Position Papers 5 & 6

Next we have a paper by Professor Chis Griffin, followed by the thoughts of Chris Holmes of C3, Collaborating for Health. All of these papers will be summarised in a later blog by the Principal Investigator Dr Fiona Spotswood.

Professor Christine Griffin, University of Bath

‘What would Stuart Hall do?’: Implications of a conjunctural analysis of research and policy debates on Behaviour Change in the UK

There have been many heart-felt tributes over the past few weeks to Stuart Hall, who died on 10 February, from across the worlds of politics, academia and the arts. He was, as Martin Jacques put it: “an utterly unique figure”, as a Black intellectual, Marxist, political activist and (co-)founder of cultural studies as a radical trans-disciplinary project. One of the most significant intellectual and political figures of the past 50 years, Stuart foresaw the profound transformations of the British – and international - political systems in the 1970s, is credited with coining the term ‘Thatcherism’, and remained an important theorist of neoliberalism until shortly before his death, writing in the journal ‘Soundings’.

In one such tribute, Tracy Jensen asked readers to consider “what would Stuart Hall do?” in countering current debates and Coalition government policies around welfare and poverty. In the influential 1978 text ‘Policing the Crisis’, Hall, Chas Critcher and John Clarke argued that figures such as ‘the mugger’ (or as Jensen proposes, the ‘welfare scrounger’) emerge at times of crisis when new formations of ‘commonsense’ are coalescing. In their preface to the new edition, Hall et al. argue: “in formerly democratic societies, ‘becoming commonsense’ is one key route to securing popular legitimacy and compliance and thus the basis of what Gramsci called ‘hegemonic’ forms of power” (2013: xiii).

Always working in close collaboration with others, Stuart Hall aimed to produce ‘symptomatic readings’ within the frame of a ‘conjunctural analysis’ (Hall and Jefferson, 2006). From this perspective, the emergence of notions of ‘behaviour change’ as a new ‘commonsense’ discourse in approaches to public health and in other domains, would lead us to ask ‘what might this focus on ‘behaviour change’ as a new cornerstone of social policy be symptomatic of?’” A conjunctural analysis would ask us to consider “why now?”, attempting to understand ‘behaviour change’ as a response to the political, economic and socio-cultural changes of its time, rather than focussing on the relative effectiveness of various BC strategies as means of managing the activities of specific social groups.

Stuart Hall famously argued that the university is a critical institution, or it is nothing. There are certainly a number of cogent critiques of the BC agenda. The dilemma for those operating within the field of public health is that some of the practices we will be examining in this seminar series in greater depth cause harm to individuals, their families and friends, in addition to the costs to the health service etc. Is it possible to retain a clear and forceful critique of the BC agenda, whilst engaging with policies, practices and debates in these arenas?

Chris Holmes, C3, Collaborating for Health

The Inconvenient Truth

Bringing behavioural science to bear on society’s big issues, be they lifestyle behaviours or sustainability challenges, faces a difficulty reality that will effect the future expression of our science and may have implications for the direction of research.

The population scale of these challenges means that intervention efficiency, whether the return is expressed in terms of quality of life or financial savings, is overshadowed by the cash investment that would be required to deliver interventions at a scale commensurate with the scale of the challenges. The cash required is simply not available nor arguably will it ever be. It is immaterial whether the return from prevention compared to treatment is orders of magnitude greater if the available funds are struggling to meet the current demand for services and the time frame of those returns is measured in tens of years.

Currently the returns from the modest investments in behaviour change are further weakened by the short-term nature of publicly funded interventions. One year funding remains the norm and this means that the set-up costs can represent 40-60% of funds without any confidence that these fixed costs can be amortised over subsequent years. Providers then face the task of finding funding for future years thereby distracting management from their core purpose and creating uncertainty amongst trained staff with the risk of loosing these skilled resources. This diverts further financial and management resource into recruitment and training assuming further funding can be found.

We, the research and policy community, can choose to ignore these inconvenient truths of application or can look to reflect this reality in the focus of our work. This is beginning to happen but the question is whether we need to drive this further and faster. If we took the step of admitting this reality into our thinking what might the implications be?

Developing Universal Outcomes.

Often universal gets translated into a single service provided everywhere. Yet our science clearly shows that people do not start with an equal chance of effecting change in their behaviours. Self-efficacy alone suggests that those on the left of the distribution curve may need much greater support than those on the right. In the financial context outlined above providing the necessary support to those on the left of the curve requires a radical rethink in how we target our services and the nature and costs of the different interventions we offer.

When designing interventions for those centre right of the curve, the cost of delivery needs to become a primary driver in our thinking. Simplistically, this means removing people as the medium for delivery of interventions or, at the very least, face-to-face interactions in favour of remotely provided support. Associated with this may be the need for interventions to generate their own revenues to fund the higher investment required centre left of the curve, where face-to-face support is probably a pre-requisite.

So what costs will the market bear? It is difficult to be precise but consumer markets probably give us some indication. There are currently circa forty thousand physical activity apps available on the market ranging in price from £0 to £4.99. People are spending £19.7bn per annum in the UK on health and beauty products, including £2.8bn on OTC medicines (Verdict, UK Health and Beauty Prospects, 2012), within an indicative price range of £0.75 to £125 (£83/10ml). Yet, how many research programmes begin with a clear cost envelope within which they are designing an intervention, which isn’t the research budget but an ongoing market price?

Effect Sizes

The only recent examples of population level behaviour change can be found in consumer markets where the availability of infrastructure (supply chain, logistics and retailing) provides reach and competition between organisations creates the catalyst to drive change through an ever evolving range of product, services and promotion. One only has to consider the changes in mobile technology use to see the evidence of the power of these consumer dynamics.

Many of these changes, we could argue, are counter productive to our goals and this could lead us to dismiss this system as a platform for research and development. Yet, the single most successful public health intervention in the last 10-years has been the reformulation of products to reduce salt content.

How might we focus behavioural science to accelerate the reformulation of products to reduce sugar and fat content and who would these interventions be aimed at. Faced with Foresight’s systems map for obesity, it is interesting that we have focused most of our effort on the largest audience, the population, developing techniques that at best demonstrate modest effect sizes for individuals at a cost that precludes these techniques being scaled to population level. Yet there are far smaller audiences in the system map, measured in 10s of people, who can have a much greater influence on the system overall.

We are all familiar with the Pareto effect, yet recent work by the Complex Systems Theorist James Glattfelder and co-authors at Zurich ETH University on financial markets (http://www.ted.com/talks/james_b_glattfelder_who_controls_the_world) has shown that great influence is held by an even smaller number of individuals than Pareto would predict. What might be the opportunity for people and the planet if we were to focus our behavioural knowledge and expertise to design interventions to influence their perceptions of the relationship between future shareholder value and sugar/ fat content or carbon footprint? Rather than laying siege to the Corporate Affairs departments of companies, whose job is to keep risk at arms length, such an approach may offer us the opportunity to harness the competitive power between organisations to drive population level change faster and more effectively that we could ever achieve directly.

What of new product development? Many of us are rightfully sceptical of so called super-foods both in terms of the beneficial claims and the motives of manufacturers and retailers in terms of enhanced margins. Yet are we confident that we have mined primary research fully for opportunities to create products and services that in themselves provide social benefit and use consumer dynamics and infrastructure to achieve scale and sustainability. For example, 2-spoons is a project underway to take our knowledge of the development of taste acceptability in young children and turn this into a consumer product providing the necessary 12 individual repeat tries of single fruit and vegetable tastes in a way that overcomes parent’s behavioural barriers to the process.

Summary

The developments in the behavioural sciences and the keen interest being shown in their potential application represent a significant opportunity. To realise the benefits for people and planet we may need to reflect in our own work the reality of how and where our tools may be applied and challenge ourselves to broaden our own perspectives on whose behaviour we need to influence and with which other disciplines we may need to collaborate to achieve success.