Introduction to Health Behaviour theme

Theme leader: Professor Paul McNamee

The health behaviour of individuals – smoking, alcohol, poor diet, physical activity – are major contributors to development of health problems. Also, amongst individuals with existing health problems, behaviour in terms of self-management is an important determinant of long-term health and well-being. In both areas, behaviour is likely to be influenced by economic variables and individual preferences, as well as other factors, such as educational attainment. 

The specific objectives are:

  • To enhance understanding of health behaviour from an economics perspective.
  • To strengthen the evidence base relating to the outcomes and value for money of health behaviour interventions.

In terms of behaviours, the focus is on dietary choice, physical activity, alcohol consumption, smoking and self-management of chronic conditions. In terms of economic concepts, current expertise lies within the areas of time and risk preference, identification of the causal determinants of health, and assessment of the cost-effectiveness of health behaviour interventions.

Current Projects

ActWell - a randomised controlled trial to assess the impact of a lifestyle intervention in women attending NHS breast screening clinics

The incidence of breast cancer in Scotland is predicted to rise by 27% by 2030 and, whilst there are measures to support reductions in morbidity and mortality, the breast cancer community is also looking to support weight management programmes in post-menopausal women.

In Scotland, 72% of women aged 55 to 74 years have a BMI >25kg/m2. A recent feasibility study of a lifestyle intervention initiated in the NHS breast screening sites, and delivered in the community, reported significant findings in weight loss and increased activity after 12 weeks in intervention versus control groups. 

The ActWELL study will be a four centre, 1:1 parallel group randomised controlled trial (RCT) of a 12-month weight management intervention initiated in breast cancer screening centres and delivered by trained Breast Cancer Now ActWELL coaches in community settings. The study will be completed by 545 women with a BMI > 25 kg/m2 attending routine breast cancer screening clinics. Measures will be taken at baseline, 12-weeks and at 12-month follow up and complemented by qualitative interviews on perceived acceptability and impact.

The ActWELL intervention programme involves two intervention meetings with ActWELL coaches plus further telephone contacts over 12 months. The programme focuses on personalised diet (including drinks) and physical activity habits. Behaviour change techniques including self-monitoring, goal setting, action and coping plans and implementation intentions will be utilised. The intervention offers significant potential to endorse and facilitate weight management at a potentially teachable moment. The Scottish Government has already made a commitment to roll out the intervention if the RCT is successful (within the cancer strategy, 'Beating cancer: ambition and action').

The ActWELL trial is registered with the ISRCTN Registry - ISRCTN11057518 and there is a website for the trial.             

HERU researchers involved in this research project: Paul McNameeGraham Scotland

External Collaborators: A. Anderson (University of Dundee); S. Treweek  (HSRU); N. Mutrie, C. McAdam (University of Edinburgh); A. Craigie (Centre for Public Health Nutrition Research); R. O'Carroll, M. Stead (Stirling University); J. Macaskill (Ninewells Hospital) and N. Sataar (University of Glasgow).

BSR-PsA - British Society for Rheumatology Psoriatic Arthritis Register

Psoriatic arthritis (PsA) presents a unique clinical challenge. Characterised by synovitis, enthesitis, osteis, and skin and nail disease, it is also associated with vascular risk and increased likelihood of metabolic syndrome. It has important (including psychological) co‐morbidities, and can have significant impact on working status.

The introduction of biologic therapies in the last couple of decades has significantly improved outcomes for patients with PsA, and anti-TNFα therapy is now established in the management of PsA. More recently, a number of other important molecules have been identified and therapeutics are developing apace, targeting different biological mechanism. 

In addition to inhibitors of TNFα (including biosimilars of existing agents) the rheumatologist now has access to IL‐12 / 23, IL‐17A, and phosphodiesterase (PDE4) inhibitors, some of which have already demonstrated impressive results in psoriasis. Although there a number of novel pharmaceuticals available for the treatment of PsA, including biologicoriginal, biosimilar, and targeted synthetic DMARDs (boDMARDs, bsDMARDs and tsDMARDs, respectively)  for many of these agents, good quality long‐term data on effectiveness, cost‐effectiveness, safety, and other important outcomes is limited. Although data from clinical trials has been extremely informative, it is often collected on a narrow subset of patients.

There remains a need for a large, high quality, prospective cohort study to complement such data, and to address questions not able to be answered in clinical trials

The overall aim of the BSRBR‐PsA is to provide ‘real‐world’ data, with respect to:

  • The impact of PsA on the individual, including function, work, quality of life and economic impact;
  • The natural history of PsA, including clinical and social (e.g. work) outcomes in the medium to longterm and the impact of disease phenotype on disease outcome;
  • The use of novel pharmacological agents (including boDMARDs, bsDMARDs and tsDMARDs), their use, effectiveness and predictors (including biomolecular predictors) of treatment response; 

In addition, the study will:

  • Provide health economic data relevant to the evaluation of cost-effectiveness of different therapy options; and

  • Provide the infrastructure to support the collection, analysis and reporting of adverse events amongst patients on novel pharmacological agents.

We believe there is a need for a well characterised cohort study in PsA, specifically designed to be able to examine a number of research questions, and to provide real-world evidence with respect to treatment effectiveness; predictors of treatment response; impact of disease phenotype on outcome; and cost-effectiveness of therapy. 

In a non‐randomised study, there may be important differences between patient sub‐populations to be examined – i.e. differences between patients who are / are not commencing therapy with novel therapeutic agents. Such differences may be prognostic, and may (consciously or unconsciously) influence treatment decisions and, thus, it may be that patients with increased risk of poor outcome are enriched in one cohort over the other. Therefore, the collection of extensive baseline (and historical) data is crucial, to allow adequate control for these differences in any analysis, and to control for confounding by indication, and to minimise the likelihood of biased estimates of effect.

  • More information on this study is available at the BSR-PsA website.
  • HERU researchers involved in this research project:  Paul McNamee

External Investigators: Jones, G. (Chief Investigator), MacFarlane, G. (Other Applied Health Sciences); and Neilson, A. (University of Edinburgh)

Childhood obesity and academic performance

Child obesity is currently a serious public health concern in the UK. This project aims to explore effective policies to tackle child obesity and to improve academic performance of children by empirically analysing the impact of child obesity on academic performance using a large British administrative dataset. Moreover, although there are some studies that analyse health consequences of obesity, research on its impact on academic performance of children is scarce. By establishing that child obesity also impacts academic performance, we aim to help policy makers to more accurately evaluate the economic costs of child obesity.

HERU researchers involved in this research project:  Yu Aoki.

External Collaborators: Arulampalam, W. (University of Warwick)

Does Minimum Unit Pricing for alcohol have unintended consequences for diet quality and health? A natural experiment comparing Scotland and England

Modelling the effect of MUP has predicted that, on average, households will buy less alcohol but spend more on alcohol because the reduction in quantity of alcohol purchased is expected to be less than proportionate to the price increase. Increased spending on alcohol will reduce the amount of money that households have to spend on other goods and reduced food spending may be one outcome. This might affect diet quality if households buy cheaper, calorie dense and less nutritious food and the effect of poorer diet on health has the potential to partially offset health gains from reduced alcohol consumption.

This will be tested using a difference-in-difference approach designed to compare food purchases and diet quality in Scotland before and after the introduction of MUP with food purchases and diet quality in the North of England as the comparator group, where MUP will not apply. Potential health effects will be modelled from any changes in diet quality identified.

HERU researchers involved in this research project: Anne LudbrookPaul McNamee and Lynda McKenzie

External Collaborators: Stephen Whybrow (The Rowett Institute)

Economic modelling: reducing health harms of foods high in fat, sugar or salt

Having a poor diet and being overweight can have a negative impact on health and wellbeing. To address this public health concern, the Scottish Government published its Diet and Healthy Weight Delivery Plan in July 2018. This included a number of actions focusing on children, the food environment, weight management services and leadership to promote healthy weight and diet. The primary aim of plan is to reduce the public health harm associated with the excessive consumption of calories, fat, sugar and salt, including the risks of developing type 2 diabetes, various types of cancer and other conditions such as cardiovascular disease. One commitment was to consult on plans to restrict the promotion and marketing of targeted foods high in fat, sugar or salt.

This research will use existing data from Kantar World Panel and collect new primary data on consumer preferences, using Discrete Choice Experiments, inform future Scottish Government policy on the impact of restricting the promotion and marketing of discretionary foods high in fat, sugar and salt.

HERU researchers involved in this research project: Paul McNamee and Patrícia Norwood

External Collaborators: C. Revoredo (Scotland Rural College)

Food culture and dietary choice

The research has three components. 

The first is to examine the impact of dietary information using Q methodology. Providing nutritional information on pre-packaged foods does not necessarily lead to healthier choices. We will examine how consumers think about food and nutritional information. The Q method will generate detailed descriptions of different points of view which will enable the identification of target groups for messages to promote healthier choices.

The second component will examine influences on children’s food choices using secondary data and will consider the feasibility of natural experiments to estimate the impact of non-household food providers, such as schools.

The final component will use food purchasing data to analyse the strength of habitual behaviour for specific food categories using either traditional demand models or discrete choice models. Habit formation will be captured using past purchasing behaviour as a factor influencing current purchases, and accounting for key socio-economic characteristics including purchasing power. We will examine how habitual behaviour may impact on responses to interventions to promote healthier diets.

HERU researchers involved in this research project: Patrícia NorwoodAnne Ludbrook, Ourega-Zoé Ejebu and Yu Aoki

External Collaborators: P. Morgan and J.Macdiarmid (Rowett Institute of Health and Nutrition)

LIFT - Lessening the Impact of Fatigue, Therapies for inflammatory rheumatic diseases

Despite major advances in the management of inflammatory rheumatic diseases, fatigue continues to be a major problem for patients in day-to-day management of the condition. In rheumatoid arthritis, for example, as many as 80% of patients report significant fatigue and over 70% consider fatigue to be equal to pain. Moreover, fatigue is a crucial determinant of impaired quality of life and a predictor of work disability. There is now evidence that non-pharmacological interventions, specifically cognitive behavioural approaches and exercise therapies, are effective treatments for significant fatigue. However, it is difficult to access these therapies. This study tests whether remote delivery is effective and cost-effective, and will explore the factors that predict treatment success.

HERU researchers involved in this research project: Paul McNamee

External Collaborators: N. Basu (NHS Grampian); S. Siebert (NHS Greater Glasgow & Clyde); A. Wearden (Central Manchester University Hospitals Trust) and V. Kumar (NHS Tayside).

MAmMOTH - MAaintaining musculOskeleTal Health study

Fibromyalgia has been identified as a research priority by Versus Arthritis. We have previously shown short and long-term effectiveness (determined by patient global assessment of their condition) of CBT delivered by telephone (tCBT) for chronic widespread pain (CWP), the cardinal feature of fibromyalgia.

We have now developed statistical models which predict the future development of CWP sufficiently well to make prevention studies possible. We therefore hypothesise that, amongst patients identified as being at high risk of developing CWP, a short course of tCBT will reduce the risk of its development.

We plan a two-arm randomised controlled trial testing a short course of tCBT against usual care. Subjects will be eligible if they are evaluated as at ‘high risk’ of developing CWP, namely have had a primary care consultation with regional pain and at least two of: a maladaptive behavioural response to illness, a high number of somatic symptoms and/or sleep disturbance.

If successful this study would provide general practitioners with an intervention option to reduce the risk of CWP development. This will be the first such trial of which we are aware, internationally, to attempt to prevent the onset of CWP.

HERU researchers involved in this research project: Paul McNamee and Huey Chong

External Collaborators: G MacFarlane, G Jones (Other Applied Health Sciences, University of Aberdeen), N Basu (School of Medicine, Medical Sciences and Nutrition, University of Aberdeen), M Artus, J McBeth (Keele University), S Kean (University of Glasgow), K Lovell, P Keeley (University of Manchester), P Hannaford (Department of General Practice & Primary Care, University of Aberdeen), G Prescott (Medical Statistics Team, University of Aberdeen) and J. Norrie (CHART, University of Aberdeen).

The trial is registered with ClinicalTrials.gov - NCT02668003.

Mental health and the PATH midlife

Midlife is often described as a time of crisis and turbulence. From a life course perspective, adversity through life may compound over time, and inequalities may be starkest at midlife. This research builds on previous waves of data collection to consider the life course trajectory of mental health problems, in order to inform policy makers on strategies that help to promote mental health and well-being in midlife.

HERU researchers involved in this research project: Paul McNamee

External Collaborators: P. Butterworth, K. Antsey, N. Cherbiun, R. McKerin, R. Burns, L. Leach, (Australian National University) and T. Slade (University of South Wales)

Modelling purchasing behaviour for alcohol

The project examines how factors such as consumers’ choice of alcohol type and brand, their previous purchases and frequency of purchase affect responses to price changes. Of particular interest is the response of frequent and heavy purchasers and the potential effect of habitual behaviour. The study will use household scanner data to provide repeat observations over time.

HERU researchers involved in this research project: Anne LudbrookLynda McKenzie and Ourega-Zoé Ejebu

PACFIND - Patient-centred Care for Fibromyalgia: New pathway Design

Fibromyalgia is a common condition with symptoms of pain, fatigue and sleep disturbance. There is not much evidence on the best way to organise health services for fibromyalgia. Patients are dissatisfied with current services and believe no-one takes responsibility.

This project will gather information from patients about their current situation and their levels of access to healthcare services. We will work with health professionals to understand how services are organised. We will then identify what better care for patients with fibromyalgia looks like. We will also estimate the benefits and costs of existing and alternative care models. We plan to undertake a discrete choice experiment (DCE) that will allow us to understand the strength of patients’ preferences for alternative models of care for fibromyalgia. By the end of the study we will have developed a new model of care for people with fibromyalgia. We will develop a plan for how the service can be put in place to ensure higher levels of patient satisfaction across the country. 

HERU researchers involved in this research project: Paul McNamee and Patrícia Norwood

External Collaborators: G. MacFarlane, G. Jones, N. Basu, K. Martin, S. MacLennan, L. 

Time preferences and health behaviours

Time preferences are key parameters in economic models determining how much individuals invest in their health. Individuals with high rates of time preference (more present oriented) are less likely to invest in their health compared to individuals with low rates of time preference (more future oriented). This has been shown to hold with respect to a range of behaviours including smoking, alcohol, drug use and self-management behaviours such as medication adherence.

This body of work explores a number of key research questions:

  1. the role of present bias in health behaviours;
  2. the role of time preference in the education–health relationship; and
  3. the role of time preference in the intergenerational transfer of health behaviours.

HERU researchers involved in this research project: Marjon van der Pol

Willingness to pay for relief from diseases and symptoms (The Icelandic Research Fund)

This project is testing the application of the well-being valuation method, or compensating income variation, as a way to provide valuations for a set of health conditions within Iceland and other countries. Within the method, individual life satisfaction is estimated as a function of various individual characteristics, such as household income, health and other factors affecting welfare, such as marital status and education.

The results from the estimation are used to calculate an income-health trade off, keeping life satisfaction constant. This trade off, or compensating income variation, represents the monetary compensation needed by an individual with a particular health problem to have the same level of life satisfaction of an individual without the same health problem. Whilst the literature in this field suggests that it is feasible to produce valuations, a question remains over the validity of the estimates generated.

HERU researchers involved in this research project: Paul McNamee

External Collaborators: Laufey, T. (University of Iceland)

Current PhD Projects

The value and costs of unpaid care for older people in China

This project assesses the monetary value and financial impacts associated with the provision of unpaid care for older people in China. Focus will be placed on deriving estimates using the well-being valuation method using responses from life satisfaction for one-child households in comparison with two-or-more-child households. The study will also explore the determinants of the provision of care and of value, by assessing the impact of care heterogeneity (duration, frequency, type) and whether health behaviours mitigate impacts. 

The study uses existing household-level secondary datasets, such as the Chinese Health and Retirement Longitudinal Study (CHARLS), and other similar datasets. The findings from the study will contribute to social care and well-being policy developments regarding improved support for unpaid carers.

PhD Student: Huixuan Gao

Supervisors: Paul McNamee and Attakrit Leckcivilize

Recently Completed Projects

Analysis of choice behaviour and potential mechanisms of change

This project reviewed the relevant economic literature to map out theoretical approaches and empirical examples for further analysis. Econometric analysis was then carried out using secondary data to investigate children’s diets and adult fruit and vegetable consumption. A discrete choice experiment (DCE) was undertaken to investigate the effect of introducing colour coding of calorie information within a traffic light food labelling system. The DCE incorporated eye-tracking technology in the pilot stage to help understand the effect of the additional information. A full-scale study was then conducted using an online panel.

Outcome and Translation

The secondary data analysis of children’s diets showed that household characteristics explain more of the variation than child characteristics, with adult healthy eating behaviour positively associated with children’s behaviour. The inclusion of both child and household effects reduces the amount of unexplained variation in children’s healthy eating although the unexplained variation remains substantial. The analysis of adult diet identified differences in determinants between fruit and vegetables and separate effects for income level and source of income.

In the food choice DCE, we found that saturated fat appears to be the attribute with largest impact on participants’ choices, followed by fat, with salt consistently ranked as least influential attribute. The willingness-to-pay (WTP) values are largely influenced by the number of sandwiches presented to the participants, with lower levels of WTP for a four sandwich choice. We also found that deciding to colour-code for calorific value has an important effect on the valuation of this attribute. Our results confirm that colour coding the nutritional information can significantly influence food choices.

HERU researchers involved in this research project: Anne LudbrookShelley FarrarLynda McKenzie, Damilola Olajide, Patrícia Norwood, Nicolas Krucien and Mandy Ryan

External collaborators: P Morgan (Rowett Institute of Health and Nutrition (RIHN))

DEterminants of DIet and Physical ACtivity (DEDIPAC)

DEDIPAC was a Joint Programme Initiative Knowledge Hub to integrate and develop infrastructure for research across Europe.  

HERU co-ordinated the University of Aberdeen contribution within the Pathways to a Healthy Life strategic research theme.  HERU staff were involved in the development of a concept toolbox for evaluating policies addressing diet, physical activity and sedentary behaviours, with particular emphasis on economic evaluation.

Outcome and Translation

The overall DEDIPAC programme was successful in developing infrastructure and capacity for future research.  

More information on the DEDIPAC project is available at the DEDIPAC website.

HERU researchers involved in this research project: Anne Ludbrook and Aileen Neilson

External collaborators: J Allan (Health Psychology, University of Aberdeen); F Douglas and G McNeill ((The) University of Aberdeen Rowett Institute).  Researchers from 68 research institutes across 13 countries were involved in DEDIPAC.

Economic aspects of alcohol policy

Various approaches to alcohol pricing have been proposed, including minimum pricing per unit of alcohol, increases in current duty rates and restrictions on below cost selling. This project considered the economic impacts and equity effects of alternative approaches and also considered the comparative effectiveness of non-financial interventions.

Outcome and Translation

Legislation on minimum pricing for alcohol has been passed by the Scottish Parliament and deemed legal by the UK Supreme Court. Evidence relating to the effectiveness of minimum pricing was presented to the Health and Sport Committee of the Scottish Parliament during the legislative process and has been used in the Scottish Government’s submission in the legal case.

In this YouTube video Professor Anne Ludbrook discusses the introduction of a minimum price on alcohol policy in Scotland during a roundtable discussion at the AMPHORA Conference in Stockholm, October 2012.

 

HERU researchers involved in this research project: Anne LudbrookLynda McKenzie and Ourega-Zoé Ejebu.

External collaborators: D Petrie (University of Melbourne).

Effects of economic insecurity on physical and mental health (HERU Post-Doctoral Fellowship - Elizabeth Russell Career Development Fellowship)

Insecure employment has consistently been shown to have a significant adverse effect on mental health, particularly for males. Using data from the British Household Panel Survey (BHPS), we  examined the mental health effects of this anticipating entry or prolonged exposure to insecure employment. By estimating the monetary value of health-utility decrements resulting from exposure and anticipation of exposure, we assessed the likely benefits of policies which are effective in reducing insecure employment.

Outcome and Translation

We show that there are valuable individual and population health benefits which could be gained through effective polices to reduce exposure to insecure employment. These benefits will be experienced by males over an anticipation period and an exposure period. For females only the contemporaneous benefits are significant.

HERU researchers involved in this project:  Daniel Kopasker, Marjon van der PolDiane SkåtunPaul McNamee

Feasibility study for Walk With Ease UK - a community-based walking programme for adults with arthritis and musculoskeletal conditions

This feasibility study had three main aims – 1) to identify and make cultural adaptations to ensure the relevance and adoption of an existing physical activity intervention, “Walk With Ease” (WWE) in a UK setting; 2) to examine aspects of recruitment, randomisation, compliance to assessments, extent of data variation, and adherence to activity to inform the design of a future RCT of WWE-UK; and 3) to explore the perceptions and experiences of WWE among participants and community partners to identify processes implicit in integrating a community-based walking programme for individuals with arthritis/MSK conditions into current care.

Participants were recruited across three study group formats: WWE instructor-led, WWE self-directed and non-walking. Participants completed a self-report survey and physical performance assessment at baseline and six-weeks, with mailed survey at three-months. Participant observation, biographical narratives and semi-structured interviews explored the implementation processes and experiences of WWE.

Outcome and Translation

In total, 149 participants were allocated to the WWE programme: 52 chose instructor-led; 45 chose self-directed, and a further 52 were participants were randomised to usual care. Participants were mostly women (70%) and aged ≥60 years (77%), with the majority reporting osteoarthritis (58%) and/or back pain (53%). Statistically significant differences in pain were observed amongst respondents who undertook the programme using the self-directed rather than instructor-led format.  Loss to follow-up among WWE program participants was approximately 20% at 6-weeks. Nearly all (99%) would recommend WWE to family or friends and 81% reported they were satisfied with the programme. At 6 weeks, about half reported that their health was at least moderately better, with noticeable improvement in physical health (47%) and emotional well-being (53%).  These findings indicate that WWE is a relevant, acceptable and feasible walking program when delivered in the UK. Wider implementation of this evidence-based program may benefit the physical health and well-being of people with arthritis.

HERU researchers involved in this research project:  Paul McNamee

External Collaborators: Martin, K. (Institute of Applied Health Sciences, University of Aberdeen); MacFarlane, G. (Epidemiology, University of Aberdeen); Morrison, Z., Rae, R. (AURIS Business Centre, University of Aberdeen); Smith, T. (University of East Anglia) and Neilson, A. (University of Edinburgh)

Implementation of a psychosocial programme of support and training for people with dementia and their family care givers

International research has shown that a psychosocial programme to improve self-management skills is effective at maintaining health-related quality of life and well-being amongst caregivers of people with dementia. There is however a lack of UK studies, and limited economic information. This study was conducted to build the evidence base in these areas, and to inform the design of a future, larger, controlled study.

Outcome and Translation

The programme was feasible to implement, and acceptable to participants. The data on health-related quality of life, well-being and costs were used to design a larger controlled study. There is also potential for the intervention to be rolled out and tested amongst other unpaid carers of people with dementia in other areas of Scotland.

HERU researchers involved in this research project: Paul McNamee

External collaborators: M Milders (Heriot-Watt University); A Lorimer, S Bell (NHS Grampian)

Nature and extent of food poverty/insecurity in Scotland

Using existing sources of information to develop further the evidence base in relation to the experience of food poverty among particular vulnerable groups of the population (not covered by other studies) e.g. older people, people in rural and remote rural areas, those facing destitution. Consider ways in which community food initiatives are currently responding to this situation and what they could or might do to mitigate it.

Outcome and Translation

This research has identified key recommendations that require policy, practitioner and research attention, including more research and information about household food insecurity (HFI), coming from the care sector itself. Medium- to longer-term policy interventions are recommended that address the root/basic causes of poverty, e.g. to generate/increase income sufficiency and bring more certainty of income to more households in Scotland is fundamentally required to address HFI in this country. There needs to be better understanding of the impact of short- and longer-term HFI on health, including the relationship with obesity and malnutrition (which can co-exist).

HERU researchers involved in this research project: Lynda McKenzieAnne Ludbrook and Ourega-Zoé Ejebu

External collaborators: F Douglas (University of Aberdeen Rowett Institute)

Obese men, SMS and weight loss incentives

Feasibility study of how to best engage obese men in narrative SMS (short message system) and incentive interventions for weight loss, to inform a future effectiveness and cost-effectiveness trial

Being obese causes 5% of deaths worldwide and puts people at greater risk of diseases like diabetes or some cancers. In 2013, 26% of UK men were obese, but men rarely participate in weight loss programmes.

This project was a two-phase feasibility study.

Phase 1 (i) built on an existing narrative SMS intervention with embedded behaviour change techniques for men using qualitative co-design, and (ii) developed an endowment incentive drawing on insights from behavioural economics, existing evidence and men’s preferences for delivery based on survey/DCE evidence. An iterative mixed-methods approach was used including a systematic review of the evidence, theory and learning from recent UK behaviour change trials to refine the interventions through PPI and user testing.

Phase 2 was a 12-month feasibility RCT with three arms: SMS only; SMS and incentive; usual practice with waiting list for SMS intervention. Iterative mixed-method data collection and analysis helped to refine the intervention parameters, design and processes in preparation for a potential, full, pragmatic effectiveness and cost-effectiveness RCT.

Outcome and Translation

The developed interventions were shown to be feasible.  An application has been submitted to progress to a full trial.

HERU researchers involved in this research project: Marjon van der Pol and Hannah Collacott

External Collaborators: P. Hoddinott, B. Williams, S. Dombrowski, M. Grindle (University of Stirling); A. Avenell (HSRU, University of Aberdeen); C. Gray (University of Glasgow); F. Kee, M. McKinley (The Queen's University of Belfast); C. Jones (University of Dundee); A. Elders (Glasgow Caledonian University) and P. Carroll (Waterfood Institute of Technology).

REBALANCE - REview of Behaviour And Lifestyle interventions for severe obesity: AN evidenCE synthesis

Adults with severe obesity (body mass index, BMI ≥35kg/m2) have an increased risk of comorbidities, and psychological, social and economic consequences. Systematic review (SR) evidence and economic evaluations on weight management programmes (WMPs) for adults with severe obesity are limited.

The overall aim of this study was to systematically review the evidence for bariatric surgery, lifestyle WMPs and orlistat pharmacotherapy for severe obesity, and evaluate their feasibility, acceptability, effectiveness, and cost-effectiveness.

The health economic objectives were 1) to review the current evidence base on cost-effectiveness and 2) to determine the long term cost-effectiveness of different strategies from an NHS perspective.

Outcome and Translation

N=46 studies were included in the review of cost-effectiveness. Many evaluations were of short duration or did not include extrapolations of input data, failing to fully capture the long term implications of obesity related disease. Modelling assumptions regarding weight regain after the period of weight loss were poorly described, and their impact on long term cost-effectiveness was rarely tested in sensitivity analyses. There was a distinct lack of high quality, long term data on the cost-effectiveness of VLCDs in a UK setting.

Data on the cost-effectiveness of orlistat had mixed results. When compared with WMPs, surgery was found to be cost-effective. When compared with no treatment, surgery was sometimes cost-saving with the savings from reduced obesity related comorbidities found to offset the surgery costs. However, the cost-effectiveness of surgery depended on the quality of the model input data, which were rarely sufficient to fully capture the costs of preparation, delivery, complications and most importantly long term follow-up subsequent to bariatric surgery. None of the studies included any quality of life decrements for surgery related complications, which might over-state the cost-effectiveness case for surgery.

The micro-simulation model was used to address gaps in the current evidence base. The model results show that WMPs were generally cost-effective compared to a baseline ‘do nothing’ approach (ICER <£20,000/QALY). However, the addition of VLCDs to WMPs was not cost-effective. The Look AHEAD programme was borderline cost-effective, with an improved case for cost-effectiveness under more realistic, longer term weight regain assumptions. Roux-en-Y bariatric surgery was the most cost-effective strategy in the base case analysis, over a 30 year time horizon, though the model did not replicate long term cost savings for surgery suggested by some studies in our SR. The economic model results were sensitive to assumptions about weight regain, model time horizon and discount rate for costs and QALYs.

This review is registered with PROSPERO International prospective register of systematic reviews (PROSPERO 2016:CRD42016040190).

HERU researchers involved in this research project: Dwayne Boyers and Elisabet Jacobsen

External collaborators: Avenell, A., Skea, Z., De Bruin, M., MacLennan, G. (HSRU, University of Aberdeen); Aveyard, P. (University of Oxford) and Webber, L (UK Health Forum).

Review of the evidence base for modelling the costs of overweight, obesity and diet-related illness

The specific objectives were to provide a review of the evidence base relating to the costs of overweight, obesity and diet-related illness for Scotland, and to review and critique the cost-effectiveness evidence base for population wide interventions affecting diet to reduce overweight, obesity and diet-related illness.

This research developed an improved understanding of the wider economic consequences of diet-related health, by describing and critiquing existing evidence of estimates of cost and cost-effectiveness developed to tackle overweight, obese and diet-related disease in Scotland.

Outcome and Translation

The international literature provides evidence for the cost-effectiveness of a range of population level interventions to improve diet and obesity.  However, these are modelling studies rather than evaluations of interventions post-implementation and specific estimates of the population impact for Scotland are lacking.  It is recommended that any future estimates for Scotland should be developed by reviewing evidence from effectiveness studies that have tracked longer term effects of interventions on weight change and health. 

HERU researchers involved in this project:  Paul McNameeAnne LudbrookPatrícia Norwood, Aileen Neilson

External collaborator: Avenell, A. (HSRU, University of Aberdeen)

SanteMed: Measurement and determinants of inequalities in health and well-being in the Middle-Eastern and North African region

Recent empirical research, including that carried out by some of the research teams participating in this project (SESSTIM-UMR912 and GREQAM-UMR 7316), has shown that the conventional methods that have been used to assess inequalities in health and well-being in developed countries cannot straightforwardly be applied to developing countries owing to their underlying assumptions, which are far from being consistent with the realities in the developing countries. Consequently, more refined approaches to the measurement of inequalities are called for.

Building on previous experiences of the research teams involved and the lessons learned from a recently completed research project that was supported by the French National Agency of Research (ANR-INEGSANTE 2010–2014), this new project seeks to improve the measurement and explanations of various aspects of inequality in health and healthcare within a broader perspective of well-being. Thanks to previous collaboration, this project will benefit from micro-data sets, recently made available, providing detailed information on different aspects of health and well-being in 13 countries in the MENA region.

Outcome and Translation

This project has provided researchers with innovative methodologies to compare distributions of health outcomes in the developing country context in terms of equity and well-being, and has developed statistical inference tools in order to test hypotheses regarding distributional change.

This project is supported by the A*MIDEX project (n° ANR-11-IDEX-0001-02) funded by the  Investissements d’Avenir French Government program, managed by the French National Research Agency (ANR).

HERU researchers involved in this research project:  Ramses Abul Naga

External collaborators: Y Arrighi (Lille); M Abu-Zaineh, B Ventelou, M.E Woode (Marseille); I Ayadi (University of Tunis); A Boutayeb (University Mohammed Premier, Morocco); A Mataria (World Health Organization, Regional Office for the Eastern Mediterranean); S Abdulrahim (American University of Beirut); N Salti (American University of Beirut)

 

Socio-economic status and integration of immigrants in the UK: the role of language skills and education

The project aims to analyse how English language skills and education affect the integration and the socio-economic status of first- and second-generation immigrants in the United Kingdom (UK). The ultimate goal of the project is to explore the policies that might be effective in mitigating health and socio-economic disparities of immigrants by examining the role of a potential source of the disparities, English language proficiency and education.

To identify the causal effect of English language skills, the Instrumental Variable estimation technique is used where age at arrival to the UK is exploited to construct an instrument for English language proficiency.

Outcome and translation

Our results suggest that the education, fertility and extent of deprivation of immigrants are influenced by their ability to speak English. Precisely, better English language skills significantly raise the likelihood of having academic degrees and reduce that of having no qualifications. Regarding fertility and health outcomes, a better proficiency in English significantly delays the age at which an immigrant woman has her first child, lowers the likelihood of becoming a teenage mother, decreases the number of children a woman has, but has little effect on self-reported adult health and no effect on child health measured by birthweight. The results for deprivation outcomes indicate that better English skills lead immigrants to live in an area where residents are less deprived in terms of income, employment and health, although the effect on health deprivation is not statistically significant.

HERU researcher involved in this research project: Yu Aoki

External collaborators: L Santiago (Office for National Statistics)

TOPS: Technologies to support Older People at home: maximising personal and Social interaction

The role of new technologies in health and social care for older people is attracting increasing interest as part of government agendas for modernising public services across the UK. However, there is concern that such technology, if used to substitute for social care provision, will lead to detrimental effects due to loss of personal and social interaction with nurses and other community-based service providers.

This study determined the extent and nature of personal and social interaction between health and social care professionals and older adults with chronic pain, explored the impact of telecare and telehealth technologies on these personal and social interactions for older adults experiencing chronic pain, and integrated understanding of social and personal interactions into the design and application of technologies for the management of chronic pain.

The economic analysis, using a discrete choice experiment study, indicated that there was a preference for having less waiting time, more than one in-person home visit and less telecare. The additional waiting time that respondents were prepared to accept in order to receive fewer video calls suggests that, relative to in-person home visits, this mode of delivery is less preferred. We also found that respondents with chronic pain had less negative perceptions of ICT than respondents living without chronic pain.

Outcome and Translation

This study can inform the future development of telecare and telehealth technologies amongst people with chronic pain.

HERU researchers involved in this research project: Paul McNamee

External collaborators: L Philip, P Wilson, P Edwards, J Farrington (Other Applied Health Sciences, University of Aberdeen); G Rodger (UHIMI Centre for Rural Health); F Williams (Institute of Rural Health, Wales); V Hanson (University of Dundee); P Oliver and P Wright (University of Newcastle); P Schofield (University of Greenwich)

Recently Completed PhD Projects

Applying economic methods to optimise self-management

Chronic conditions are illnesses that have no cure and for which current care can only control symptoms. In Scotland, it is estimated that nearly 40% of the population lives with at least one chronic condition. Self-management of chronic conditions occurs when the patient acts as the primary decision-maker in the treatment of her/his condition.

This PhD thesis uses econometric analysis of secondary data to investigate the effect of preferences and personality on self-management of chronic conditions. From an economic perspective, the decision to self-manage can be described as an investment in health because it incurs immediate costs to produce future health.

A key economic factor that affects an individual’s intertemporal decision-making is time preference, which describes an individual’s propensity for immediate benefits over delayed ones. Furthermore, future health is inherently uncertain, and individuals’ risk preference may also be an important factor affecting the type and quantity of self-management activities adopted. Beyond classic economic models, this thesis also explores the effect of health on individuals’ time preference, which is often assumed to be exogenous. 

Outcome and Translation

This thesis produced several important novel findings. First, it was found that the time discount rate was associated with maintained physical activity participation but not healthy eating or low-risk alcohol consumption. Second, economic insecurity, defined as the anxiety produced from an unsafe financial future, was associated with smoking in women and physical activity in men. Finally, to investigate whether health itself may influence perceptions of the future, the effect of a lagged health shock was modelled as a proxy for the time discount rate. It was found that a health shock led women to become more future-oriented whilst the opposite occurred amongst men. Overall, it is concluded that the findings of this thesis could be used in the development of policy and interventions to support uptake and adherence of self-management regimes for people with long-term conditions.

Student: Laura Dysart

Supervisors: Paul McNamee and Marjon van der Pol (HERU)

Economic aspects of food choice and its association with health inequalities in Scotland and the UK

This PhD project focused on non-price determinants of food choices with the aim of improving individuals’ diet. These non-price determinants included perceptions of food and time preference. Negative externalities provided an economic rationale for intervention as over-consumption of food results in additional costs to the health service. Many factors affecting food choices. The first empirical chapter used the Scottish Health Survey to investigate how perceived barriers towards healthy eating influence food choices. Primary data collection allowed the association between time preference and food choices to be explored. A discrete choice experiment and field experiemnt was undertaken to investigate whether the impact of a food tax is affected by displaying the tax rate.

Outcome and translation

Overall, this PhD project has added to the understanding of non-price determinants of food choice by investigating perceived barriers, time preference, signposting tax rates, and how these were associated with food choices. Empirical results, for example specific perceived barriers to healthy eating or the rate of time preference, can be used to inform the development of policy interventions to improve individual food choices. The project has highlighted a number of potential avenues of future research including potential methods to implement a tax on foods. 

PhD Student: Liam Mc Morrow

Supervisors: Anne Ludbrook (HERU) and J. Macdiarmid, (Rowett Institute, University of Aberdeen)

 

The role of time preference in the medical decision making context

The aim of the thesis was to examine patient and physician time preferences and investigate how these relate to treatment adherence.

The existing health economics literature focussed largely on time preference of individuals, especially in regard to health behaviours (smoking, alcohol consumption and obesity). Adherence to medical advice has only been explored in a few small studies. More importantly, such research has largely ignored the role that the doctor plays in guiding the patient through the diagnosis and treatment choices and whether this process is affected by the preferences of the provider as well as those of the patient.

This research investigated this link, and its interaction with patient time preferences. A key hypothesis was that, while doctors may prescribe treatments that exhibit exponential discounting and provide the best ‘whole-life’ outcome for the patient (pre-treatment), if the time preference embodied in treatment is sufficiently different from that of the patient adherence is likely to be low and lead to a poorer outcome (post-treatment) than if the doctor had initially prescribed a treatment more closely matching the patient’s time preference.

The first paper compared Scottish GPs’ professional time preferences (for the patient) and private time preferences (for the self). GPs had similar time preferences for themselves and their patients. We also found a large proportion of ’increasingly impatient’ doctors.

The second project was a theoretical model exploring time inconsistency with paternalistic doctors. Doctors face an economic screening problem when they can’t tell in advance whether a patient is present-biased. This was extended to an experiment for the final project. Students in the doctor role made treatment recommendations to patients could observe adherence. Present-bias patients will not adhere to the ‘best’ treatment. Participants adapted to non-adherence as predicted by the model, and a performance payment led to stronger adaptation.

Outcome and Translation

Scottish GPs were found to have the same time preferences for themselves as for their patients in a between-sample design. We also found a large proportion of increasingly-impatient doctors, implying they were less willing to wait for treatment benefits as these are moved into the future. The theory model provided the first examination of non-adherence as an outcome of hidden present-bias time preferences, and showed that responding to this non-adherence depends on the welfare effects and probability that a person is present-biased. Finally, the experiment demonstrated that students in the doctor role did not need direct financial incentives to adapt to non-adherence. The adaptation was as predicted by the model. While a performance payment increased the adaptation, it would not be feasible to implement such strong incentives in reality. The experiment showed that providing doctors with information about adherence was sufficient for them to adapt optimally to non-adherence.

PhD Student: Alastair Irvine

Supervisors: Marjon van der Pol (HERU); Euan Phimister (Economics, University of Aberdeen Business School)

Using insights into time preference and present bias to develop an intervention to improve adherence to exercise

Exercise is a potential ‘miracle cure’ for many health conditions. However adherence to exercise proves difficult for many people.

Insights from behavioural economics and psychology can help improve the understanding of exercise behaviour to inform the development of effective interventions. Despite a correlative association between time preference (how present- or future-oriented an individual is), present bias (the enhanced significance an individual attaches to immediate outcomes) and a range of health behaviours including exercise, time preference and present bias have not, to date, been taken into account when designing interventions to enhance uptake of exercise.

The overall aim of the PhD was to develop and test an interactive web-based tool to improve an individual’s adherence to exercise by taking into account that individual’s time preference rate and present bias. The tool draws on a study carried out by Hall and Fong in 2003 who showed that a ‘time perspective intervention’ (which helped the user explicitly make the connection between their current behaviour and their future health status) when used in Canada improved adherence to exercise. It also draws on the existing evidence around commitment contracts such as stickK.com (where money is deposited as a commitment to a behaviour change) to overcome present bias. The main research questions were:

  1. Does a ‘time preference’ intervention improve adherence to exercise?
  2. Does adding a commitment contract improve adherence to exercise?
  3. Does the effectiveness of these interventions depend on an individuals’ time preference rate and present bias?

PhD Student: Uma Thomas

Supervisors: Marjon van der Pol (HERU); Julia Allan (Health Psychology, University of Aberdeen)