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Estadistica4
Estadistica4
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Estadistica4

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  • 1. Research Counselling patients about behaviour change: the challenge of talking about diet Katie Phillips, Fiona Wood, Clio Spanou, Paul Kinnersley, Sharon A Simpson, Christopher C Butler on behalf of the PRE-EMPT Team Abstract INTRODUCTION benefits with small effects on cholesterol Rising levels of obesity are of major concern levels and other outcomes.7 This uncertain in the UK.1 Levels of obesity in adults have evidence base is further complicated by the risen to over 25% of men and 28% of women misinterpretation of public-health in England.2 Although there was a general messages8 and the complex interaction reduction in cholesterol levels between 1994 between food beliefs, attitudes towards Background and 2008,2 there has been little reduction in healthy eating, and associated saturated fat intake (which is still, typically, behaviours.9,10 Furthermore, there is above recommended levels2) and only a variability in clinicians’ confidence in raising As obesity levels increase, opportunistic small increase in daily fruit and vegetable and providing adequate information.11-13 behaviour change counselling from primary portions.2 Rising levels of obesity impact on A useful structure to follow when care clinicians in consultations about healthy morbidity and mortality, particularly in considering providing patients with eating is ever more important. However, little is Aim known about the approaches clinicians take relation to cardiovascular disease; information is to think about what is said to with patients. consequently, health promotion and patients (the content) and then how this behaviour change consultations are information is provided; this is called the To describe the content of simulated increasingly important. process of information provision.14 To consultations on healthy eating in primary care, Clinicians in primary care are well placed improve how health professionals provide Design and setting and compare this with the content of smoking to provide opportunistic and cost-effective advice, researchers have adapted behaviour cessation consultations. behaviour counselling about healthy eating change techniques for healthy eating and weight reduction.3,4 Patients consult counselling, derived from motivational Qualitative study of 23 audiotaped simulated their GP on average 5.5 times a year5 and, if interviewing.3,15 Successful use of this healthy eating and smoking cessation clinicians do not engage in health technique regarding reducing alcohol intake consultations between an actor and primary care clinicians (GPs and nurses) within a promotion there is the risk that patients and quitting smoking suggests this Method randomised controlled trial looking at assume there are no concerns.6 Smoking approach could be used for dietary behaviour change counselling. levels have dropped in the UK over the last concerns.16 However, how information is decade, whereas obesity rates have risen;2 provided is unlikely to lead to significant Consultations were audiotaped and transcribed talking about healthy diets, physical activity, change if there is a lack of clarity regarding verbatim, then analysed inductively using and other factors relating to obesity are, what dietary changes to recommend and thematic analysis. A thematic framework was therefore, a pressing challenge. implement. developed by all authors and applied to the data. The content of healthy eating Implementing dietary changes to reduce The PRE-EMPT (Preventing disease Results consultations was contrasted with that given for weight and cholesterol is challenging. through opportunistic, Rapid Engagement smoking cessation. Studies have explored individual factors, by Primary care Teams using behaviour such as increasing one’s intake of fruit and change counselling) study designed an There was a lack of consistency and clarity vegetables and reducing saturated fats, salt, intervention using behaviour change when clinicians discussed healthy eating and sugar; most reports show limited counselling derived from motivational compared with smoking; in smoking cessation consultations, the content was clearer to both the clinician and patient. There was a lack of specificity about what dietary changes should be made, how changes could be achieved, and how progress could be monitored. Barriers to change were addressed in more depth within Conclusion the smoking cessation consultations than within the healthy eating encounters. K Phillips, MRCGP, associate academic fellow; Public Health, Neuadd Meirionydd, University At present, dietary counselling by clinicians in F Wood, PhD, lecturer; P Kinnersley, MD FRCGP, Hospital of Wales, Heath Park, Cardiff, CF14 4XW. primary care does not typically contain professor, Institute of Primary Care and Public E-mail: phillipsk15@cardiff.ac.uk consistent, clear suggestions for specific Health; SA Simpson, PhD, senior research fellow; Submitted: 23 August 2011; Editor’s response: change, how these could be achieved, and how CC Butler, MD FRCGP, professor and director of 11 October 2011; final acceptance: progress would be monitored. This may Institute of Primary Care and Public Health, Keywords contribute to limited uptake and efficacy of 9 November 2011. dietary counselling in primary care. Cardiff University, Cardiff. C Spanou, PhD, senior ©British Journal of General Practice lecturer, Psychology and Mental Health, This is the full-length article (published online Staffordshire University, Stoke-on-Trent. 27 Dec 2011) of an abridged version published in communication, behaviour change counselling; Address for correspondence commnication; healthy eating; primary care. print. Cite this article as: Br J Gen Pract 2012; Katie Phillips, Cardiff University, Primary Care and DOI: 10.3399/bjgp12X616328e13 British Journal of General Practice, January 2012
  • 2. How this fits in complemented by a further seminar on skills and strategies. To complete the training, the clinicians in the intervention group undertook an audiotaped consultation with an actor. Six months later, a further simulated consultation occurred for clinicians in the intervention arm, Obesity is a growing problem and clinicians enabling feedback on their use of behaviour need to discuss healthy eating with change counselling. patients as effectively as possible. This study shows that, in contrast with smoking Clinicians in the intervention group were cessation consultations, clinicians lack asked to choose one of the four behaviours clarity and consistency in the advice they to discuss during the simulated training give patients about dietary change. consultations. Four scenarios had been Stressing the shorter-term, more developed3 and different actors played each immediate benefits of dietary change, and scenario. This consultation was undertaken the close monitoring of change seem to be at clinicians’ surgeries during a normal particularly important.interviewing for use by clinicians. The clinic session and audiotaped andprimary aim was to examine the efficacy of transcribed verbatim.17using such counselling during The purpose of the research studyconsultations by reporting the proportion of reported here was to test the content ofpatients making changes in one or more of what was discussed in smoking cessationfour behaviours: smoking, alcohol intake, consultations compared with that discussedeating, and exercise.3 in the healthy eating consultations. Eleven Although the emphasis of the PRE-EMPT transcripts were available for the scenariotrial was on how practitioners advised of a patient who had a raised cholesterolpatients through recordings of simulated level and was overweight, with theconsultations by clinicians, it also provided counselling focus to be on healthy eating.an opportunity to study what advice was Twelve transcripts were available for thegiven. This article reports on an analysis of scenario of a young woman who wasaudiotaped consultations between pregnant and continuing to smoke.simulated patients, and GPs and nurses,which enable a contrast between the Analysis of simulated consultationscontent of smoking cessation and healthy The audiotaped simulated trainingeating consultations to be made. consultations were transcribed and anonymised by a researcher not furtherMETHOD involved in this study. Data analysis followedThe PRE-EMPT study a thematic approach.18 After initialThe method of this cluster randomised inspection, a thematic framework wascontrolled trial has been reported developed by one of the researchers; thiselsewhere.3 Twenty-nine general practices was discussed and modified by thein Wales were recruited and randomised to research team. Five main thematicusual care or to the intervention arm; one categories emerged:doctor and one nurse from each practiceparticipated. The intervention involved • what change would be beneficial;clinician training in behaviour change • how to change;counselling using a blended learning • how change would be demonstrated andprogramme. The main trial focused on four monitored;risk behaviours: smoking, excess alcohol • what the benefits of change would be;intake, low physical activity levels, and andunhealthy diets. After training in behaviourchange counselling for the intervention • barriers to change.group, each practice in both arms of thetrial recruited up to 40 patients; primary The data were then coded according tooutcomes were patients’ self-reporting the framework. A second researcherbehaviour change at 3 months. double-coded a third of the transcripts to check levels of agreement.Simulated consultation generated from Both the initial and 6-month simulatedthe intervention training consultations were included in the analysis.The blended training for the main trial It was decided that data analysis would notincluded a seminar at the practice followed match consultations for each clinician inby an e-learning programme. This was instances when the scenario was repeated. British Journal of General Practice, January 2012 e14
  • 3. Data analysis focused on clinician talk P: I mean it’s how it’s [food] cooked I relating to change within the five thematic suppose, it’s all greasy stuff and … I suppose categories. The actors are referred to as that’s a big factor in it [improving diet] if patients within this study because the that’s the case with cholesterol. But I just intention was that they should be as similar don’t know how to address that really … as possible to real patients. C: Well, really, as I said, if we were focusing on the dietary sort of things, it’s, as I said, to RESULTS be aware of what cholesterol is, what foods Exemplary data extracts from the simulated contain the cholesterol and just try and consultations are used to illustrate key address it from that point of view really. themes. There was no notable difference in (Healthy eating 7) content between consultations in the first phase of the study and those repeated after Although some clinicians discussed only 6 months. diet, others mentioned changes in diet Smoking cessation consultations took a within a context of more general lifestyle mean time of 7.9 minutes to conduct during changes, such as increasing exercise: a routine surgery (range: 5.4–9.4 minutes). Consultations about healthy eating were, C: Um, and then you can have a think as typically, longer and took a mean time of well about, um, you know, areas in your — 12.2 minutes (range: 6.2–21.4 minutes). you know diet and exercise is very much linked and perhaps we can make another What to change appointment for you to come back in and Discussing what to change within the have a chat about exercise. smoking cessation consultations provoked (Healthy eating 4) a universal agreement that stopping smoking completely was the ideal goal: A few clinicians also addressed weight as a factor that would be influenced by both Clinician (C): So you’re keen to cut down dietary changes and increasing exercise, and, ideally, stop? and as important factor in reducing the risk Patient (P): Ideally, yeah. of cardiovascular disease. (Smoking 4) How to change For the healthy eating consultation there Unsurprisingly, given that what to change was less agreement between clinicians was clear, many of the smoking cessation regarding what to change; some offered no consultations focused on how to achieve the specific advice on what to change in the diet, desired target of stopping smoking. In most focusing more on an assumption of the consultations, in line with the e-learning patient’s prior knowledge of what programme, discussion included eliciting constituted healthy eating: how confident the patient was about stopping smoking, and advice was given regarding C: I suppose what I would say is that most setting targets and dates. Previous people consume a bit more bad diets than experiences with smoking cessation were what they think they do, and I bet that if I got discussed and individual problems you to write a list of things you thought were addressed. The emphasis was on individual bad on one sheet of paper and [a] list [of] preferences to make it work for the patient. what you thought were good on another Most clinicians challenged personal and sheet you wouldn’t be far off the mark. It’s social perpetuating factors. Therefore, about how you incorporate that into your discussion on how to change was detailed daily routine … and consistent. Discussion on how to quit (Healthy eating 11) was patient centred in the majority of consultations and reflected a complex Other clinicians concentrated on reducing behaviour, of which the patient was clearly fats in a diet or increasing fruit and vegetable aware: intake, and a few consultations took the approach of advocating balanced diets with a C: What have you done to try and cut down discussion of which foods to increase or so far? What kind of things have you avoid. There was little similarity between managed to do? clinicians in what was recommended, P: Just breaking the routine sometimes, you compared with the consultations on know, when I feel like one [a cigarette] it’s smoking cessation, and advice on what to just willpower isn’t it, you know? That’s why change was often unclear or superficial: I haven’t managed to cut it out totallye15 British Journal of General Practice, January 2012
  • 4. because I haven’t found that willpower The example above shows that theenough ... clinician is trying not to direct, but rather toC: So I wonder if, whether we can have a engage, the patient in addressing lifestylethink of some other ways that we can help issues and guide them through theyou try and stop completely. process of initiating change. This is(Smoking 3) consistent with the behaviour change counselling training received on how to Medication and advice regarding cravings discuss the topic, but the narrow focus onwere discussed, although smoking cheese illustrates that what is beingcessation services were not always offered. discussed is limited for both patient andSome clinicians provided written clinician.information to the patient. Dietary advice was often supported by The healthy eating consultations also written information sheets, which theincluded information on how to change, but patient could take home.this was more variable and delivered in a Advice on how to increase exercise wasvariety of ways. Clinicians advised eating in offered during two consultations usingmoderation, eating a balanced diet, having divergent approaches. One clinician offeredsmaller portions, or being organised and advice on how to increase opportunitiesplanning meals in advance. Some clinicians within an existing lifestyle, while the otherreferred the patient to a dietician or practice recommended an average quantity ofnurse for specific food information. It was exercise that should have an impact on thenotable that, in contrast with the smoking patient’s health each week.cessation consultations, in which patientswere encouraged to find their own How change is demonstrated andsolutions, in the healthy eating monitoredconsultations the clinicians were quick to In the smoking cessation consultationscome up with solutions for patients: clinicians offered options for regular review, which was either arranged fortnightlyP: But it’s like you say, I’ve got to find the (especially if starting medication) or ashealthy alternatives really, haven’t I? required and to be determined by theC: Yeah and, um, if you can’t take it [your patient. Goals were left to the patient, butlunch] with you, I mean you could probably the message of setting a target of cuttingtake some fruit with you, if you’re worried down, with an endpoint of stopping, wasabout it, you know, going off, if you’re out clearly communicated in all the smokingand about all day. cessation consultations:P: Yeah.C: And you can buy those little cool bags C: So, what would be your … what’s yourcan’t you with, um, the little coolers to put in, next goal? What’s your next plan?to help keep the food cooler if you’re taking P: Well, I’m on about, I think I’m smokingsandwiches or salads, um, so I think, you about 10 a day, so … I reckon I’d cut down byknow, to start with that, you know, that’s ... about half anyway … I mean, like I say, Isee how you go. would like to stop altogether …(Healthy eating 10) (Smoking 4) Some clinicians focused on increasing Most clinicians felt that reviewing dietarythe intake of fruit, vegetables, and fibre; changes with a follow-up consultation wasothers included more specific advice on important; repeating cholesterol tests wasfoods within the ‘bad’ and ‘good’ categories: the main focus for monitoring. The timing of repeating this test, however, ranged fromP: I do have a lot of margarine but I do eat between 1 month and 6 months, with noquite a lot of cheese because I like cheese. formal follow-up planned for the interimC: OK, right. So if you were to sort of cut period. The wide range of time given bydown on, obviously cheese is quite full of … various clinicians for follow-up depended onquite a lot of fat. the interim specified for repeatingP: Yeah, yeah. cholesterol testing and reflected anC: So how would you feel about maybe uncertainty and lack of clarity on how tocutting down on the cheese? further manage the case:P: Yeah, yeah I could do that … um, what,would it be advisable to put something in its P: So when would be the best time to haveplace instead of it? another check?(Healthy eating 9) C: I think if, what we tend to do is to give you British Journal of General Practice, January 2012 e16
  • 5. 3 months, um, to maybe take this home, or socially, clinicians took these: have a look at your diet and the drinking, um, just look at small changes, reasonable P: Perhaps my mum should think about it changes that ... I mean you might like to as well. chat with your wife, talk them through, C: Yeah, yeah, yeah. I mean if mum, could something reasonable, um, and then maybe give up as well, then you will be doing it we can re-do your cholesterol in about together. 3 months’ time? (Smoking 8) (Healthy eating 4) Within the healthy eating there was less A few clinicians, however, suggested emphasis on the benefits of change for the weight loss as a means of monitoring individual. Clinicians focused on the change, proposing monthly reweighing at importance of preventing heart disease and the surgery as a way of maintaining stroke generally, but often without clear motivation and demonstrating change: reference to individual risk profiles for that particular patient. C: The other incentive I try to make is, if The second point noted with all clinicians people want to lose weight if they want to was that, although major longer-term come and just weigh once a month. benefits for reducing cholesterol levels and P: Oh right. eating healthier diets were discussed, C: To see if they are sticking to their diet and shorter-term gains were not used as an to see if that’s any help because, obviously, incentive. In the smoking interactions, the weight loss will help as well. changes in smells and finances were strong (Healthy eating 3) immediate benefits with the goal of a longer-term healthy pregnancy, baby, and Benefits of change better health in the future. There was no The benefits of stopping smoking were apparent parallel discussion for the healthy discussed in terms of benefits to the patient eating consultations: and her pregnancy and baby. All clinicians discussed antenatal risks associated with P: OK. I mean how dangerous is it? I mean smoking, focusing on growth restriction and I, I — it just worries me when I hear about underweight babies at delivery. Childhood things. asthma was addressed in most C: Yeah, of course, yeah. It’s not detrimental consultations, which was an opportunity for in that it’s life threatening right now, it’s clinicians to express the importance of usually ... cholesterol builds up in your continued cessation after pregnancy. In this arteries over a long period of time, so, you scenario, the patient reported being aware know for somebody your age, you know, we of risks to her health from smoking; in are looking sort of 10, 15 years, you know, some consultations, however, the down the line. cardiovascular risks were reiterated and the P: Yeah. benefit of smoking cessation quantified. C: Some possible damage to the coronary Financial benefits and the benefits of arteries. reducing stigma associated with smoking P: Right. were also raised: C: So, you know, every small step you take right now will definitely help to, you know, C: What sort of negatives, would you say, sort that problem out and get it [cholesterol could you see with your smoking? Is there level] lower a bit. anything in particular you dislike about your (Healthy eating 5) smoking? P: I don’t like, well, obviously, I don’t like the The simulated patient presented to the fact that I’m pregnant now and I’m still study with a family history of high doing it and it can harm my baby, so that’s cholesterol and cardiovascular disease; the biggest thing, but I also don’t like the however, the importance to the patient of fact that I smell to other people. I’m modifying this risk behaviour was often not constantly chewing mints and all of that delivered: because I don’t like, I hate that, you know, the smell of it. C: OK. Um, how do you feel about the fact (Smoking 1) that your father has got high cholesterol and the implications that it might have on If opportunities arose to promote you? smoking cessation among others at home P: Um ...e17 British Journal of General Practice, January 2012
  • 6. C: Long term, I mean now. negatively affected patients’ confidence inP: I haven’t really thought about it, um ... I their ability to successfully initiate any newmean he hasn’t had any problems. changes. Whereas the clinicians appearedC: Hasn’t he, no? to anticipate barriers to smoking cessation,P: No, but [it’s] only initially that he has been in the healthy eating consultations they usedtold he has high cholesterol. fewer opportunities to discuss(Healthy eating 5) accommodating change: Those clinicians who discussed exercise C: I mean, obviously, you’ve got a lot goingwithin the consultation mentioned both the on at the moment, you’ve got two jobs and,short- and long-term benefits of increasing you know, busy active life at the moment so,exercise. This had more similarities with maybe if things calm down in a few monthsdiscussions that took place in the smoking we can, you know, you can come back andcessation consultations than the healthy we can go through things again at a latereating ones. date and, you know, if you’re ready then to make some changes to look at your diet andBarriers to change lifestyle and we can, you know, sort of makeThe smoking cessation consultations some, put some plans in action for you.provoked discussion from both clinicians (Healthy eating 5)and patients regarding the problemsassociated with quitting. These included DISCUSSIONphysical addiction, and fears of cravings and Summaryweight gain on stopping. Positive aspects of This qualitative analysis identifies particular,smoking were raised by both clinicians and complex challenges of discussing healthypatients, including enjoyment, relaxation, eating compared with smoking cessation inand the fact that it is often sociable and a primary care consultations. This could explain the longer consultations recordedpart of routine and habit. Clinicians for healthy eating interactions.demonstrated an ability to address these Although all clinicians were trained tobarriers, drawing solutions from the patient improve how behaviour change is discussedin line with behaviour change counselling: with patients, there were clear differencesP: I do enjoy smoking. regarding what was discussed. In theC: Is it a social thing? smoking cessation consultations, theP: It is a social thing. Most of my friends clinician and service user were both clear on:smoke. Um, my mum smokes and I live with • what to change;my mum.C: Right … Well that’s quite difficult then. • how to change and monitor this;P: So yeah, so it’s kind of like, you know, it’s • what the barriers were; andin the house so it’s not really when I go out • the benefits of change.with my friends, it’s in the house as well, mymum smokes. Um, so that’s it really, they There was less consistency and clarity inare then negatives because I do enjoy it and, consultations regarding healthy eating.as I say, my friends and stuff. So it is quite a Individual clinicians focused on differentsocial thing. elements of dietary change and gaveC: Do you think it would affect your idiosyncratic advice on how change could berelationship with your family and your achieved, thereby directing, rather thanfriends if you give up? Is that something guiding, patients.that’s in your mind? Monitoring was not clearly planned in theP: I would, I suppose. Maybe it wouldn’t healthy eating consultations. Benefits ofaffect it … healthy eating were presented for longer-(Smoking 2) term health gains, in all but one consultation, without reference to benefits The healthy eating consultations also that could encourage the patient in theraised discussions regarding barriers to shorter term, such as weight loss if thechange. The time involved with planning patient were overweight.meals, shopping for fresh food, and in food Clinicians appeared less able topreparation was perceived as an extra task anticipate and discuss barriers to dietarywithin an already full lifestyle and, therefore, change than to smoking cessation.difficult to maintain. Access to fresh, healthyfood was also discussed. Previous diets not Strengths and limitationsmaintained were seen as experiences that This study is limited by the use of simulated British Journal of General Practice, January 2012 e18
  • 7. consultations. However, the simulated Comparison with existing literature patients did consult during routine clinical Clinicians in primary care have sessions and had no ‘out-of-role’ acknowledged that smoking cessation interaction with the clinicians, which adds consultations are straightforward, whereas considerable authenticity to the process. there is more variability in the Feedback confirmed that the consultations conceptualisation of those related to were accepted as authentic by the healthy eating.11 They have been identified clinicians within the study. These clinicians as differing consultations — success for may already have had an interest in smoking is measured as an absolute behaviour change, be research minded (smoking cessation), but success for and, thus, atypical of primary care healthy eating traverses along a clinicians; in addition, they had all continuum, measured by various factors undergone training in behaviour change (such as weight loss11 and reduced counselling. The topic was chosen by the cholesterol level). The current study is in clinician and may have been a perceived agreement with others that suggest a need area of strength, leading to improved for clinicians to improve their knowledge20 performance in the consultation; and more detailed assessments of patients’ conversely it may also have been a weaker eating habits and perceptions of food and area in which they hoped to improve. health.8 The patient-generated content of the Current literature reports that, beyond consultation may lack originality, but what superficial screening, clinicians are the study does provide is a measure of reluctant to discuss healthy eating and clinician management of a standardised weight management with patients.11,12 It consultation. Simulated consultations can has been reported that offering support and produce realistic stress physiological setting follow-up for weight loss and responses in clinicians and can, therefore, healthy eating consultations is done be realistic.19 The clinician-initiated poorly.21 These points are mirrored within material within the consultation is this study. comparable between consultations and, Two trials have reported little effect inFunding consequently, data analysis has focused on cholesterol reduction as a result of dietaryThe PRE-EMPT study was funded by the the clinicians’ talk. advice interventions.22,23 Uptake of healthyNational Prevention Research Initiative with A patient with high cholesterol levels was diets and reductions in cholesterol levelssupport from the following organisations: used in this scenario as a model for a were more sustained when patients wereBritish Heart Foundation; Cancer Research consultation in which healthy eating advice aware of illnesses and more motivated toUK; Chief Scientist Office, Scottish was needed. This was the pre-designed change. These reports emphasise theGovernment Health Directorate; scenario, but offers a realistic scenario that potential of focusing on the benefits ofDepartment of Health; Diabetes UK; occurs on a frequent basis in primary care. change,24 and personalising risk and gainEconomic and Social Research Council; The patient in the scenario was overweight; for individuals that may increase motivationHealth & Social Care Research & this may not necessarily be the case in and sustain change. This study confirmsDevelopment Office for Northern Ireland; reality and highlights the importance of that benefits of changes in diet are often notMedical Research Council; Welsh Assembly ascertaining patient-centred goals and discussed in a way that patientsGovernment; and World Cancer Research short-term benefits that can result from immediately relate to, thereby failing toFund (reference: NPRI, G0501283). behaviour change. capitalise on motivating factors for change. The particular scenarios used could be Although clinicians focus on the importantEthical approval criticised for using dissimilar patients, long-term considerations and risk ofMulti-Centre Research Ethics Committee thereby reducing comparison potential. coronary or cerebrovascular disease,for Wales, reference: 07/MRE09/11. However, it is arguable that clinician patients’ motivation, may be driven by moreProvenance knowledge of smoking cessation or healthy immediate benefits.Freely submitted; externally peer reviewed. eating needs to be robust enough to adapt Clinician variability and lack of to individuals’ personal circumstances; this engagement in healthy eating and weight-Competing interests study demonstrates, overall, that there is loss consultations are associated withThe authors have declared no competing less ability to do this in the healthy eating clinicians’ varying attitudes, the stigma .interests. scenario than in the smoking one. relating to the issue, perceived competencyAcknowledgements The number of consultations used within in this area, and the perception of efficacy of the analysis is small and may limit the the treatment that is available to theThe authors acknowledge the funders of the breadth of thematic material available. patient.11,12 This study suggests that thesePRE EMPT Trial, as well as the contribution Each clinician had two consultations with factors relate to a deficit in what cliniciansof the study clinicians and actors. the actor and, given that no two are including within their consultation.Discuss this article consultations are identical, including both Researchers have used techniques toContribute and read comments about was felt to be acceptable. The findings enhance behaviour change in healthy eatingthis article on the Discussion Forum: reported were consistently represented consultations with only marginalhttp://www.rcgp.org.uk/bjgp-discuss across the consultations. success.21,25 Models conceived for smokinge19 British Journal of General Practice, January 2012
  • 8. cessation such as the Stages of Change This lack of clarity over healthy eatingmodel and the American-based 5As model discussions may partially explain primaryhave had translational difficulties.21,25 and care clinicians’ unsuccessful attempts toonly show small effects when used to encourage behaviour change and requirespromote healthy eating. However, what this attention if clinicians are going to make anstudy indicates is that training clinicians in improved contribution to reducing obesityhow to deliver information is advancing and promoting healthy eating.without fully exploring the lack of the Comparing healthy eating consultationsknowledge and conceptualisation of the with those on smoking cessation in terms ofproblem. The two concerns, perhaps, need what is discussed in relation to changeto be addressed in relation to each other in suggests a need for improved clarity fromfuture research. clinicians in general practice. Guidance on how to change diets, together withImplications for practice and research personalising risks and benefits of change,This conceptualisation has practical are potential areas that should be focusedimplications and can help develop ways in on in order to secure improvement. The rolewhich clinicians can improve their ability to of behaviour change counselling to improvemotivate patients and facilitate sustained how we manage discussions regardingimprovements. Clinicians appeared less healthy eating is exciting, but unlikely toable to anticipate and discuss barriers to succeed unless clinicians are clear aboutdietary change than to smoking cessation. what information needs to be discussed. British Journal of General Practice, January 2012 e20
  • 9. REFERENCES 12. Foster GD, Wadden TA, Makris AP, et al. Primary care physicians’ attitudes about obesity and its treatment. Obes Res 2003; 11(10): 1168–1177. McPherson K, Marsh T, Brown M. Modelling future trends in obesity and the Brown I, Stride C, Psarou A, et al. Management of obesity in primary care:1. impact on health. London: Foresight, Government Office for Science, 2007. 13. nurses’ practices, beliefs and attitudes. J Adv Nur 2007; 59(4): 329–341.2. Scarborough P, Bhatnagar P, Wickramasinghe K, et al. Coronary heart disease statistics: British Heart Foundation health promotion research group. London: 14. Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides. Acad Med Department of Public Health, 2010. 2003; 78(8): 802–809.3. Spanou C, Simpson SA, Hood K, et al. Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change 15. Rollnick S, Butler CC, McCambridge J, et al. Consultations about changing counselling(PRE-EMPT): protocol for a general practice-based cluster behaviour. BMJ 2005; 331(7522): 961–963. randomised trial. BMC Fam Pract 2010; 11: 69. 16. Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a4. Sim MG, Wain T, Khong E. Influencing behaviour change in general practice Part systematic review and meta-analysis. Br J Gen Pract 2005; 55(513): 305–312. 1-brief intervention and motivational interviewing. Aust Fam Physician 2009; 17. Rollnick S, Kinnersley P, Butler C. Context bound communication skills training: 38(11): 885–888. development of a new method. Med Educ 2002; 36(4): 377–383.5. Hippisley-Cox J, Fenty J, Heaps M. Trends in consultation rates in general 18. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol practice 1995 to 2006: analysis of the QRESEARCH database. Final report to the 2006; 3(2): 77–101. Information Centre for Health and Social Care and Department of Health. 19. Brown R, Dunn S, Byrnes K, et al. Doctors stress responses and poor communication performance in simulated bad-news consultations. Acad Med London: The Information Centre, 2007.6. Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physician 2009; 84(11): 1595–1602. activities related to obesity management. Arch Fam Med 2000; 9(7): 631. 20. Fei G, Jiang X, Gui-lian W, et al. Community-wide survey of physicians’7. Brunner E, Rees K, Ward K, et al. Dietary advice for reducing cardiovascular risk. knowledge of cholesterol management. Chin Med J (Engl) 2010; 123(7): Cochrane Database Syst Rev 2007; (4): CD002128. 884–889.8. Wood F, Robling M, Prout H, et al. A question of balance: a qualitative study of 21. Alexander SC, Cox ME, Turer CLB, et al. Do the five As work when physicians mothers interpretations of dietary recommendations. Ann Fam Med 2010; 8(1): counsel about weight loss? Fam Med 2011; 43(3): 179–184. 51. 22. John J, Ziebland S, Yudkin P, et al. Effects of fruit and vegetable consumption on9. Dibsdall LA, Lambert N, Frewer LJ. Using interpretative phenomenology to plasma antioxidant concentrations and blood pressure: a randomised controlled trial. Lancet 2002; 359(9322): 1969–1974. understand the food-related experiences and beliefs of a select group of low- income UK women. J Nutr Educ Behav 2002; 34(6): 298–309. Stevens VJ, Glasgow RE, Toobert DJ, et al. One-year results from a brief, Andajani-Sutjahjo S, Ball K, Warren N, et al. Perceived personal, social and 23.10. computer-assisted intervention to decrease consumption of fat and increase consumption of fruits and vegetables. Prev Med 2003; 36(5): 594–600. environmental barriers to weight maintenance among young women: a community survey. Int J Behav Nutr Phys Act 2004; 1(1): 15.11. Ampt AJ, Amoroso C, Harris MF, et al. Attitudes, norms and controls influencing 24. Kelly C, Stanner S. Diet and cardiovascular disease in the UK: are the messages lifestyle risk factor management in general practice. BMC Fam Pract 2009; getting across? Proc Nutr Soc 2003; 62(3): 583–589. 10(1): 59. 25. Shepherd R. Resistance to changes in diet. Proc Nut Soc 2002; 61(02): 267–272.e21 British Journal of General Practice, January 2012

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