Behavioural and cultural insights

Behaviours are essential to health. What we eat and drink, whether we exercise, and our use of alcohol or tobacco all have critical implications for our health. The same goes for whether we vaccinate, follow a treatment plan, and attend cancer screenings. Health worker behaviours are similarly essential – for example, whether hospital staff follow procedures for hygiene and other infection prevention measures, whether physicians prescribe antibiotics appropriately, or whether health professionals interact with patients in respectful and culturally appropriate ways.

It is estimated that behaviours are the single most influential factor determining people’s health (36%). Other influential factors are medical care (11%), genetics (22%), environment (7%) and social circumstances (24%).

Some illustrative facts are provided below.

• People who are insufficiently active have a 20% to 30% increased risk of death compared to people who are sufficiently active, and more than 80% of the world's adolescent population is insufficiently physically active.
• New HIV infections could be reduced by over 90% if people at risk were offered and took up pre-exposure prophylaxis (PrEP) treatment.
• Alcohol behaviour is a major risk factor for breast cancer, yet studies indicate only one in five women in the WHO European Region are aware of this risk.
• Inappropriate prescribing of antibiotics is acknowledged as a critical health worker behaviour contributing to antimicrobial resistance.
• Cervical cancer deaths could be reduced by 67% if women in low- and middle-income countries were offered good quality screening and attended every five years.
• Regional coverage of the first dose of measles-containing vaccine decreased from 96% to 93% during the period of 2019–2022.
• In one city, daily bike trips to work/school increased from 35% to 49% over ten years following municipal investment in bike infrastructure and better opportunities for active mobility and health-promoting physical exercise.

Every single health challenge is behavioural in one way or another. Behaviours can lead to disease and premature death. Behaviours can also prevent disease and death and improve well-being.

These behaviours are often grounded in complex psychological, social and cultural contexts. Deciding how best to support, enable, promote or restrict these behaviours requires deep insight, and is essential to address health challenges.

In the past, it was often thought that providing information is the most impactful way to change health behaviours. Today we know that providing information is rarely enough.

This complexity calls for evidence-based action that draws on an understanding of the specific health behaviour and the cultural context in which it takes place, and engaging with those affected. Using evidence, models and methods from behavioural and cultural sciences allows for the tailoring of health-related services, policies and communication, thereby improving outcomes.

WHO/Europe has developed guidance for anyone who would like to apply an evidence-based and participatory approach to health behaviours. The Guide to tailoring health programmes (THP) approach comprises four phases, each involving several steps, as well as a theoretical model and framework. An accompanying tool book offers ideas and exercises that complement the advice given in this guide. The THP approach can be applied to any health behaviour in any population group.

The field of BCI brings together scientific methods and evidence to:

• understand the factors that affect behaviours
• implement solutions to address the barriers which people experience
• evaluate the impact of interventions on behaviours and health outcomes.

BCI draws on disciplines such as psychology, behavioural economics, anthropology, sociology and cultural studies. By adding the cultural facet to behavioural insights, we highlight the importance of the sociocultural context, systems and structures alongside individual factors. All these factors are essential when assessing and addressing health behaviours.

There are many great examples. WHO/Europe’s BCI Unit has published an inspiration booklet with 25 case examples of BCI in practice. These examples illustrate the range and diversity of how BCI can be applied to support, enable and promote behaviours. The case examples focus on implementation, as well as evaluation and proven impact. They are presented in three categories, with BCI applied to health policies, health services, and health communication.

Other examples of BCI projects can be found in the BCI Unit’s annual progress reports for 2023 and 2022.

In the past, research on behaviours often focused on an individual’s motivation, knowledge or perceptions. Today, however, it is well acknowledged that the social and cultural context has tremendous influence on whether the behaviour is really possible. This means individual motivation or knowledge is not enough. Cultural traditions and cues, norms, values and beliefs, social demands and pressures, and social support are critical. This social and cultural dimension can relate to the family or wider community or to the social support provided in the health system, for example by a health worker.

To understand the social and cultural context of a behaviour, one may explore, for example, whether community leaders (i.e. religious, political, social) support the health behaviour; whether family and friends also engage in the behaviour or not; whether the school or workplace is supportive; whether the behaviour is socially accepted or even a norm; or whether the current behaviour is the result of traditions or beliefs.

The BCI Unit supports countries to advance the use of more evidence-based and people-centred approaches to health behaviours. This work is guided by a European regional resolution , a global resolution and the WHO European Programme of Work, which identifies BCI as a flagship priority within the Region.

Our key areas of work relate to:

• exploring behaviours, through in-country research and BCI projects, using the Tailoring Health Programmes approach;
• training public health authorities, through capacity-building, including both online and face-to-face trainings;
• sharing knowledge, through the dissemination of evidence and policy considerations, including the online knowledge hub at BCI-Hub.org; and
• collaborating and partnering, through advocacy, including a community of practice with public health authorities.

WHO/Europe’s programme of work highlights BCI as a flagship initiative . To implement the ambitions of this programme, the BCI Unit in 2022 worked closely with Member States to develop a regional resolution and 5-year action framework. By adopting this resolution in September 2022, the Member States committed to five strategic commitments:

1. build understanding and support for BCI among key stakeholders;
2. conduct BCI research;
3. apply BCI to improve the outcomes of health-related policies, services and communication;
4. commit human and financial resources for BCI and ensure their sustainability; and
5. implement strategic plan(s) to apply BCI for better health.

A global resolution on behavioural sciences for health was also adopted in May 2023. In line with this, WHO/Europe is supporting Member States across the Region to scale up their use of BCI for health. To support intercountry collaboration and support, WHO/Europe established a Community of Practice with ministerially nominated BCI focal points from the countries of the Region. This Community meets regularly to share experiences, tools and approaches. The BCI focal points also report to WHO on BCI activities at the country level.

To learn more about WHO/Europe’s work in this field, read the BCI Unit’s annual progress reports for 2023, 2022 and 2021.

The work related to BCI for health is guided by an ambitious 5-year plan, which was adopted by all Member States in 2022. With this plan, health authorities made ambitious commitments to advance this field of work and report to WHO/Europe about their progress. The commitments relate to increased investment, prioritization, stakeholder engagement, and the implementation of BCI-related work.

The first country reporting to WHO/Europe was conducted in 2023. Supplementing this, WHO/Europe, together with the European Centre for Disease Prevention and Control (ECDC), also conducted an interview study with public health authorities to understand the barriers faced at the country level and the opportunities ahead. Together, these reports provided nuanced insights into the challenges and opportunities at the country level.

Some key barriers identified were:

• gaps between evidence and policy-making;
• unsustainable funding;
• a lack of trained human resources, and a need for the capacity-building and upskilling of staff; and
• a need to establish mechanisms that allow cross-disciplinary collaboration and the integration of BCI to add value and impact across health areas.

A rich pool of evidence, theoretical frameworks and practical methods exist to help public health authorities apply evidence-based and people-centred approaches to health behaviours.

The BCI Unit published a “how to” guide which presents the THP approach, supporting countries to apply BCI for health and develop BCI-informed interventions.

The THP approach comprises four phases, each involving several steps, as well as a theoretical model and a theory of change. A set of exercises are offered to help prioritize, move from one step to another, and translate research findings into an evidence-informed intervention. The guide includes a tool book with clear and detailed instructions for end-to-end BCI projects.

A range of other documents, including policy considerations, status reports and case examples related to BCI, have been published in recent years. Please see an overview below.