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Tackling multiple unhealthy risk factors



  • Previous research by The King’s Fund has shown that unhealthy behaviours cluster in the population. Around seven in ten adults do not follow guidelines on tobacco use, alcohol consumption, healthy diet or physical activity, yet most behaviour change services address these behaviours separately, not reflecting the reality of people’s lives.

  • This report shares learning and insight from services that are using innovative ways to address the problem of multiple unhealthy risk factors in their populations. It draws on interviews and information from eight case studies in local authorities and the NHS and updates the evidence base on tackling multiple unhealthy risk factors.

  • Most services included in the report are local authority led and are integrated health and wellbeing services. These provide behavioural advice and support to people across a range of different behaviours, including smoking, weight management and physical activity.

  • The NHS is also addressing multiple unhealthy behaviours. We set out learning from two hospitals supporting individuals with multiple risk factors.

  • The evidence for these behaviour change services to draw on, in the context of multiple unhealthy risk factors, remains limited. These services are in a position to develop the evidence base on how best to address multiple unhealthy behaviours.

  • The report makes recommendations on how services can develop and share evidence, and for how the Department of Health and Social Care and Public Health England can support further innovation in such services.

Why tackle multiple unhealthy risk factors?

In 2012, The King’s Fund published Clustering of unhealthy behaviours over time, which focused on tobacco smoking, alcohol consumption, diet and physical activity and analysed the proportions of the adult population that did not adhere to government guidelines on combinations of these. The report found that seven in ten people in England experienced two or more unhealthy behaviours: this is important because partaking in three or four of these behaviours dramatically escalates the risk of premature death. The research found that 5 per cent of people have all four risk factors, with just 6 per cent adhering to guidance for all four. Yet, most services at that time were set up to tackle behaviours singly, not reflecting the reality of people’s lives and how they experience behaviours. This new report focuses on how services are now attempting to address the issue of multiple unhealthy behaviours in a more holistic way, reflecting the broader contexts of people’s lives. The academic literature remains underdeveloped in this area, and these services are at the cutting edge of practice and – if supported – will generate evidence for others to use when tackling unhealthy behaviours.

Our research

After an initial scoping exercise eight case study sites were selected for in‑depth study, based on the consideration being given to individuals with multiple risk factors. We held interviews in mid-2017 with people who were designing or delivering interventions to address multiple unhealthy behaviours. Six of the case studies were integrated health and wellbeing services (IHWSs). Two case studies were interventions by NHS providers to address multiple unhealthy behaviours, both of which identified patients with multiple risk factors and then offered these people different levels of support in the hospital. The report provides practical learning and insight for commissioners and providers considering developing behaviour change services.

Findings from the case studies

IHWSs deliver co‑ordinated support for different risk factors. They are often commissioned by local authorities, with involvement from other organisations. All IHWSs provide a single point of access for clients. In some cases IHWSs are developing with a multi-behaviour change focus, using a single adviser who supports individuals with multiple behaviours. Other IHWSs retain specialist services within an integrated offer, by referring clients from a single point of access through to single-behaviour change classes and groups. Some multi-behaviour change IHWSs provide some single-behaviour change elements, particularly for smoking cessation. Similarly, single-behaviour change IHWSs sometimes provide a separate multi-behaviour change intervention for individuals who have complex needs. We found that different IHWSs were innovating in different ways. Some services focused on the wider determinants of health – linking up with housing support, for example – and recognising the link this could have to behaviour change, while others had a stronger focus on psychological support. Both NHS case studies were looking at how individuals with co-occurring risk factors could be supported from the perspective of a hospital. They involved screening and brief interventions, taking a holistic approach to patients’ behavioural needs. One of the NHS case studies took this a step further, providing psychological and social support for patients with complex behavioural needs within the hospital itself.

Two types of integrated health and wellbeing service

Lessons for practice

We identified several lessons for other services that want to focus on tackling multiple unhealthy behaviours.

  • Target individuals who may have a particular risk of multiple risk factors using evidence that is available on who those people might be in a local area.

  • Approaches to behaviour change should ensure that the social factors behind accruing multiple risk factors are taken into account.

  • Unhealthy behaviours do not respect organisational boundaries, and some of the best partnerships on addressing multiple risk factors occur when local authorities and the NHS set up formal referral routes between them.

  • The academic evidence on how best to tackle multiple unhealthy behaviours remains weak. Our case study sites are therefore important real-world laboratories. More can be done at the national level to invest in research in this area but the quickest win is to support local areas providing these services to learn and self-evaluate in practice. We set out our recommendations on how services can do this, and how Public Health England and the Department of Health and Social Care can support them.