitage said, there are fewer studies of its predictive validity than older models of health behaviour. In his study, opportunities and motivations were predictive of behaviour, but capabilities were not.

"I feel like we're at a tipping point. Covid has made communicable disease a big issue again globally, and behavioural aspects have come under the spotlight."

Capability and communications were to the fore in Jo Hall and Rachel Mallon's work in the Derbyshire Psychological Insights Team. Aware that 75 per cent of patients did not opt-in to Derbyshire's Diabetes Education service, and that the lower opt-in was disproportionately from more deprived areas, where health literacy was known to be lower, they set about co-producing a new leaflet with service users.

This aimed to increase understanding of diabetes and its treatment, and to address misconceptions surrounding how to self-manage the condition. Health literacy friendly approaches are now embedded within Derbyshire's Diabetes Education service, with one manager saying, 'It's all your fault… all this health literacy, I can't think about anything the same again!'

Cathryn Pinto (University of Southampton) raised interesting issues around Motor Neurone Disease, a condition where there are few specifically designed psychological interventions. There is no cure, and care focuses on managing symptoms and improving quality of life. Pinto found a mixed response to interventions, particularly around the use of images or videos. 'To do' lists and the monitoring of activities were viewed negatively.

Acknowledging certain difficulties and adding motivational messages. Issues with acceptability and engagement were reported, with participants saying 'I've done the mindfulness course, I've done this CBT, I've seen the counsellor, then it all stops…', or simply 'I think I am not ready for them yet'.

Others also outlined a focus on the components of behaviour change. Natalie Clark (South Tees Hospital) reported that the 2020/2021 Covid years have seen a 25 per cent decrease in deceased organ donors, and the transplant waiting list grows. Public health campaigns around organ donation should focus on the most influential positive statements, the most detrimental negative affective attitudes (which include bodily integrity, medical mistrust, the 'ick' factor, and the 'jinx' factor), and the order statements and attitudes are presented.

Dr Rachael Thorneloe (Sheffield Hallam University) researched flu vaccine uptake in NHS employees in Wales, as the government struggles to reach a target of 80 per cent uptake in 2021/2022 season. Semi-structured interviews explored barriers. Those with high uptake had a plan for obtaining their vaccine, perceived a high personal need, had experienced negative consequences from flu, and wanted to be a role model. Those not taking up the vaccine tended to feel nagged by colleagues, the vaccination team and managers, and expressed concerns about potential side effects and an impact on ability to work. Theory-informed interventions such as modelling can then address key barriers and facilitators.

A final example of targeting comes from Dr Anika Petrella (UCL Hospitals NHS Foundation Trust), investigating fear of cancer recurrence (FCR), a persistent concern among those living with and beyond cancer, having a negative impact on quality of life and psychological wellbeing. Rates of recurrence among sarcoma patients, affecting connective tissue, are higher than other solid cancers.

In an online survey conducted between August and October 2021, Petrella found an association between the psychological impact of sarcoma and FCR, but not the physical impact. She called for further investigations of the potential benefits of fostering 'psychological flexibility' in FCR interventions (e.g. through Acceptance and Commitment Therapy-based approaches).

Engaging at scale

Perhaps no other team embodies a creative approach to engagement and dissemination quite like the Centre for Appearance Research at the University of the West of England. Take a look at tinyurl.com/CARresource for podcasts, videos, a board game and more. At this conference, we heard from Jade Parnell about the development of a brief and free toolkit to help teachers normalise all appearances – to 'change the narrative before children create one'.

Maia Thornton's Participatory Action Research led to an e-book on supporting your child with an appearance affecting condition or injury. Abbi Matthews worked with 12-17 year-olds with Congenital Melanocytic Naevi, a congenital birthmark condition affecting 1 in every 20,000 births, the 'Public Patient Involvement advisors' producing an online psychoeducational resource for teens.

Then there was Marijn de Bruin, moving 'from team science to national impact' with health psychology during the pandemic in the Netherlands. 'I will solve this' was a pretty bold attitude to adopt in March 2020, but de Bruin backed himself and colleagues to make better use of existing data, and to generate evidence for clinical impact. Seeing the biological, epidemiological approach of the Outbreak Management Team, he exclaimed: 'It's like they're communicating with the virus, not with humans.'

That was the start of the Corona Behavioural Unit, but after 'one meeting in the Hague' there was a 'black hole of WhatsApp messages'. Once the group said they'd quit, 'it all started to click into place. In five weeks, we went from "we're out" to a dynamic cohort study with 90,000 respondents.' It was, said de Bruin, 'the coolest, most productive and effective stage of my career'.

The Unit identified 'legitimised non-adherence' to control measures, and observed how 'strictness and loneliness follow the same curves'. On average, though, 'people bounce back quite quickly.' Trust and perceived justice declined over time, and de Bruin could see the impact of policies that fail… 'the disco peak'. Noticing a 'wait and see whether symptoms worsen' attitude to testing, the team could adapt the media message to emphasise that's not OK with Covid: 'x positive cases last week in isolation avoided xxx new cases in the next six months'. 'We've been sort of the starting engine', de Bruin said.

The data also revealed aspects such as the effects of distance to PCR location on test behaviour: 15 minutes by bike is an important limit for Dutch people. But mostly, de Bruin emphasised the need to move beyond the typical approach of mass media advice and closures, towards multi-level, integrated and evidence-based interventions. In the Netherlands, employers, schools, pubs and restaurants play a key role in translating national policies. Local stakeholders support the resilience and wellbeing of people involved, and enhance adherence through context-specific interventions. Small changes and lack of clarity in national policies can have a major impact on stakeholders locally.

Anticipating another vaccination campaign, there are now 25 or so industries and sectors working on plans. 'Citizens and organisations are the experts in what works in what context and for long-term policy support. The government's take on it is now "It's up to society… you make plans and present them to us".' Again, de Bruin said, we come back to COM-B: 'think in terms of capability, opportunity and motivation'. However, he warned, it's 'easier said than done to engage society'.

Patient-centred care

Perhaps the most thought-provoking talk for me was from Heather Buchanan (University of Nottingham). Did you know that in China, patients are mostly not given their diagnosis of cancer? Families hold the 'power', acting as 'gatekeeper'. 'If the patient comes to us and asks', one doctor said, 'we need to ask the family for advice before we can give the patient their diagnosis'.

Culturally, cancer = death, no cure, and death is a taboo. There are also misconceptions around the disease processes, such as a belief that you can catch cancer like a virus. 'In foreign countries when a patient is diagnosed with cancer, we can talk cancer. However, in China when a patient is diagnosed with cancer, we often talk of a tumour.' The doctors in Buchanan's study talked of their conflicted role, working in constant fear of litigation – 'you're successful as a doctor if you haven't been sued' – in a job that is not held in high esteem, and is even actively dangerous. 'I keep a sports bat in the office: it's not for fun, it's for defence'.

All parties to some extent buy into this 'culture of secrecy', and for me that raises pretty fundamental questions around whether it actually matters, and what 'patient-centred care' even is.

Healthcare professionals were also under the spotlight from Rebecca Lee (University of Manchester). 'Healthcare professionals communicate in weird and wonderfully complex ways about children and young people with pain to other healthcare professionals,' she said. 'These conversations can potentially influence management and outcomes.' A lack of training, resources and time can mean that health care professionals are 'reluctant to assess and communicate about chronic pain in children and young people'.

In an ethnographic study, Lee produced structured field notes on aspects such as what language professionals use when discussing pain. There was a tendency to start descriptions of pain with descriptions of personality, temperament etc. 'Children remember many of the nuances of pain conversations,' Lee warned, 'and have strong opinions on the topic.'

"Healthcare professionals communicate in weird and wonderfully complex ways about children and young people with pain to other healthcare professionals."

Experiencing the evidence

In her keynote address, Jo Hart (University of Manchester) recounted a career around enhancing health professionals' education and communication, to make it more behaviourally focused. Health psychologists have led the way in this, yet Hart noted that 'often we don't talk about our leadership roles'.  

Health psychologists have expertise in working across and combining research, teaching, consultancy and practice, Hart said: 'It's in the way we're trained, and it makes us flexible and agile'. She described her own path, from systematic reviews on how doctors practise under the threat of litigation, to psychological literacy – 'being insightful and reflective about one's own and others' behaviour and mental processes, and having the ability to apply psychological principles to personal, social and organisational issues in work, relationships and the broader community'.

Hart pointed out that doctors report feeling untrained in discussing health behaviour change with patients. 'It can be a frustrating experience: opportunities to discuss behaviour change with patients missed.' Hart has therefore been involved in NHS initiatives such as Making Every Contact Count, and the 'Tent Pegs' behaviour change communication toolkit for medical students, giving seven easy ways to help patients change lifestyle. Following online training, the students were more likely to plan to initiate behaviour change consultation in their work.

Hart was also part of a scheme that attached medical students to a family, which she described as 'experiencing the evidence' to increase self-efficacy. 'They could really see what Psychology, and behavioural science more generally, meant to people, how practical it was'. These conversations ultimately led to The Change Exchange: 'With our co-development approach to research and practice, we get the psychology of behaviour into places where it can make a difference'.

That includes 16 low- and middle-income countries, including Uganda, where 'AIM 4 Africa' took their one day course for health professionals and trainees around acute illness management (teaching an ABCDE approach: airway, breathing, circulation, disability, exposure), and modified it to be less didactic and focused on fear messages.

Other work such as 'Cards of Change' demonstrate the approach Hart and colleagues have taken to engaging at scale in a concrete, sometimes playful way. She concluded with nuggets of advice on leading in health professional education: 'COM-B thyself and others, use the hive mind and community, be translational, focus on making a difference, enable excellence and support others through mentoring and being mentored… want to fix things, show off our collective skills, be in the room and bring others in too.'

BOX: The pandemic life

Karen Mak (University College London) found that younger adults were more likely to report an increase in engagement with the arts during the pandemic. She suggested investing in digitalisation in arts and cultural activities, while addressing the risk of digital exclusion. Mak's colleague Alison McKinlay, also using data from the Covid-19 Social Study, identified the use of art as a tool to self-reflect, among other problem-focused strategies such as creating structure to the day, and reducing news intake.

The digital divide also loomed in Nick Hulbert-Williams' (Edge Hill University) presentation, a meta review of the use of web-based psychological interventions in cancer. From 20 studies he identified anxiety around technology, and time burden during a stressful period, as common barriers to uptake. There were overall positive effects on depression and stress, but mostly null or negative effects on distress, quality of life and wellbeing. Multi-component interventions and virtual clinician contact were associated with superior outcomes, leading Hulbert-Williams to conclude with a 'challenge for us – getting that balance right around the cost effectiveness, scalability and accessibility of online intervention'.

Of course, for some 'digital natives' living their lives online, the issues are more around 'Fear of Missing Out'. Joel Crawford (University of Liverpool) studied its role in Heavy Episodic Drink. If FoMO is particularly high the day after a missed event, for example when seeing all the fun photos from the night on social media, does that increase people's intention to consume in the future? Yes, said Crawford (while suggesting that the pandemic may have meant his participants were then less able to follow through on those intentions). Health campaigns around drinking need to acknowledge that drinking is often about achieving social gains and avoiding social losses, and people should be reminded that the negative depictions of events rarely make it into their feeds.