Monday, July 26, 2010

[EQ] Health Systems and Health Related Behaviour Change: A Critical Review of Primary and Secondary Evidence

Health Systems and Health Related Behaviour Change:
A Critical Review of Primary and Secondary Evidence

Catherine Swann, Chris Carmona, Mary Ryan,1 Michael Raynor, Enis Barış,2 Sarah Dunsdon, Jane Huntley and Michael P. Kelly

Centre for Public Health Excellence, National Institute for Health and Clinical Excellence

1 Independent consultant

2 Division of Country Health Systems (DCS), WHO Regional Office for Europe, Copenhagen, Denmark
London: NICE/ Copenhagen: WHO - 2010

Available online as PDF file [250p.] at:

The first part of the report presents findings from a thematic analysis of evidence statements. These were taken from a set of 12 evidence reviews which had originally been developed to inform NICE public health guidance on CVD prevention. In addition to the model proposed by WHO (2008), several additional themes and sub-themes were identified including:

• the important role of policy and national programmes, media and marketing, the environment and planning in health stewardship and behaviour change

• the role of finance and sustainable resources in health-promoting systems
• how improvements in service design and delivery, such as tailoring and targeting interventions, building partnerships and networks, and using appropriate modes of delivery, can contribute to behaviour change and health promoting systems.

Literature review

The second part of the report presents a review of recent literature reviews relevant to health systems and behaviour change and carried out in member countries of the Organisation for Economic Co-operation and Development (OECD). A systematic literature search identified 32 reviews that included relevant concepts or outcomes.

Thematic analysis of the full papers identified several key concepts which were used to develop the model, including:

• the importance of a stable political context

• legislation as a tool for behaviour change

• the role of health systems in promoting equity

• the importance of involving stakeholders in the development of health systems and the wider community
  – and of partnerships beween health systems and the wider health network.

Additional ‘outcome’ evidence (that is, evidence of effectiveness) was identified in relation to several issues, including:

• the impact of ‘flatter’ organisational structures on ease of information flow and management within a health system

• factors that influence managers and their allocation of resources

• the impact of partnership and collaboration on health outcomes

• changing professional behaviour within a health system.

These themes and concepts were added to the developing model.

Finally, the third part of the report describes a thematic analysis of stakeholder responses to consultations on four pieces of NICE public health guidance: behaviour change, community engagement, immunisation, and identifying and supporting those at risk of dying prematurely. Emergent themes and concepts included the importance of:

• clear leadership and chains of accountability

• investment in training and development

• use of information and intelligence for service development – learning systems

• partnerships and the concept of ‘conectedness’………….”


Table of contents

1. Introduction
2. Health systems and behaviour change: a review of evidence reviews

3. Health systems and behaviour change: A review of the literature

4. Health systems and behaviour change: a thematic analysis of stakeholder perspectives

5. Discussion

5.1 A revised conceptual model: structures

5.2 Health systems and behaviour change: intended and unintended consequences

5.3 Organisations as motivated agents: effecting change within health systems

5.4 Health systems that effect change

5.5 Relationships between system, behaviour and change: what sort of knowledge do we need?



Appendix 1: Evidence tables – review of evidence reviews

Appendix 2: Search strategy

Appendix 3: References – papers excluded from literature review

Appendix 4: QUORUM diagram for literature review

Appendix 5: Themed stakeholder responses


Professor Mike Kelly PhD FFPH Hon FRCP- Director, Centre for Public Health Excellence

National Institute for Health and Clinical Excellence


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