Careers: The journey of a psychologist in public health

Amanda K. Bunten outlines her role in improving health at the population level.

As an undergraduate psychology student at Southampton University I sought part-time employment to help fund and complement my studies. During this time I worked as an applied behavioural analysis tutor with children diagnosed with autistic spectrum disorder and as a rehabilitation support worker for a young man with acquired brain injury. Having the opportunity to experience the practical application of psychology in different settings enabled me to start considering my career opportunities. On completing my degree I applied for a self- funded place on the taught Master’s in Health Psychology at City University, London which I went on to complete full-time in one year.

Whilst trawling the NHS jobs website, on completion of my master’s, I came across an advert supporting a Director of Public Health (DPH) in a deprived inner London borough. Despite never having heard of ‘public health’ as a discipline before, I was intrigued and felt my skills matched the job specification.

I was fortunate enough to become a member of this team as a Public Health Strategist. Little did I know, but this was to be the start of my journey understanding, integrating, and championing the synergy of health psychology and public health.

Over the five years I worked in a local public health team I led on areas of health improvement, health protection and commissioning of services to improve health and well-being. I was involved in designing, implementing and evaluating services, working collaboratively across the local health system and with local communities to improve health outcomes and reduce inequalities.

I designed and delivered targeted campaigns, training to the public and various healthcare professionals, wrote strategies and action plans, developed and managed contracts, and implemented service improvements working with providers and users of services.

I worked on issues including sexual health, planning and responding to pandemic flu and improving uptake of the seasonal flu vaccination, health emergency planning for the London 2012 Olympics and Paralympics, and supporting the implementation of a TB cohort review locally. This helped me recognise the importance of health psychology not just in delivering individual interventions but also in achieving improvements in health and well-being across a local population at a strategic level, ensuring services were meeting the needs of the local communities and providing more tailored intensive interventions where needed.

To increase my understanding of population level health I completed a course on epidemiology at the London School of Hygiene and Tropical Medicine. I was encouraged to pursue specialist public health training; however, I decided I wanted to continue my professional development in health psychology. I was lucky enough to be supported by my Director in applying for a place on the Professional Doctorate in Health Psychology at City University, London, and subsequently completed the mandatory two years’ supervised practice in this local public health team.

During this time I was aware of only one other health psychologist working in a similar role – my academic supervisor at City University. I was astonished that there appeared to be so few health psychologists working within the public health sphere. The roles that did exist were most likely to be found in a research or clinical setting, working in smoking cessation or rehabilitation services, where supporting behaviour change was still predominantly focused on the individual through 1:1 or group behavioural support.

In a society where the biggest preventable killers are now nearly all lifestyle related, the need to find opportunities to enable people to make health-enhancing choices and behave in a way that has a long-term positive impact on their health and well-being is paramount. The five big preventable health killers – heart disease, stroke, cancer, lung and liver disease – account for more than 150,000 deaths a year among under-75s in England alone. Making the healthier choice the easier option, creating opportunities, harnessing motivation and ensuring capability are key for behaviour change to occur. Providing health and social care professionals with effective skills to support behaviour change is one piece of the puzzle, but we need to engage with people across the life course whilst making the most of life transition points, and engage with people where they live, work, play and pray. We need to explore opportunities for intervention in the environment around us, engaging with teachers, parents, employers and the commercial sector. Many of us are encouraged to plan for our older age by investing in pensions and insurance, but what about developing effective self-management skills, identifying our community assets and understanding our level of resilience? There’s a clear role for the application of health psychology across prevention, promotion, managing long-term conditions, adapting to and maintaining change.

In 2013 I saw through the transition of the local public health function into local government as a response to the Health and Social Care Act 2012. At this time the public health system became fragmented and, despite Directors of Public Health retaining the responsibility for the health and well-being of the local population, many services were now to be commissioned by different bodies. As the role of the local public health team started to shift more into commissioning and contract management, the applicability of health psychology was seen more in terms of the role of providers of services.

I still very much saw the role health psychology had to play in public health and in September I became aware of a new Behavioural Insights Team within the newly established National Executive Agency, Public Health England (PHE). The ambition of this new organisation struck a chord with my passion to reduce health inequalities and translate evidence into practice.

I was amazed to see health psychology as a prerequisite for the new roles and I jumped at the chance of being part of this team. It became clear to me that this new executive agency had indeed grasped the benefit of integrating health psychology within the public health agenda at a population level. I joined the team in November as a Behavioural Insights Analyst working alongside a Lead Behavioural Insights Researcher (Dr Tim Chadborn, expert in epidemiology and field research), and a Behavioural Insights Advisor (Anna Sallis, a Chartered Psychologist and Registered Practitioner Health Psychologist).

Behavioural insights is an applied approach that draws on insights from behavioural science (including research in behavioural economics, social anthropology and psychology) to understand why people behave as they do, and the context in which decisions are made. It accepts that dual process models of behaviour (conscious/reflective and less conscious/automatic system) are involved in decision making and explores the importance of the relatively under-researched automatic processes.

Our team has a remit to test the application of behavioural insights with a focus (but not exclusively) on automatic processes, to facilitate health-related behaviour change, and support population-level improvements in health and well-being. My role involves designing behaviour change interventions through the application of behavioural insights, to enable people to make positive health choices that will have an effect on population-level health. We implement and evaluate these robustly, with the aim of driving scalable change through the translation of evidence into practice, whilst informing policy.

At times this feels like an unachievable task, particularly when major developments in public health are often linked to restriction or legislation: think of the 1854 cholera outbreak in Soho, where the removal of the handle of the pump in Broad Street reduced the transmission of infection, and more recently the introduction of the smoking ban. Restriction and legislation are both viable levers that can be used to achieve population-level behaviour change where appropriate, but there are many other behaviour change techniques that can be used at low cost and that can address memory, attention and decision processes, the environmental context and our social influences, depending on the behaviour that is being targeted. What these significant public health challenges actually demonstrate is the importance of the collation of evidence for the development of science, which results in knowledge that can be applied and translated into action for social good.

At present we aim to work with local areas where there is a clearly defined issue, where we can provide expert advice and where possible, support the implementation and evaluation of an intervention. I spend a lot of time out of the office on field visits and meeting with those involved in delivery, provision and management of services. I think that’s necessary to gain an understanding of the context in which the behaviour occurs, and to collect data and monitor change through objective behavioural outcomes. I also conduct literature reviews to help inform an understanding of the health issue and behavioural components.

Once the target behaviour is identified we explore the factors associated with maintaining the current behaviour and potential opportunities for intervention. If appropriate a behavioural analysis will be conducted using COM-B and the Theoretical Domains Framework, and then elements from relevant frameworks including the Behaviour Change Wheel, Behaviour Change Taxonomy, MINDSPACE and EAST are used to help inform the intervention design.

Criteria for conducting behavioural insights research trials include considering the impact (consideration of health inequalities), affordability, acceptability, scalability, feasibility of trial implementation and evaluation, objective behavioural outcome measures, value added by behavioural insights and alignment with guidelines and priorities.

We have a formal partnership with the Behavioural Insights Team (who have recently become part mutualised from the Cabinet Office now teaming up with the charity Nesta, the UK’s Innovation Foundation), to help build our team’s expertise in designing and applying behavioural insights to public health policy. We also work in partnership with other government departments, academics and businesses to identify collaborative opportunities to apply behavioural insights, support implementation and disseminate findings. It is exciting to be developing close working relationships with leading academics in health psychology and to have met with the Public Health Minister to discuss behavioural insights work and future plans.

I am currently working on research trials to test the application of behavioural insights to improve the referral process to local stop smoking services for pregnant smokers; increase the uptake of NHS Health Checks; and reduce rates of childhood obesity. Other research trials our team has been working on include testing changes to the Stoptober website to increase the number signing up to quit; assessing referrals to promising interventions to reduce social isolation; and evaluating interventions to reduce anti-microbial resistance. As we develop as a team within PHE and as a wider discipline across government, our approach and remit will inevitably evolve.

Having attended many research methods and statistical workshops over my years of training in psychology has provided me with a good grounding for understanding and conducting research. But the practical realities of designing appropriate, robust field research trials feels quite different. I am learning a great deal trying to work with existing infrastructures and databases in a complex healthcare landscape, with data protection challenges and electronic systems that in many instances are not well integrated.

I had found it challenging to find opportunities in my previous role to develop my research competencies. Within this role I find I am using and developing all the expected health psychology competencies every day!

The PHE Behavioural Insights Team also has a key role in building capacity for applying behavioural insights to health interventions across the public health landscape. We have developed a master class that we are delivering internally to PHE staff and externally to local public health systems on applying behavioural insights and designing population level interventions.

We are keen to identify expertise across the public health field in population-level health behaviour change and find examples of local practice where behavioural science is being harnessed. Hertfordshire County Council has decided in order to move towards achieving desired improvements in public health that they need to utilise evidence-based behaviour change principles at the individual, community and population levels. They have therefore been exploring the market for developing a Behavioural Science Unit.

We have been working with forward-thinking Director of Public Health, Jim McManus on this new initiative. A market-testing event was held in June where a number of different potential providers proposed different models in which this vision can be realised. We will be continuing to support Hertfordshire in this venture and are keen to identify other areas working to utilise evidence-based population-level behavioural change initiatives embedding behavioural science in public health.

I am now an active member of the Health Psychology in Public Health, East of England network and look forward to identifying other practitioners across England who share my vision and ambition and exploring more opportunities to apply behaviour change principles to achieve population-level behavioural change.

I am really encouraged by how health psychology appears to be gaining recognition within the public health sphere and see my role in championing this symbiotic relationship, raising awareness of the applicability of behavioural science to the health and well-being agenda. We still have a long way to go to bring implementers, academics and policy makers together not just in the field of health but across the wider determinants, to make a real impact on the health of our population and to ultimately improve people’s lives.

- Amanda Katharine Bunten is a Stage II Health Psychology trainee enrolled on the Professional Doctorate in Health Psychology Training Programme, City University London. She is working as a Behavioural Insights Analyst in the Public Health England Behavioural Insight Team. [email protected]

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