Training practitioners in primary care to deliver lifestyle adviceBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1763 (Published 19 March 2013) Cite this as: BMJ 2013;346:f1763
- Eileen Kaner, professor of public health research,
- Ruth McGovern, social worker and senior research interventionist
Lifestyle choices and modifiable behaviours are responsible for a substantial number of premature deaths worldwide and years lived with disability or disease, as measured by disability adjusted life years (DALYs). The 2010 Global Burden of Disease study reported that the top three risks to health and wellbeing were high blood pressure (7% DALYs), smoking (6.3% DALYs), and alcohol use (5.5% DALYs). Dietary risk factors and physical inactivity jointly contributed a further 10% of DALYs.1 Hence the promotion of positive lifestyle change could improve patients’ health, and primary care is a key setting for this work. In a linked study (doi:10.1136/bmj.f1191), Butler and colleagues recognise that a necessary precursor to promoting behaviour change in patients is the need for practitioners to support such change.2 To make every clinical contact count,3 practitioners must recognise the underlying behavioural contribution to a presenting condition and apply a relevant intervention that supports positive behaviour change.
Changing behaviour is challenging and complex. Low intensity brief advice or counselling to reduce smoking and excessive alcohol consumption seems to have a positive effect, as does medium to high intensity counselling by specially trained clinicians in high risk patients to promote healthy eating or weight loss (or both).4 However, evidence regarding interventions to promote physical activity is limited, and there is an evidence gap about the impact of interventions to change multiple behaviours in primary care.4 5 Nevertheless, behaviours often co-occur in a positive (for example, physical activity and healthy eating) or detrimental way (for example, smoking and alcohol use). From a practice perspective it therefore makes good sense to tackle these problems in a joined up way.
Motivational interviewing is recommended in the “making every contact count” behaviour change competency framework.3 However, this is not a simple therapeutic approach, and practitioners have reported a lack of confidence in developing these skills.6 Thus its condensed version, “behaviour change counselling,”7 is a helpful development for busy practitioners with time limited consultations. Nevertheless, a recent UK trial found that neither behaviour change counselling nor structured advice provided statistically significant additional benefit in reducing alcohol consumption compared with feedback after screening plus an information leaflet.8 Other research has found that, although no single behaviour change technique has consistently improved single or multiple behaviour patterns,9 the most effective techniques are clear risk communication, promotion of self monitoring of behaviour, and the use of social support.9
Training is perceived by practitioners as important for the effective delivery of behaviour change interventions.10 However, a systematic review of 10 motivational interviewing studies in primary care found variable approaches to training delivery (from 20 minutes to two days’ input) and limited assessment of skills competence; just two studies considered patient level outcomes, which were favourable.11 Butler and colleagues’ study is therefore a great step forward for the field—their multifaceted experiential and online training programme is precisely described, practitioner competence is assessed, and patient level outcomes are measured after behaviour change counselling.2 However, their controlled trial found no significant difference in effect on primary outcome between practitioners who received the training programme and those who were not trained. The primary outcome was a composite measure of reported beneficial change in at least one of four risk behaviours at three months.2 More patients in the intervention group recalled receiving counselling and intending or trying to change their behaviour at three months compared with controls. However, there was no difference between groups in overall reported behaviour change at 12 months or in any biometric or biochemical measures in the 53% of patients who came for face to face assessment at 12 months.
It is unclear whether the trial’s null findings relate to measurement error or the inability of training to consistently change practitioners’ behaviour (or both). Half the clinicians in the intervention practices reported using the new counselling skills from “some” to a “great” extent, and half did not. Provision of educational materials or didactic continuing medical education is commonly used to promote professional behaviour change. However, these strategies tend not to be effective in changing practice, unless education is interactive and continuous, and it includes feedback on performance (often by peers), with personal learning plans.12 Furthermore, professional development needs to be built into routine care as much as possible, and preferably it should include decision support tools and real time patient specific reminders to help doctors make the best decisions.11 12 It is also unclear if the lack of significant effects in this study resulted from the counselling being unable to change patient behaviour because it was of poor quality or took the wrong approach. Further work is necessary to determine the effectiveness of behaviour change counselling across single versus multiple behaviours.
Bearing in mind that a recent international comparison of performance regarding premature death rates found the United Kingdom to be substantially below the mean for 18 comparator nations,13 it seems that further research in this field is a priority. Until then, practitioners should heed current available evidence and support patients’ lifestyle change for positive health improvement in areas where an effect has been shown.4
Cite this as: BMJ 2013;346:f1763
Competing interests: Both authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.