Introduction
Methods
Recruitment
Interview topic guide
Data analysis
Results
Gender | |
---|---|
Male | 6 |
Female | 24 |
Job title | |
GP | 10 |
Practice nurse | 10 |
Healthcare assistant | 7 |
Manager | 3 |
How long they have been involved with the NHS Health Check | |
Since it was introduced in 2009 | 20 |
Less than a year | 2 |
More than a year (1–3 years) | 8 |
Borough | |
Lewisham | 20 |
Lambeth | 10 |
Themes | Sub-themes | Theoretical domain (TDF) | Illustrative quote |
---|---|---|---|
Conceptualising health behaviour change | Complexity of health behaviour change | • Beliefs about patients’ capabilities to change their behaviour. • Perceived patients’ environmental context and resources. | “It’s taking us a lifetime to form our behaviours, but they’re expecting us to change overnight. It’s not easy. So we know that changing these behaviours is not easy.” (Interview 15, Manager) |
What is a “healthy behaviour”? | • Patients’ and HCP’s knowledge of health behaviour. • HCP’s emotion towards behaviour change and health behaviour. | “There’s a lot of different conflicting information, even for us in terms of the evidence, it’s still very – so I have to say to my patients, “This is the best I can tell you at the moment, that’s the best information I have.” Will it change? Yes, well it may change. But, you know, we are not saying these are absolute absolutes. This is what we know for the moment.”” (Interview 23, GP) | |
Health as a priority | • Perceived patients’ goals to change behaviour. • Perceived patients’ intention to change behaviour. | “So I would kind of usually very much always approach it by kind of where he is at in terms of his attitude to his health and what he feels, you know, he needs to adapt before I even say to him, “Look, here are your figures,” and take him through the meaning or the implications of them. So getting an idea of, of what his understanding is about his health and what concerns he has, to then build on them.” (Interview 20, GP) | |
Delivering MHBC interventions in primary care | Beliefs about the intervention consequences | • Beliefs about the consequences of implementing behaviour change interventions. • HCPs emotions towards implementing behaviour change interventions. • Reinforcement to implement behaviour change interventions. | “But I think generally the impression I get is the only thing I could tell you is that it’s a waste of time…But yes, generally felt that the brief intervention that you get, what’s the point?” (Interview 29, GP) |
Multiple health behaviour change intervention | • Environmental context and resources that discourages or encourages the implementation of MHBC interventions. • Skills needed to implement MHBC intervention. • Goals. | “I think you can’t obviously deal with everything at once... it would be up to the patient to decide what it is they would like to deal with in the first instance.” (Interview 1, Manager) | |
Who should implement health behaviour change interventions? | • Social/professional role and identity. • Social influences. • Skills. | “And I think, I think probably [HCA] because she does more of the health promotion, but she probably has learnt more ways of kind of motivating people and, and has a different relationship with them. So tends to find out a bit about them personally and their family and things. (Interview 24, GP) | |
Skills to implement health behaviour change interventions | • HCPs perceived knowledge about MHBC interventions. • Skills needed to implement MHBC interventions. • HCP’s beliefs about their capabilities to implement MHBC interventions. | “In terms of dietary requirements.... yes, it would be nice to just be more specific. Yes. I think, including me, we need more education on dietary advice, for sure.” (Interview 5, HCA) | |
Delivering the health check programme | The NHSHC programme consists of several steps | • Environmental context and resources. • Skills needed to implement the health check. • Patients perceived knowledge. • Beliefs about capabilities. | “Time is always a major factor. Unfortunately, the GP-land, or practice nursing, as a rule, you’re dealing with everything.” (Interview 6, Nurse) “You can’t give somebody advice if you’re not sure what you’re talking about.” (Interview 14, HCA) |
The health check population | • Behavioural regulation. • Patients’ views of the programme social influences. • Knowledge. | ‘But I don’t think that the health check scheme works, because I think it’s targeting the wrong population and it’s, it just - as I said, I think it’s best done opportunistically when we see patients alongside other health issues, which might be more relevant even.’ (Interview 8, GP) |
Conceptualising health behaviour change
Complexity of behaviour change
“Environmental and societal factors hinder people from changing their behaviour, they’re fighting a losing battle.” (Interview 21, GP).
“Unhealthy behaviour is multi-factorial, the reasons why somebody becomes obese are just not as simple as because they eat too much or exercise too little. There are a whole host of socioeconomic and psychological factors. Behaviour change should be facilitated through laws.” (Interview 8, GP).
The nature of a “healthy behaviour”
“There’s so many messages. I know you can ignore the messages, but people don’t need to be told, “You need to exercise, you need to eat well,” because we all know it.” (Interview 11, GP).
“The definition of healthy behaviour is subjective. people have their own ideas about what good health is.” (Interview 15, Manager).
Health as a priority
‘I think that the only way that I’ve experienced for people to actually make changes, is for them to come up with the ideas themselves…using their agenda, not mine.’ (Interview 25, Nurse).
Delivering MHBC interventions in primary care
Beliefs about the consequences of MHBC interventions
“Whether it makes any difference at all to their lifestyle - as we know from the evidence, it doesn’t. In fact, it makes things worse… it’s just a waste of time.” (Interview 8, GP).
“So I’m very open. I would prefer a non-drug approach to these problems. I think these problems are ultimately based in society and they are behavioural problems… And I know a tablet can’t cure that. And yet the easiest thing for us to do is to prescribe a tablet. And when you do prescribe tablets, tablets do work.” (Interview 4, GP).
“I think we’re slightly apathetic about it from a GP point of view, just because, I don’t know, it’s more soft work that we don’t get a definite outcome from.” (Interview 11, GP).“I think you definitely get a sense, a good feeling of sense of achievement, whatever, if you feel that you’ve really been able to enthuse someone to make some lifestyle changes.” (Interview 12, Nurse).
“I’m confident with the information that I give to patients. And they always leave positive.” (Interview 3, HCA).“Is it useful? On an individual basis, it may be useful with a particular patient. But on a broader base, is it? I think that’s what often we question. The time to do it, who does it and how well do they do it? In general, I’d say I’m fairly pessimistic because I think it’s difficult.” (Interview 16, GP).
“We’re only doing it, I think, because of the money, because if we don’t, we get the money removed from us and we’ll go under. So I think it is absolutely related to the money. It’s nothing to do with us believing it works or it doesn’t work.” (Interview 8, GP).
Multiple health behaviour change (MHBC) interventions
“We don’t have loads and loads of time to keep getting people back to give them more advice. But I mean we don’t have a lot of time to do, you know, weight and dietary advice, just dietary advice. There’s a lot of sick people that come in and have to be given a lot of time.” (Interview 10, Nurse).
“I think in an ideal setting, you would want to tackle, you know, the multiple risk factors, each one of them separately. But there isn’t time to bring patients back for multiple consultations. So you somehow try to discuss all of them.” (Interview 18, GP).
“In terms of what’s available to patients, I think it’s very poor in the UK... And even when they are available, it’s not so accessible, it’s not so easy to negotiate. There’s often a cost involved.” (Interview 16, GP).
Who should implement behaviour change interventions?
“I think then the discussions of lifestyle interventions takes time, which obviously, in today’s work environment, is difficult for GPs. But we do try to train nurses and healthcare assistants to be able to do that as well… I think it’s probably better use of resources to be done by another clinician.” (Interview 16, GP).
“You have a one-to-one relationship with a patient. It’s too much like the patient has done something wrong, or the patient is weak. It’s interpreted as a weakness if they don’t know how to reduce their diet, if they cannot reduce their smoking…It’s, it becomes less relationship of equals and more relationship of parent-child, good parent, naughty child.” (Interview 4, GP).
“But often hearing these healthy lifestyle advices coming from a doctor, often people might value more than from a healthcare assistant.” (Interview 16, GP).“The doctor-patient relationship do affect that because in a community setting, you are in a different setting. The patient tends to be more open in terms of all the other factors that is affecting them, than when they sit in a clinical room.” (Interview 15, Manager).
Skills to implement behaviour change interventions
“And I think where people like me get really concerned about these questions, “Have you had any training?” Yes, so we’ve been medically trained. I’ve then been trained as a general practitioner. All of the skills required to do a health check are delivered to me. They do not depend on a one-day training programme.” (Interview 23, GP).
“Well I think clinicians are sort of culturally geared to deal with illness. And dealing with people’s sort of illnesses that they come in with. And less geared up to deal with promoting health and promoting healthy behaviours.” (Interview 19, Manager).
“You can’t really have a template for the advice. It is kind of depending on each person.” (Interview 14, HCA).
“And they relate to me. You know, clearly I’m not thin. So when they sit down and I say, “You weigh a little bit more than is good for you,” I say, “And you weigh a little bit more for you than is good for you, like I do.” You know, “You’re not the only one that has those problems.”” (Interview 25, Nurse).
“The most difficult one I find is talking about the alcohol, because kind of some people aren’t kind of upfront about the amount of alcohol.... So I find that the hardest really.” (Interview 9, HCA).
Delivering the health check programme
The programme consists of several steps
“One of the problems has been, as with any service, by putting too many steps in, you can lose, you know, people get lost. So we want to try and tighten that up…One of the challenges of the health check, I think, is it’s got complicated assessment. I think it’s quite a big ask.” (Interview 1, Manager).
“I think it’s virtually an impossible explanation to give.” To say somebody, “You have a risk in the next decade of dying,” it’s impossible. It’s just impossible to say to somebody, “Your QRISK is...this is based on a population sample.” (Interview 8, GP).
The health check population
“I sometimes think we only get the ones booking, who want to do something - the ‘worried well’ I call them. Yes, whereas, I think the ones we pick up opportunistically are the more needy. And actually they’re far harder to work with.” (Interview 12, Nurse).
“And they often come in not quite sure what it’s all about, but knowing that it’s a health check… But yes, so patients will see it as a, ‘just a check to see that I’m healthy, to see that I’m okay.’” (Interview 10, Nurse).