Preventing disease through opportunistic, Rapid EngagEMent by Primary care Teams using Behaviour Change Counselling.

Lead Research Organisation: Cardiff University
Department Name: School of Medicine

Abstract

Smoking, excessive alcohol, unhealthy eating and lack of exercise are the most important modifiable causes of ill health and early death and in the Western world. The public expect clinicians to be interested in their health related behaviours and regard clinicians as credible sources of information and advice. Brief advice to patients about health threatening behaviour is one of the most cost effective things doctors and nurses can do. However, patients sometimes find these interventions unhelpful and they do not often change as a result. Advice is given about a single risky behaviour, but health related behaviours are interlinked: losing weight involves eating differently and exercising more and may be affected by alcohol use and smoking. Motivational interviewing (MI), developed for use by specialist addiction counsellors, is an exciting and effective approach for helping patients explore and resolve ambivalence about change. We have adapted MI during 15 years of wide-ranging development work for GPs and practice nurses to engage people about a range of unhealthy behaviours for the early prevention of disease. The result is a consulting method called Behaviour Change Counselling (BCC). A scientific evaluation is now needed to determine whether or not patients make meaningful changes when seen by GPs and practices nurses trained in BCC. We plan to do this study by recruiting at least one GP and one practice nurse from each of 24 from general practices. The clinicians from half the practices selected by chance will be trained in BCC at the beginning of the study. The rest will provide their usual care and so act as a comparison group, and be offered the same BCC training at the end of the study. Patients attending both intervention and control practices will be screened for four unhealthy behaviours and clinicians given the results. After the consultations, patients will be asked if they recalled getting an intervention about unhealthy behaviours, what they felt about it, and their plans for change. Patients will be assessed for the four health behaviours again at three and twelve months. Results will be compared for those patients who saw clinicians trained in BCC with patients who saw clinicians not trained in BCC. If the patients who saw the trained clinicians make significantly more meaningful changes, we will refine BCC, do larger studies and roll out training to the NHS.

Technical Summary

General Practice holds considerable potential for primary prevention through modifying patient?s multiple risk behaviours, but feasible, effective and acceptable interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modelling and exploratory trials spanning 15 years, we have developed an internationally known intervention called Behaviour Change Counselling (BCC) based on Motivational Interviewing. This efficacy cluster RCT will be the first evaluation of outcomes and costs of this intervention for GPs and nurses to opportunistically engage patients in the primary prevention of disease. At least one GP and one practice nurse from each of 24 general practices will be recruited. These practices will then be randomised. Clinicians from half of the practices will be trained in BCC at the beginning of the study. The rest will provide their usual care, and be offered BCC training at the end of the study. Training in BCC will use a blend of innovative methods including web-based learning, training workshops with opportunity to practice with patient-actors, context bound learning, critical incident and reflective learning during real consultations, and ongoing interaction with BCC coaches and web forums. The primary outcome will be the proportion of patients making positive changes in one or more of four behaviours (smoking, risky drinking, unhealthy eating, and lack of exercise) at three months. A target sample size of 1440 patients is required which includes allowance for clustering and loss to follow up. Patients attending both intervention and control practices will be screened for the four unhealthy behaviours using established questionnaires. BMI will be measured. Clinicians will receive the results, with cut-off points indentified reflecting thresholds for each behaviour that should usually trigger an intervention in general practice. After the consultations, patients will be asked if they recall an intervention about health related behaviour, what they felt about it, intentions for change, and ?enablement?. Patients will be assessed for the four health behaviours again at three and twelve months using DINE, IPAQ, Heaviness of Smoking Index and AUDIT questionnaires. SF12 will also be measured. At 12 months, BMI and cotinine in smokers reporting quitting will be measured. Results will be compared for those patients who saw clinicians trained in BCC with patients who saw clinicians not trained in BCC. A range of secondary outcomes will be analysed. Positive results are likely to lead to method refinement, phase four studies and roll out.
 
Description 3 trials project 
Organisation Smile-on
Country United Kingdom 
Sector Academic/University 
PI Contribution We have worked in collaboration with a learning software company (Smile-on) to develop these online programmes. We commissioned the company to develop the platform on which the different trials interventions were developed. Our team contributed to design and contributed the academic input to the development process.
Collaborator Contribution Working with Smile-on has enabled us to develop software for educational interventions for clinicians in 3 different trials. Smile-on and our team have worked together with excellent results which were recognised by an Innovation Award in 2007. Some of our team have been working with Smile-on on a newly funded project developing a psychoeducational intervention for patients with bipolar disorder.
Impact Working with Smile-on has enabled us to develop software for educational interventions for clinicians in 3 different trials. Smile-on and our team have worked together with excellent results which were recognised by an Innovation award in 2007. Some of our team are now working with Smile-on on a NIHR funded project developing and evaluating a psychoeducational intervention for patients with bipolar disorder. We have published five articles related to these studies (PubMed ID 18844993, 19309493, 19674448, 19646190, 20858273).
Start Year 2006
 
Title Talking Lifestyle Educational Programme 
Description We have developed a theory based educational programme that includes both online and offline aspects. 
IP Reference  
Protection Copyrighted (e.g. software)
Year Protection Granted
Licensed No
Impact Not applicable
 
Title Talking Lifestyle educational Programme 
Description The Talking Lifestyle learning programme is effectively a course that takes practitioners through a portfolio-driven set of learning activities. Its goal is not to ensure complete clinical competence in the use of a guiding style for talking about behaviour change. Rather it is to start this process. As such it is an introduction to a set of skills that learners can practice and get better at using as they refine their efforts in everyday practice. The programme owes quite a lot of its content to motivational interviewing, but also leans on wisdom from other sources, like behaviour therapy. Above all, the goal was to adapt some of these more complex psychological methods into a form that is applicable in the everyday practice of doctors and nurses in primary care. 
Type Preventative Intervention - Behavioural risk modification
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2009
Development Status On hold
Impact The study is still ongoing and aims to assess the effectiveness of our Behaviour Change intervention in changing health related behaviours, i.e. smoking, alcohol drinking, unhealthy eating, and lack of physical activity. Therefore, the anticipated impact would be on the quality of this type of communication, as well as improvements in patients' health. The training programme is designed to be part of the CPD for practitioners within primary care and therefore, once tested and if successful, it is likely to influence the existing postgraduate teaching curriculum. The platform and the blended learning approach offer huge potential to deliver CPD in a novel way and to take continuing education forward in many different subject areas. 
 
Description Derbyshire and Nottinghamshire GP trainers workshop: reporting results and training in Pre-Empt methods 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact I presented a talk on motivational interviewing to GP educators and registrars. The intervention and results of this study were covered in an invited plenary to over 100 GPs and then also cover in two subsequent workshops with about 20 participants each; the results of the study and the Study intervention were cartel to this education event
Year(s) Of Engagement Activity 2018
 
Description Keynote speaker, London, UK 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact Invited to present to nurses and GPs on changing health behaviour in primary care. this study was used as an example of applying theory to practice; details are listed below: • Primary Care LIVE, London 1st October 2009, UK: "Influencing behaviour change: A practical guide in approaching lifestyle change".

further invitation to present design of intervention
Year(s) Of Engagement Activity 2009
 
Description Keynote speaker, Manchester, UK 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach National
Primary Audience Health professionals
Results and Impact Invited to present to nurses and GPs on changing health behaviour in primary care. this study was used as an example of applying theory to practice; details are listed below: • Primary Care LIVE, Manchester 5th November 2009, UK: "Influencing behaviour change: A practical guide in approaching lifestyle change".

Further invitation to present design of intervention
Year(s) Of Engagement Activity 2009
 
Description Motivational Interviewing Symposium, Cardiff, UK 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact Motivational Interviewing Symposium, Cardiff, November 2009: talk on brief behaviour change counselling and lifestyle change, from theory to practice.

Enhanced understanding of importance of the use behaviour change skills and strategies within primary care.
Year(s) Of Engagement Activity 2009
 
Description Presentation: International Society of Behavioural Nutrition and Physical Activity 2012 in Ghent Belgium - 22nd-25th May. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach International
Primary Audience Health professionals
Results and Impact International Society of Behavioural Nutrition and Physical Activity 2012 in Ghent Belgium - 22nd-25th May.
Title; Preventing disease through opportunistic, Rapid EngagEMent by Primary Care Teams using Behaviour Change Counselling
Authors: Sharon Simpson, Chris Butler, Kerry Hood, Steve Rollnick, David Cohen and Elizabeth Randell, Tim Pickles, Laurence Moore, Fasihul Alam, Adrian Edwards, Paul Kinnersley, Claire Lane, Jim McCambridge , Christine Smith, Clio Spanou, Fiona Wood, Hazel Thornton


Generated considerable interest int he study
Year(s) Of Engagement Activity 2012
 
Description Talk on PRE-EMPT Study and Motivational Interviewing at UN Older Persons Day 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact Over 100 health and social care professionals attended the symposium

Title - "how to motivate older people and how not to...... "
UN Older Persons Day
27/09/12
All Nations Centre, Cardiff

I had three email requests for my slides and several verbal comments on the value of the approach and comments that the methods would be used in practice.
Year(s) Of Engagement Activity 2012
 
Description UKSBM Invited Plenary 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact This was the annual NPRI lecture and closing address at the UK Society of Behavioural Medicine in Stirling, UK on 11/12/11.

Title "Promoting behaviour change in primary care: clinical and research challenges"

Intense discussions about the approach we took to skill acquisition and brief intervention in primary care.
Year(s) Of Engagement Activity 2011
 
Description Workshop on adaption of Motivational Interviewing for health care; Derbyshire and Nottinghamshire Primary Care Medical Educators Symposium 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact I gave a keynote address and two workshops using role play and video, based on materials developed for the Pre-Empt study. Feedback was excellent with many practitioners saying they had used the techniques with their patients and were teaching GP registrars the techniques.
Year(s) Of Engagement Activity 2018