Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the most important modifiable causes of premature morbidity and mortality in the developed world and may account for about 70% of health care expenditure [
1]. Primary care in the UK is an important domain for preventive health care, since multiple, inter-related health behaviour problems are widespread and potentially amenable to rapid patient engagement and change. Over 80% of the population consult annually [
2], and patients regard practitioners as a reliable source of advice. In primary care, people can receive help early on, when at lower risk. GPs and practice nurses also have the unique opportunity to intervene across a range of behaviours in the same individual, over time [
3].
Efforts to change single risk behaviours using opportunistic brief interventions in health care consultations can be highly cost-effective [
4,
5] and have a small but important effect [
6,
7]. However, the
adoption of these methods into routine care by primary care teams is sub-optimal [
8]. There is a policy shift in the UK from, 'advice from on high to support from next door' [
9].
Systematic reviews of primary prevention, through multiple risk factor engagement in primary care, conclude that existing evidence for effectiveness is inadequate [
1,
10]. Fleming and Godwin [
11], the OXCHECK Study and British Family Heart studies [
12,
13] all showed modest effects. However, these studies relied on calling patients into the practice (i.e. the approach was not opportunistic), gave little attention to practitioner training or to individual patient plans, and the interventions were
not based on motivational approaches that place the patient centre stage as the problem solver.
Over 20 systematic reviews of interventions to change practitioner behaviour [
14,
15] and reviews of those reviews [
16,
17] suggest that such interventions should be multifaceted, have a focused and active educational outreach component, include skills development, and be congruent with clinicians' values [
18,
19]. Nevertheless, there is as yet inadequate research on developing and evaluating interventions to facilitate discussion of health related behaviours in primary care consultations. There is an urgent need to test a generic intervention that enables practitioners to move routinely between multiple, inter-related risk behaviours, while respecting patients' inevitable motivational struggles [
20,
21].
Motivational Interviewing and Behaviour Change Counselling
Motivational Interviewing (MI) is 'a facilitative, patient-centred counselling style for helping people explore and resolve ambivalence' by collaborating with them to articulate why and how they might change. Over the past 15 years, we have adapted MI, designed for use by specialists, into a generic, feasible and acceptable method to address the challenge of efficient, respectful and effective multiple-behaviour consultations in primary care [
22,
23]. Our method is called Behaviour Change Counselling (BCC) [
24].
BCC incorporates a flexible menu-driven framework, with a definition and list of skills [
24] designed specifically for brief health care consultations. It embraces the key elements of the '5 As' guideline (Assess, Advise, Agree, Assist, Arrange) [
1], while also involving selection of concrete strategies according to individual need (e.g. establishing rapport, agenda setting, assessing importance and confidence, scaling questions, pros and cons, brainstorming solutions, negotiating attainable goals and follow-up).
A strong justification for an intervention like BCC is that unhealthy behaviours tend to be concentrated in the same people and strategies for addressing them may be better inter-linked [
25]. Nevertheless, many patients with important risk factors do not receive interventions in primary care [
8]. Reasons include: lack of time; lack of a sense of effectiveness; inadequate training and influences on clinician-patient relationships [
26]. The 2003 GP contract in the UK encourages longer consultations (albeit only 10 minutes) and rewards effective health promotion, thus lowering one important barrier. However, implementation is unlikely to be increased by financial and organisational considerations alone. A generic, theory-driven method is needed that can be used by any professional group across behavioural domains which is sensitive to motivational struggles and does not leave patients feeling "preached to". It should also be satisfying for practitioners to use and for patients to receive.
The efficacy of methods such as brief intervention and cognitive-behavioural therapy depends on addressing two determinants of behaviour change embedded in prominent health psychology models: beliefs about the value of change (expectations of outcome or importance) and beliefs about one's capacity to succeed (self efficacy or confidence) [
27‐
30]. Research on Motivational Interviewing (MI) [
31] has introduced interpersonal predictors of behaviour change into this model by addressing the domains of importance and confidence within a relationship that can either hinder or promote motivation to change behaviour [
32,
33].
Literature [
34‐
39] indicates that adaptations of MI are effective for a range of behaviour problems [
40], superior to minimal or non-treatment controls and as good as, whilst being much briefer than, more intensive treatment interventions [
41‐
44]. However, no study has evaluated training members of primary health care teams in BCC and examined efficacy on a range of patient behaviours.
Furthermore, simply advising practitioners to change their way of consulting is ineffective (e.g. antibiotic prescribing [
45], brief alcohol intervention [
46] and guidelines implementation [
47]). Training is required to enhance practitioners' perceptions of the value of change and their ability to succeed [
48]. This should ideally be an internally driven process [
49,
50], linked to everyday clinical challenges [
23], adequately supported to ensure maintenance of change [
51] and be properly evaluated [
52].
We have developed two novel training methods [
53,
54] that are key to the "Talking Lifestyles" learning programme. They draw on the literature on clinician behaviour change and maximize the potential for acquiring and using new skills. The 'context-bound learning method' is a bottom-up, adult learning, experiential approach that relies on clinicians themselves evaluating the importance of the issue and then reflecting on authentic case scenarios. We have also developed a self-directed blended [
55,
56] e-learning program
http://www.3trials.net that allows learners electronic access to video-rich clinical challenges before and after face-to-face training [
57,
58]. This method has potentially wide applicability at low cost and may assist in maintaining change.
Research objectives
Primary Objective
The primary objective of the study is to evaluate the effect of training primary care health professionals in BCC on the proportion of patients self-reporting change in one or more of the four risk behaviours (smoking, alcohol use, exercise and healthy eating) at 3 months.
Secondary Objectives
The secondary objectives of this study are to evaluate the effect of training primary care health professionals in BCC on:
-
Patient satisfaction, enablement and intention to change immediately post consultation.
-
Patients' self-reported change at one year.
-
Random cholesterol/HDL, salivary cotinine in individuals reporting quitting smoking, waist-to-hip ratio and blood pressure at one year.
-
Practitioners' attitude and skills regarding opportunistic health promotion, and ease of adoption and implementation of skills gained in the training programme.
Economic costs, consequences and process evaluation of trial implementation analyses will be carried out including interviews with clinicians in both groups exploring their views of taking part in the trial.
The study has been approved by the Multi-centre Research ethics Committee (MREC, 07/MRE09/11) and all Local Health Boards (LHBs) in Wales.