Facilitating health behaviour change in looked after young people; evaluation of an intervention targetting multiple risk behaviours. Hannah Dale, Health Psychologist, NHS Fife Lorna Watson, NHS Fife Pauline Adair, University of Strathclyde Gerry Humphris, University of St Andrews

Overview Background Results Challenges Methods Discussion Conclusions & Recommendations

Looked after young people (LAYP) have poorer health outcomes No reported interventions on LAYP evaluate on outcomes ‘Hard-to-reach’ Risk behaviours have been linked (Aicken et al, 2010) Factors such as feelings of safety and belonging (neighbourhood, school, family) may protect against multiple risk behaviours (Brooks et al, 2012) Physical activity associated with reduced risk for all substances and sexual risk behaviour (Nelson et al, 2006) Background

Objectives were to develop and evaluate a health behaviour change intervention for LAYP to improve their lifestyle around multiple risk behaviours

Development of intervention through 3 main sources Methods Qualitative – focused on sexual health initially. Needs assessment Behaviour and behaviour change theories Theory 33 Effective interventions for young people around lifestyle. Evidence 1.Needs assessment revealed gap between knowledge and behaviour, need for flexible services and interventions spanning all lifestyle issues 2.Theories include Social Cognitive Theory, Theory of Planned Behaviour and Health Action Process Approach 3.Evidence mixed for some areas, especially for vulnerable populations 2 1

Research, theory and evidence around health behaviour change Behaviour change interventions Consultancy Teaching and training Intervention Scope

The intervention was delivered by a health psychologist in a personally tailored way to individuals It aimed to motivate and provide LAYP with the skills for change and is very flexible to needs, targeting: –Sexual health –Smoking –Activity –Healthy eating –Alcohol and drugs Considered to have 2 phases – motivational and volitional Behaviour change interventions

With thanks to Jilly Martin

All young people eligible to take part in the evaluation Consent for the evaluation taken Evaluation measures taken at the start and end of the intervention and a 6-month follow-up questionnaire also sent Measures: - Range of measures to assess behaviour and intention - How many cigarettes do you usually smoke in a week? - How much do you plan to stop smoking in the next month? (5 point likert scale from strongly disagree to strongly agree - Well-being (Warwick-Edinburgh Mental Wellbeing Scale; WEMWBS) - Audit of behaviour change techniques (Michie et al., 2011) Evaluation methods

Results Baseline evaluation data (n=93) Post-intervention evaluation data (n=52) Discontinued intervention early (n=41) Didn’t re-attend drop-in (n=12) Dropped out of sessions early (n=20) Moved away from Health Board area (n=2) No consent (n=7) Discontinued intervention early (n=41) Didn’t re-attend drop-in (n=12) Dropped out of sessions early (n=20) Moved away from Health Board area (n=2) No consent (n=7) No baseline data (n=32) Written consent not gained due to physical disability or dislike of written documents (n=2) Consent not gained due to time limitations during drop-in sessions (n=11) Person did not engage with intervention longer than 1 appointment (n=9) Due to focus on building rapport, evaluation consent not pursued (n=10) No baseline data (n=32) Written consent not gained due to physical disability or dislike of written documents (n=2) Consent not gained due to time limitations during drop-in sessions (n=11) Person did not engage with intervention longer than 1 appointment (n=9) Due to focus on building rapport, evaluation consent not pursued (n=10) Eligible for the evaluation (n=125) Young people referred into service (n=144) Ineligible for evaluation (n=19) Drop-out before first appointment (n=10) Still receiving intervention (n=9) Ineligible for evaluation (n=19) Drop-out before first appointment (n=10) Still receiving intervention (n=9)

N (unless otherwise stated) Sex Females Males AgeMean=14.43 Range=11-21 Residence type Residential school Residential home Foster care Kinship care Living with parents Supported accommodation Living in own flat Referral type Self-referral Social worker NHS Worker Foster carer Residential care staff Private agency Referral monthRange= March 2009-October 2013 Number of sessionsMean=6.2, SD=5.778, Range=1-40 Health issues discussed Sexual health Smoking Healthy eating Physical activity Drugs Alcohol Mental Health Physical condition Self esteem Hygiene Anger Sleep Oral Health

BehaviourN in analysesPre-score Mean (median) Post-score Mean (median) Significance value and effect size Smoking (number/week)3826 (0) 16 (0) p=0.01 r=-.30 Exercise (hours/week)253 (2.5) 6 (5) P=0.000 r=-.52 Fruit and vegetable intake (number/day) (1) 2.58 (2) p=.001 r=-.48 NN Intention to use condoms Do not intend to Unsure Intend to Strongly intend to p=0.003 r=-.44 Condom use Never Not very often About half the time Most of the time Always P=0.026 r=-.53 Pregnancy contraceptive Yes No McNemar’s test p=0.006 Undertaken STI test Yes No McNemar’s test P=0.219 Alcohol (units per week)24.52 (.000).333 (.000) p=.715 Cannabis use (number/month) (.000) 0.00 (.000) p=.180 Wellbeing19Mean= Median= 39 SD=11.28 Mean= Median= 53 SD=10.68 p=.002 r=-.49

47 techniques (33 from 40 item taxonomy of BCTs) used across sessions, most commonly (25+ sessions): Audit of behaviour change techniques Goal setting (behaviour) Action planning Barrier identification/problem solving Set graded tasks Review behavioural goals Plan social support/social change Building confidence to say ‘no’ to sex Provide general encouragement VolitionalTechniques Motivational interviewing Provide information on consequences of behaviour in general Provide information on consequences of behaviour to the individual Discrepancy assessment (between own standard and actual behaviour) Provide normative information about others’ behaviour Promoting positive values and attitudes towards sexual health and relationships Elicit aspirations about the future Motivational Techniques

Discussion Enabled consideration of multiple health issues throughout involvement Numbers in analyses are low, however the data is promising Engaged young people in health issues and making changes Range of motivational and volitional techniques were utilised Due to the sometimes complex backgrounds of LAYP, many may require intensive tailored interventions to assist in behaviour change and include motivational elements Flexibility is also key in initiation and maintenance of engagement

Challenges Barriers to engaging and evaluating vulnerable groups Challenges of trying to evaluate drop-ins People dropping out due to changed priorities and people moving away from the health board area Also suggests more rigorous research such as RCTs may be even more problematic LAYP generally geographically sparse so even snowball sampling methods difficult

Some possible solutions text Logo Drop-ins and flexibility help with engagement Questions that can be asked informally and verbally, rather than a structured paper questionnaire, may assist in engagement with research questions First appointments could be set up to build rapport and inform about the service or research then evaluation questions asked later N-of-1 studies may be possible Verbal consent for evaluation may be preferable

Conclusions & Recommendations Due to the vulnerable and hard-to-reach nature of LAYP there was a lack of data The development of a tailored one-to-one service for LAYP around healthy lifestyle issues is, however, possible and can result in behaviour change A whole-person approach is achieved through targeting multiple risk behaviours Interventions for LAYP may need to be of high intensity Due to the sometimes difficult nature of engaging young people, training for staff in behaviour change techniques may be important

Thank you Any questions? Hannah Dale, Health Psychologist

Health Psychology fringe session Friday lunch time pm Alvie Room We’d love to see you there!