Who do we seek to change, how, and will it last?

As the Covid enquiry prepared to take its first oral evidence, the pandemic loomed large over my one-day trip to the Division of Health Psychology Annual Conference. 'Cast your mind back,' said Dr Rhiannon Phillips (Cardiff Metropolitan University), recalling the moment she realised 'hang on, this is in the community now', and asked her Head of Department for £50 for an online survey. 'It seems like a different lifetime… but this has not gone away. There are still over 300 weekly deaths. It has just been absorbed into our day-to-day lives.'

That survey became a longitudinal qualitative study over 12 months, with 11,000 people signing up. 'We learnt about how you carry out research in a rapidly changing scenario,' said Phillips. Perception of risk changed over the first two years of the pandemic, with vaccine hesitancy at 12 months independently associated with low fear of the disease and more negative attitudes towards Covid-19 vaccination. With over 8000 open text comments, social justice was prominent: 'other people aren't playing by the rules'. Trust in government was very low: 'we had to open a new theme for Dominic Cummings,' Phillips noted.

We know that ethnic minority groups had poorer health outcomes through the pandemic, and that intersected with age, deprivation, and existing comorbidities. An 18-month project led by Dr Atiya Kamal (Birmingham City University) worked with national and local public health authorities and community organisations in London and Birmingham to understand 'vaccine hesitancy'. Interviews were conducted in English, Portuguese, Spanish and Urdu. 'It was a joy for me to do some interviews with 70-year-old ladies in Urdu,' Kamal said: 'these are the people who wouldn't have completed the survey, but now their voice is included.' And these interviews often revealed a more engaged and active public, driven by knowledge around vaccination rather than fear. 'I would have never questioned vaccines previously, taking them,' said one participant, 'but now I know I would do more research for myself. I wouldn't just take it.' 'Vaccines have become politicised and no longer blindly accepted,' Kamal warned. 'People want ongoing conversations… and not to lead with fear but with hope and optimism'. That means building on Kamal's 'pillars of effective communication for diverse communities': trust, partnership, accessibility, inclusivity, empowerment.

Effective communication was also the theme of a study from Dr Louisa Pavey (Kingston University). Rules can be 'proscriptive' ('should not') or 'prescriptive' ('should'). These approaches have distinct motivational and behavioural outcomes. A proscriptive style is associated with prevention, avoidance, protection, inhibition, a more mandatory message. Prescriptive is about promotion goals, approach motivation, advancement, activation, enhancement, positive end states and more a matter of personal preference. In the study – conducted in February 2021, with Pavey reminding us 'a lot of the Covid research is specific to that particular time' – people (but particularly younger people) preferred the more proscriptive approach if the message was seen as a legitimate one. If not, the proscriptive style tended to lead to more negative 'reactance'. Factors which influence the perception of legitimacy of government health information then become key, including trust and the perceived fairness of a social contract.

For those unfortunate enough to be suffering with long Covid, Sarah Keith's (University of Stirling) longitudinal study found that anxiety and depression at timepoint 1 were predictors of QoL at timepoint 2; depression was also a predictor of functioning. Interventions to help manage low mood, anxiety and improve illness perceptions could prove valuable in patient recovery.

Change, and sustaining it

Bringing about change in health behaviour is always a main theme of a DHP conference, but this year there was also an interesting thread around the barriers and facilitators to keeping it going.

Emma Gibson (Birmingham City University) considered healthcare professionals working in primary health settings caring for adult patients with type 2 diabetes. Physical activity is important in the ongoing management of the illness, but the professionals often reported that both their own time and their perceptions of their patients' time was a barrier to suggesting it. 'We can't cover all aspects of diabetes care with them in one visit, never mind the aspects of wider care [physical activity].' They didn't always know what type, intensity and duration of physical activity to recommend, and their own physical activity and lived experience could be both a barrier and facilitator to their advice.

Presenting findings from his PhD, Sam Warne (University of St Andrews) looked at workplaces taking place in the 'Step Count Challenge'. The Scottish weather proved to be a bigger barrier to participation than work was. The challenge did have a huge effect on motivation, particularly the competitive element, but the effects aren't long lasting for all. Warne noted the positive influence of working mostly from home, and having a dog (hard agree from me).

Physical activity was also the topic for Maria Goodwin (Loughborough University), finding that it declined more rapidly over time in adults with hearing loss; Channais Matthias (Manchester Metropolitan University) finding that combined CBT and exercise, face to face, 1-2 times a week, for 50-90 mins, can be effective in treating depression; and Richard Cooke (Staffordshire University) with a fascinating 'unstructured discussion' around making health psychology interventions more sustainable, based around a 'walking football' group for older men. Set up as part of an intervention, it's still going strong seven years later; longevity which Cooke puts down to the fun and sociable elements creating a virtuous cycle. 'The intervention developed met the needs of its target group, and they were able to take ownership.'

Who needs to be involved?

In her keynote, Professor Harbinder Kaur Sandhu (University of Warwick) discussed the challenges, testing and application of behaviour change interventions in clinical trials: namely, the I-WOTCH study of behaviour change in opioid reduction. It has been a multi-disciplinary effort, including statisticians and health economists, and driven by co-creation and patient and public involvement.

The past decade has seen a 400 per cent increase in prescribed opioids, and between 1993 and 2019 there was a four-fold increase in opioid associated deaths in England and Wales. 'My angle as a health psychologist,' Sandhu said, 'was non-pharma intervention – not swapping a pill for a pill.' Participants were included in I-WOTCH if they reported using strong opioids for at least three months and on most days in the past month. The pain was still there, and most reported a low quality of life: 'I'm literally a zombie around my kids'. The trial looked to overcome the fears around withdrawal.

Drawing on the ever-popular COM-B model of behaviour change, I-WOTCH addressed people's Capability (getting people to really engage in decision making, in an interactive way), Opportunity (both physical and social), and Motivation (giving people time to reflect, and discuss with peers). Participants were randomised to either usual care or three day-long group sessions that emphasised skill-based learning and education, supplemented by 1-on-1 support delivered by a nurse and lay person for 12 months.

After that time, there was no difference between the two groups in terms of pain interference, but 29 per cent of the intervention group had ceased opioids completely, compared with 7 per cent of control group. 57 per cent had reduced use by 50 per cent (control group 27 per cent). Sandhu highlighted changes in self-efficacy and mood, while recognising the challenges of 'living a complex life with chronic pain'. 'People needed the support, and the group was key in sparking motivation.'

Sandhu also shared general lessons around leadership, communication skills, and wellbeing. 'Embrace the leadership. Be open to feedback, training, and learn from peers and senior colleagues. Talk with your team around expectations. With such a big trial, we could all be going off in different directions – it's important to have a safe space for conversations. And look after yourself, otherwise you're not going to be able to lead a productive team.'

An enormous contribution to make

Day one finished with a barnstorming 'public health talk' from Greg Fell, Director of Public Health at Sheffield City Council. 'You'll remember us from the pandemic,' he began, 'but we have other tricks up our sleeve'.

Public health is, Fell said, 'the science and art of promoting and protecting health through the organised efforts of society'. His long job description – encompassing health protection, improvement, intelligence and more – is digested for him by his boss as 'improve healthy life expectancy, and close the gap in that between the haves and haven'ts, from 'Dore to Darnall'. Fell reminds us that his budget is shrinking – 'state spending power is 50 per cent smaller than it was a decade ago' – but that his budget is also, in effect, the '£14 billion of Sheffield PLC – the economy of Sheffield'.

That's important, because his main lesson from Covid is that 'we went into it with an infectious disease playbook, but it quickly became apparent it was a whole society playbook that was needed. Behavioural scientists and psychologists made a massive difference in that. SAGE input to the government was top notch.'

Fell urged the audience to focus their efforts where they might have the biggest impact. We know the main causes of ill health and mortality – 'fags, booze, obesity'. Yes, treating nicotine addiction works, Fell said. 'But we also spend £300K a year on trading standards officers to target those selling vapes to children.' Sure, you could get into liver medicine and not be short of work in the coming years. But the 'business end is price, advertising, availability, the very narrative on which policy sits,' Fell said. Coca-Cola have invested heavily in behavioural science, and spend more on advertising a single product than the whole of the World Health Organisation budget.

With a note of optimism, Fell reassured us that 'we do know what to do – Mike Marmot wrote the report. And we are doing it. But we're just about holding the gap, and I'd like to be closing it.' But medicalised health policy is not the answer: 'that leads to medicalised answers, treating one person at a time. You can't treat your way out of big social and political problems.' Fell lays much of the blame at the door of 'neoliberal thinking and ideology – the privatisation of profit and socialisation of risk.'

Back to the pandemic. 'There will be another one,' Fell warned: 'I'm on my third.' If it's not for another 20 years or so, Fell fears we may have forgotten all but the biggest of lessons. These include making local government the default system for health: 'the Department of Health and Social Care should be renamed the Department of Hospitals, because that's what it is.' We need to work with and through community leaders, and consider whose behaviour we are trying to influence. To give another example, Fell said that for 1 in 20 people who died in Sheffield this year, air quality would 'be in the mix. You guys can and should make an enormous contribution to that'.

When I spoke with new Division Chair Professor Aimee Aubeeluck, she noted that 'with the pandemic, it's been very clear what the role of health psychology and health psychologists is in terms of global and public health. But I don't think we can take that for granted. We have to bang the drum and let people know that the work we do is so awesome. The world needs health psychologists, and there's a lot to do.'

- See also our Health Psychology Collection, and look out for the interview with the new Chair of the Division Professor Aimee Aubeeluck.