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Use of the behaviour change wheel to improve everyday person-centred conversations on physical activity across healthcare

BMC Public Health volume 22, Article number: 1784 (2022) Cite this article

Abstract

Background

An implementation gap exists between the evidence supporting physical activity in the prevention and management of long-term medical conditions and clinical practice. Person-centred conversations, i.e. focussing on the values, preferences and aspirations of each individual, are required from healthcare professionals. However, many currently lack the capability, opportunity, and motivation to have these conversations. This study uses the Behaviour Change Wheel (BCW) to inform the development of practical and educational resources to help bridge this gap.

Methods

The BCW provides a theoretical approach to enable the systematic development of behaviour change interventions. Authors followed the described eight-step process, considered results from a scoping review, consulted clinical working groups, tested and developed ideas across clinical pathways, and agreed on solutions to each stage by consensus.

Results

The behavioural diagnosis identified healthcare professionals’ initiation of person-centred conversations on physical activity at all appropriate opportunities in routine medical care as a suitable primary target for interventions. Six intervention functions and five policy categories met the APEASE criteria. We mapped 17 Behavioural Change Techniques onto BCW intervention functions to define intervention strategies.

Conclusions

This study uses the BCW to outline a coherent approach for intervention development to improve healthcare professionals’ frequency and quality of conversations on physical activity across clinical practice. Time-sensitive and role-specific resources might help healthcare professionals understand the focus of their intervention. Educational resources aimed at healthcare professionals and patients could have mutual benefit, should fit into existing care pathways and support professional development. A trusted information source with single-point access via the internet is likely to improve accessibility. Future evaluation of resources built and coded using this framework is required to establish the effectiveness of this approach and help improve understanding of what works to change conversations around physical activity in clinical practice.

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Introduction

In keeping with global trends, Non-Communicable Disease (NCD) dominates morbidity and mortality in the UK [1]. This position is unsustainable for the health and care system. A fundamental shift is required to move from a reactive treatment service to a proactive prevention-focused National Health Service (NHS) [2,3,4] that supports self-management by people living with long-term conditions [5, 6]. One way of achieving this is through a values-based, person-centred approach that enables people to effectively self-manage their long-term medical conditions with appropriate support from healthcare services [6]. Done well, up to 80% of people could self-manage their long-term medical conditions using this model of care [6].

Physical inactivity is responsible for almost 10% of the major NCDs, including heart disease, type 2 diabetes, and breast and colon cancers [7]. People living with long-term conditions are amongst the least active and stand to gain the most from even minor improvements in physical activity levels [8]. Regular contact with this hard-to-reach group makes healthcare a critical component of population approaches to addressing inactivity [9,10,11]. Successful integration of behaviour change strategies, which promote self-management, into routine care, including changes in healthcare professionals’ consultation behaviour, remains elusive [12]. Consequently, the management and care of people with long-term conditions are still perceived as the healthcare professional’s responsibility, rather than an active collaboration between empowered patients and a healthcare system delivering effective self-management support [5].

In keeping with the UK’s ‘Make Every Contact Count’ initiative [13], the National Institute for Health and Care Excellence (NICE) identify routine clinical conversations between healthcare professionals and patients as a vital interface to unlocking patient-driven behavioural change [11, 14]. Person-centred conversations and behaviour change are intertwined: conversations can effectively develop autonomous motivation to adopt and sustain desirable behaviours. On the other hand, the conversation itself consists of interaction behaviour that can be learned and thus changed. As part of a whole-system approach, targeting this interaction behaviour between healthcare professionals and patients may be fundamental to changing clinical practice in the NHS [5, 15].

Encouragingly, most healthcare professionals perceive conversations about physical activity to be important (ranging from 70% [16, 17] to over 90% [18,19,20]). Despite this, a gap exists between the proportion of times healthcare professionals perceive patients would benefit from brief opportunistic advice and the frequency with which they deliver such interventions. However, there is a disparity between perceived importance and the frequency of conversations on physical activity [12, 21] demonstrating that although healthcare professionals are receptive to the objective of physical activity promotion, a wide range of barriers exist, both individual and organisational, to putting it into practice [21, 22].

Healthcare professionals among primary and secondary care groups lack the knowledge, skills and confidence to have physical activity conversations underpinned by behaviour change theory [18, 22,23,24,25,26,27,28,29,30,31,32,33]. Whilst healthcare professionals are vocal in their support of behaviour change and self-management, they frequently minimise their ability and responsibility to deliver behavioural change work [12, 32]. Although many factors contribute to this avoidance, time concerns and previous negative experiences are powerful deterrents [22, 34]. Consequently, when healthcare professionals attempt to engage patients in conversations about change, it is often a one-sided transaction that focuses on delivering information based on the healthcare professional’s agenda for change, denying the individual the opportunity to take up more time or offer resistance [35]. Emphasis on other components of medical management reinforces this approach, such as medication review and assessment of biomarkers, which are more familiar to healthcare professionals and given greater priority by the systems in which they work. Addressing the broader context of conversations in clinical practice is essential since it is not simply a lack of time that is the issue, but prioritisation amongst the other vital components of medical management.

Collaborative discussion using evidence-based behaviour change techniques to build on a person’s thoughts about and motivation for change is more effective, better received and often more time-efficient than directive interactions [36, 37]. To help promote patient engagement and empowerment, good conversations on physical activity may use a guiding rather than directing style [34, 38]. Focus should be on the likelihood of an individual to change their own behaviour and therefore incorporate skills to emphasise autonomy such as empathic listening, fit into the available timeframe and agree individualised solutions driven by the individual’s agenda [34]. A mindset change is required to move the conversation from “what’s the matter with you” to “what matters to you”. Therefore, changing conversations on physical activity is not as simple as teaching interaction skills or telling healthcare professionals that it is important since these conversations reflect interactions that happen across an entire system.

Change in the medical workforce requires a complex combination of behaviours, decisions and interactions between healthcare professionals, patients, families and other parties. Developing an enabling culture that includes training for core skills and supporting resources to support healthcare professional behaviour change forms a central component of this complex system [39]. The effectiveness of behaviour change interventions to promote change is frequently limited by a lack of integrity with which these complex skills are delivered [40]. Whilst it is perhaps beyond the scope of practitioners to embed a comprehensive treatment fidelity framework within their clinical practice [41], an example of a practical strategy to enhance self-management would be to employ an enactment framework using video or audio recordings for patient consultations. Videos can then be reviewed and coded by the practitioner or independently by a trained third party, potentially including the use of instruments to assess specific behaviour change skills such as the implementation of Motivational Interviewing [40].

Healthcare professionals require the capability, opportunity and motivation to change their own behaviour in order to influence their patients through conversations about physical activity. We set out to understand these behavioural determinants of physical activity conversations to develop educational resources for healthcare professionals that could help them in routine clinical practice. We identified a range of high-quality pre-existing educational resources available on physical activity, such as the Swedish scientific handbook Physical Activity in the Prevention and Treatment of Disease [42]. However, we observed a lack of translation into clinical practice.

The Medical Research Council consider a theoretical basis essential for the successful development of complex interventions in healthcare [43]. The Behaviour Change Wheel (BCW) is an implementation model developed from synthesising 19 different behavioural change frameworks [44]. It provides a comprehensive structure addressing behavioural factors within nine intervention functions and seven policy categories and is advocated for use in this context by NICE [45]. The BCW helps contextualise change on an individual level and the determinants of what needs to happen to achieve organisational or system-level change. It has been used successfully to develop similar interventions improving the Capability Opportunity Motivation-Behaviour (COM-B) of healthcare professionals to deliver physical activity interventions in cancer care [46], therapeutic radiography [47], gestational diabetes [48], depression [49] and prevention of psychosis in ultra-high risk young people [50]. We believe this is the first study to utilise the COM-B framework to inform interventions focused on improving the frequency and quality of conversations on physical activity in managing long-term conditions. We are aware of studies that have used the COM-B framework to assess changes in self-reported knowledge and skills to deliver brief advice on physical activity following training [47] and studies that have explored health professionals’ practice in health care contexts such as mental health using the framework [51].

This study aims to use the BCW to analyse the behaviour of healthcare professionals and outline a coherent approach for developing interventions to improve the frequency and quality of conversations on physical activity by healthcare professionals across clinical practice.

Methods

Overview

The BCW outlines eight steps towards interventional design incorporating behavioural analysis using the COM-B model to understand and explore behaviour [52]. This model allowed us to draw on a parallel workstream using the COM-B model to understand the behavioural factors influencing healthcare professionals’ capability, opportunity and motivation in a national pilot developing a physical activity service in secondary care [53].

We worked through each stage of the BCW following the recommended structure summarised in Table 1 [52]. Each behaviour change component maps onto nine intervention functions (education, persuasion, incentivisation, coercion, training, enablement, modelling, environmental restructuring, and restrictions) and seven policy strategies (Environmental/social planning, communication/marketing, legislation, service provision, regulation, fiscal measures and guidelines) [44, 52]. The COM-B model recognises that behaviour is seated at the heart of this complex interacting system involving the capability (both physical and psychological), opportunity (social and physical) and motivation (reflective and automatic) of an individual or group to perform a particular behaviour [44, 52]. We expanded our behavioural analysis with the Theoretical Domains Framework (TDF), which is a framework compromising 14 domains to help identify and describe the factors influencing a particular behaviour [54, 55]. The TDF helped us achieve a deeper exploration of the barriers and facilitators to behavioural change amongst healthcare professionals and strengthen the links between the theories and techniques of behaviour change in order to anticipate and address implementation challenges [54, 56]. Following behavioural analysis and the identification of intervention options, we identified promising Behavioural Change Techniques (BCT) to inform successful intervention design [52, 57]. BCTs make up the active ingredients of interventions that allow them to be evaluated and replicated when identified in the design and evaluation of projects [45, 57,58,59].

Table 1 Developmental stages of the COM-B model
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Stage 1 understanding behaviour

Step 1 define the problem in behavioural terms

To address step 1, over 8 weeks, the authors worked with a range of healthcare professionals working across different clinical pathways in the Active Hospital project to understand the problems faced by healthcare professionals. In addition, we, the authorship team, had weekly meetings to discuss and refine answers to the following questions defined in step 1 of the BCW:

  • What is the behaviour?

  • Where does the behaviour occur?

  • Who is involved in performing the behaviour?

In addition, we undertook a broader scoping review [60] interrogating published evidence around physical activity conversations in clinical practice to address the question:

  • What are common barriers to performing the behaviour?

Step 2 select the target behaviour

In step 2, we considered all factors that interventions to increase the quality and frequency of physical activity conversations could target in routine clinical care.

When deciding which behaviours to target, we considered the following four factors recommended by the BCW to inform which options are likely to be the best intervention targets:

  1. (1).

    The potential impact of behaviour change

  2. (2).

    Likelihood of the intervention leading to behavioural change

  3. (3).

    The impact of this behavioural change on other system components, for instance, engaging in an education program to improve skills, may increase the use of a resource to help conversations in clinical practice. The behaviour change wheel categorises this as a ‘spillover score.’

  4. (4).

    How easy and practical it will be to measure the target behaviour

We explored possible solutions through (1) our clinical networks across two regional meetings involving 70 multidisciplinary professionals and patients from community and hospital rheumatology and musculoskeletal services and (2) service managers, multidisciplinary leads and patients across three inpatient and one community pathway in the active hospital project [53]. We met to rate potential target areas in the four domains as unacceptable, unpromising, but worth considering, promising or very promising [52]. We made decisions by majority consensus, following discussion that considered results from the scoping review and reflected on clinical group feedback and personal experience.

Step 3 specify the target behaviour

In step 3, we explored the nature and characteristics of the target behaviours defined in step 2 in more detail and considered the context in which each behaviour occurs. Questions we addressed as a group included who needed to undertake the behaviour, what they needed to do, and where and when they might do it. If we were unclear about the application of the target behaviour, we spent time exploring contrasting clinical pathways to identify common characteristics. This step helped generate discrete target areas for influencing behaviour.

Step 4 identify what needs to change

We identified the capability, motivation and opportunity factors required to change the identified target behaviours based on the scoping review of the literature, feedback from clinical groups, departmental meetings with clinical service leaders, and discussions with inpatients involved in the active hospital project. We subsequently used the theoretical domains framework to add context to each behavioural target by working the targets through diverse clinical pathways and identifying areas of commonality. This process helped us generate discrete targets with a theoretical rationale to change practitioner behaviour successfully.

Stage 2 identify intervention options

Step 5 intervention functions

In a paper exercise, we mapped COM-B components from the behavioural diagnosis onto intervention functions according to the BCW. First, we met as a group to discuss and assess each intervention function using the APEASE criteria – Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side effects and safety and Equity [52]. Following this, we mapped selected intervention functions onto behavioural targets.

Step 6: policy categories

We identified policy categories reported in the literature and those highlighted by healthcare professionals during active hospital pathway development. As with intervention functions, we met to assess policy categories according to the APEASE criteria and mapped relevant policy categories onto behavioural domains defined in the BCW [52].

Stage 3 identify content and implementation options

Step 7. Behaviour change techniques

BCTs form the active ingredients of interventions and enable coherent approaches to evaluation [61]. The BCW identifies the most frequently used BCTs by intervention function referencing ‘BCTTv1’ - a comprehensive taxonomy of 93 BCTs developed by international expert consensus [57]. We used a snowballing approach to augment BCT data from studies identified during our scoping review [60]. We identified systematic reviews reporting BCTs with promising/proven efficacy in physical activity behaviour change interventions in clinical practice [62,63,64,65,66,67,68,69]. Following this exercise, we met to map the promising BCTs onto intervention categories and identify suitable implementation strategies drawing on results from the scoping review and feedback from healthcare professionals in the active hospital clinical pathways and working groups.

Step 8. Mode of delivery

The final step of the BCW is to develop a delivery framework based on a recognised taxonomy of delivery modes [52]. A review of interventions that change healthcare professional behaviour [70] informed our delivery framework development, and we assessed each category using the APEASE criteria and consensus amongst ourselves.

Results

Stage 1 understanding behaviour

Step 1 define the problem in behavioural terms

We agreed on the following answers to the questions posed in step 1:

  • What is the behaviour? Healthcare professionals initiating person-centred conversations on physical activity at all appropriate opportunities in routine medical care

  • Where does the behaviour occur? Across the spectrum of healthcare provision for managing and treating people living with long-term medical conditions. Delivery will range from community and primary care settings to hospital inpatients in secondary and tertiary care facilities. Settings may include clinic rooms, wards, day rooms and all other environments delivering healthcare services, including remote or telehealth consultations.

  • Who is involved in performing the behaviour? All healthcare professionals.

  • What are common barriers to performing the behaviour? Consistent barriers to physical activity conversations in clinical practice are reported amongst a range of healthcare professionals practising in various clinical domains across numerous countries. Table 2 summarises barriers identified during the scoping review [60]:

Table 2 Summary of barriers to physical activity conversations in clinical practice
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Step 2 select the target behaviour

Following analysis of the potential behavioural targets, we agreed on the initiation of conversations on physical activity by healthcare professionals as the primary target behaviour. This discrete and tangible target can be easily measured and, if achieved, is likely to prompt healthcare professionals to develop their skills. Furthermore, once initiating conversations becomes a part of healthcare professionals’ routine consulting practice, they are likely to influence others’ practice positively. Table 3 outlines the behavioural analysis.

Table 3 Prioritising behavioural interventions
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Step 3 specify the target behaviour

After specifying the primary and secondary target populations and behaviours, we specified the behavioural target regarding who, what, where and when the behaviour is performed. This helped us generate the discrete target areas for influencing behaviour outlined in Table 4.

Table 4 Specifying target behaviours
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Step 4 identify what needs to change

The behavioural diagnosis identified barriers and facilitators to all six core components of the COM-B model. Expanding each domain using the theoretical domains framework helped us define tangible targets for intervention design, as demonstrated in Table 5.

Table 5 Behavioral diagnosis and theoretical domain mapping
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Stage 2 identify intervention options

Step 5 intervention functions

In total, we selected six out of nine intervention functions. We deemed incentivisation not affordable or practical, coercion not practical or acceptable, and restriction not practical for implementation in general clinical environments. Table 6 maps intervention functions onto behavioural targets.

Table 6 Selecting intervention functions
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Step 6: policy categories

We selected 5 out of 7 policy categories, although regulation relies on external bodies for practicability. Despite this, we agreed to include regulation because service leaders in clinical pathways we were developing in the active hospital project were keen to change the systems regulating practice by healthcare professionals in their pathways, for instance, through the electronic records system. Fiscal and legislative policy categories were deemed impracticable and unacceptable. Table 7 outlines an assessment of each policy category and examples of potential delivery mechanisms for a resource to support conversations on physical activity.

Table 7 Identifying policy categories to support intervention delivery
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Stage 3 identify content and implementation options

Step 7 behaviour change techniques

We identified 17 promising BCTs and mapped these onto BCW intervention functions, as demonstrated in Table 8. Selected BCTs included 1. Goals and planning, 2. Feedback and monitoring, 3. Social support, 4. Shaping knowledge, 5. Natural consequences, 9. Comparison of outcomes, 12. Antecedents, and 15. Self-belief.

Table 8 Mapping BCTs to COM-B component, intervention functions and implementation strategy
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Step 8. Mode of delivery

We focused on population-level delivery approaches to make a resource accessible to as many healthcare professionals as possible. In addition, Digital channels predominate to make the project affordable and broaden its reach. Table 9 outlines our review of the BCW delivery framework.

Table 9 Defining the intervention delivery framework using APEASE criteria
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Discussion

This study uses the BCW to outline a coherent approach for intervention development to improve the frequency and quality of conversations on physical activity by healthcare professionals managing long-term conditions. Time-sensitive and role-specific resources will help healthcare professionals understand the focus of their intervention. Educational resources aimed at healthcare professionals and patients will have mutual benefit, should fit into existing care pathways and support professional development. A trusted information source with single-point access via the internet will improve accessibility and provide an ideal delivery mechanism for a wide range of resources, including an avenue for distributing free promotional information.

Our concurrent clinical activity in the development of three inpatient and one community clinical physical activity pathway in the Active Hospital pilot provided an ideal environment to explore and test promising ideas from published literature. We balanced our behavioural analysis across community and hospital environments. However, we recognise there is a risk of a bias toward understanding the implementation landscape in a hospital environment, potentially limiting the applicability of our findings to interventions in other settings, such as primary care. Although our clinical backgrounds positively impact the clinical relevance of this study, the quality of our work is potentially limited by the lack of a robust academic background in behaviour change amongst the healthcare professionals in our team. This impacted some of our decision-making; for instance, we included modifying patient behaviour as a secondary behavioural target due to promising literature suggesting the benefits from this approach without behavioural analysis of patients themselves. We identified the risk of our academic limitations at the outset, which informed our decision to use the BCW due to its straightforward and step-wise guidance. As others have reported, we discovered that following the BCW system is an exacting challenge [46]. Systematically following all steps was laborious and time-consuming, but it ensured consideration of all components of effective behaviour change [109, 110]. We followed the model diligently; for instance, we spent time defining the primary behavioural target despite other authors deeming this unnecessary [46]. As we subsequently progressed through the stages, we found that defining the target was a great benefit as it helped us maintain focus on changing the consulting behaviour of healthcare professionals rather than the physical activity behaviour of their patients. In some areas, we found the scope of the challenge exceeded our resources and looked to previously published evidence for guidance. For example, we narrowed down BCT choice by identifying promising BCTs in the published literature. However, failing to fully consider and explore all 93 BCTs on their individual merits may mean we missed effective BCTs whose use may be novel in this area.

A growing body of evidence demonstrates the potential of time-efficient behavioural change approaches in clinical practice [82, 111, 112]. People living with long-term conditions value and welcome behavioural change support on physical activity from healthcare professionals [69, 113]. However, traditional transactional models of clinical consultation offer an over-simplistic and ineffective approach to encouraging behavioural change. This model of medicine, established over generations, is not without limitations when considering straightforward prescription, such as antihypertensives [114] or even major surgery, such as solid organ transplant [115]. Conversations to support behavioural change should start with the individual and consider personal choice, circumstance and behavioural context, suggesting the traditional consultation model of ‘diagnose and treat’ requires a rethink [116]. This study confirms that successful resources should consider individual preference, circumstance, behavioural context, and system constraints such as appointment length to support physical activity conversations effectively.

Whilst education and training alone are insufficient to change healthcare professional behaviour, embedding education and training opportunities into a practical structure to support routine practice improves practitioner engagement and increases the likelihood of behavioural change [117]. Healthcare systems must value and promote such an intervention as the prevailing professional, and organisational culture may be most influential in changing practitioner behaviour [70, 102, 118]. Success may be when healthcare professionals habitually include person-centred physical activity conversations in their practice. Given the range of competing interests on their time, automisation of their behaviour through habit formation is likely to free up cognitive capacity [119]. Although automaticity has been successfully targeted in simple healthcare tasks such as hand washing, complex tasks such as physical activity conversations appear less conducive to habit-forming [120]. However, targeting specific behavioural components may be a way around this challenge [119]. For instance, system support can influence habit formation through intervention such as integrating prompts in computer systems or clinical pathways.

As well as prompting habit formation, building educational resources into routine care by supporting real-time decision-making and providing point-of-care prompts for best practice can enhance professional development [102]. Such education strategies have a more significant impact when derived from influential opinion leaders [70, 98]. Developing strategies informed by likely barriers and facilitators of behavioural change to translate research findings into clinical practice can further enhance effectiveness [121, 122]. Digital approaches successfully support clinical decision-making and the delivery of preventative care [98, 102, 123, 124]. Delivery via the internet supports several behavioural domains identified in this study and is a simple way to deliver a scalable and cost-effective intervention [122, 125].

Future research may include understanding how to leverage the influence of patients on healthcare professional behaviour and improve habituation within complex communication skills. Greater understanding is required of how healthcare systems and the professionals within them can best balance the fundamental medical requirements of long-term condition management with individualised and person-centred behavioural change support. Designing interventions with evaluation in mind is critical to help understand the optimal approach to increasing the frequency and quality of conversations on physical activity across clinical practice. To this end, the findings of this study have informed the development of a hybrid online resource combining educational material with conversational guidance coded with BCTs to support evaluation [44, 59]. We encourage independent evaluation of the resources at www.movingmedicine.ac.uk and call upon researchers to focus on improving our understanding of what works to improve conversations on physical activity across clinical practice.

Conclusion

We have iteratively developed a framework using the BCW to improve healthcare professionals’ capability, opportunity and motivation to have person-centred conversations on physical activity. The framework is grounded in the priorities of busy healthcare professionals addressing a range of barriers, including time, knowledge, skills and system support. At the heart of a successful intervention lies the principles of person-centred care and an approach that may be unfamiliar to healthcare professionals trained in a didactic consultation style. Resources need to be time-sensitive and role-specific, whilst educational resources aimed at healthcare professionals and patients will have mutual benefit, should fit into existing care pathways and support professional development. A trusted information source with single-point access via the internet will improve accessibility and provide an acceptable delivery mechanism for a wide range of resources. All healthcare team members have a role in delivering constructive physical activity support.

Building practical resources based on this framework will improve efficacy, integrate the principles of behaviour change and provide a platform to inform future research and develop clinical physical activity services. Therefore, we encourage open evaluation of resources built using this framework to help improve understanding and implementation of what works.

Availability of data and materials

All the datasets generated and/or analysed during this framework analysis are available in the Centre for Open Science OSF repository at https://osf.io/muxdy/?view_only=223e9f46226245e3a4ff2882b061e41a

Abbreviations

BCT:

Behaviour Change Technique

BCW:

Behaviour Change Wheel

FSEM:

Faculty of Sport and Exercise Medicine

NHS:

National Health Service

NICE:

National Institute for Health and Care Excellence

NCD:

Non-Communicable Disease

UK:

United Kingdom

References

  1. Bennett JE, Stevens GA, Mathers CD, Bonita R, Rehm J, Kruk ME, et al. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards sustainable development goal target 3.4. Lancet. 2018;392:1072–88.

    Article  Google Scholar 

  2. Ham C. Next steps on the NHS five year forward view. BMJ. 2017;357:j1678. https://doi.org/10.1136/bmj.j1678.

    Article  PubMed  Google Scholar 

  3. NHS. The NHS Long Term Plan. 2019. www.longtermplan.nhs.uk. Accessed 6 Apr 2021.

    Google Scholar 

  4. Darzi A. The Lord Darzi review of health and care interim report. London; 2018. www.ippr.org. Accessed 30 Jul 2018

  5. Coulter A, Roberts S, Dixon A. Delivering better services for people with long-term conditions: King’s Fund; 2013. p. 1–28. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/delivering-better-services-for-people-with-long-term-conditions.pdf

    Google Scholar 

  6. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff. 2001;20:64–78. https://doi.org/10.1377/hlthaff.20.6.64.

    Article  CAS  Google Scholar 

  7. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380:219–29. https://doi.org/10.1016/S0140-6736(12)61031-9.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol. 2011;40:121–38.

    Article  PubMed  Google Scholar 

  9. The International Society for Physical Activity and Health ISPAH. International Society for Physical Activity and Health’s eight investments that work for physical activity. 2020. https://www.ispah.org/wp-content/uploads/2020/11/English-Eight-Investments-That-Work-FINAL.pdf.

    Google Scholar 

  10. Weiler R, Feldschreiber P, Stamatakis E. Medicolegal neglect? the case for physical activity promotion and Exercise Medicine; 2012. p. 228–33. https://doi.org/10.1136/bjsm.2011.084186.

    Book  Google Scholar 

  11. NICE. Physical activity : encouraging activity in all people in contact with the NHS. 2015.

    Google Scholar 

  12. Hunter C, Chew-Graham CA, Langer S, Drinkwater J, Stenhoff A, Guthrie EA, et al. “I wouldn’t push that further because I don’t want to lose her”: a multiperspective qualitative study of behaviour change for long-term conditions in primary care. Health Expect. 2015;18:1995–2010. https://doi.org/10.1111/hex.12304.

    Article  PubMed  Google Scholar 

  13. Health Education England. Making every contact count (MECC). 2018. http://www.makingeverycontactcount.com/. Accessed 17 Sep 2018.

    Google Scholar 

  14. NICE. Physical activity: brief advice for adults in primary care primary care. Natl Inst Heal Care Excell Public Heal Guidel. 2013;44:44 nice.org.uk/guidance/ph44.

    Google Scholar 

  15. Speake H, Copeland RJ, Till SH, Breckon JD, Haake S, Hart O. Embedding physical activity in the heart of the NHS: the need for a whole-system approach. Sport Med. 2016;46:939–46. https://doi.org/10.1007/s40279-016-0488-y.

    Article  Google Scholar 

  16. Cho H-JJ, Sunwoo S, Song Y-MM. Attitudes and reported practices of Korean primary care physicians for health promotion. J Korean Med Sci. 2003;18:783–90. https://doi.org/10.3346/jkms.2003.18.6.783.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Ribera APA. McKenna J, Riddoch C, of CR-TEJ, 2005 U. attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary health-care system. Eur J Pub Health. 2005;15:569–75. https://doi.org/10.1093/eurpub/cki045.

    Article  Google Scholar 

  18. Douglas F, Torrance N, van Teijlingen E, Meloni S, Kerr A. Primary care staff’s views and experiences related to routinely advising patients about physical activity. A questionnaire survey. BMC Public Health. 2006;6:138. https://doi.org/10.1186/1471-2458-6-138.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lawlor D, Keen S, Practice RN-F. Increasing population levels of physical activity through primary care: GPs’ knowledge, attitudes and self-reported practice. Fam Pract. 1999;16:250–4 http://www.ncbi.nlm.nih.gov/pubmed/10439978. Accessed 30 Jul 2018.

    Article  CAS  PubMed  Google Scholar 

  20. Reed B, Jensen J. Preventive DG-A journal of, 1991 U. physicians and exercise promotion. Am J Prev Med. 1991;7:410–5 https://www.ajpmonline.org/article/S0749-3797(18)30880-8/abstract. Accessed 30 Jul 2018.

    Article  CAS  PubMed  Google Scholar 

  21. Keyworth C, Epton T, Goldthorpe J, Calam R, Armitage CJ. Are healthcare professionals delivering opportunistic behaviour change interventions? A multi-professional survey of engagement with public health policy. Implement Sci. 2018;13:122. https://doi.org/10.1186/s13012-018-0814-x.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Huijg JM, van der Zouwe N, Crone MR, Verheijden MW, Middelkoop BJCC, Gebhardt WA, et al. Factors influencing primary health care professionals’ physical activity promotion behaviors: a systematic review. Int J Behav Med. 2015;22:32–50. https://doi.org/10.1007/s12529-014-9398-2.

    Article  PubMed  Google Scholar 

  23. Dacey ML, Kennedy MA, Polak R, Phillips EM. Physical activity counseling in medical school education: a systematic review. Med Educ Online. 2014;19:24325. https://doi.org/10.3402/MEO.V19.24325.

    Article  PubMed  Google Scholar 

  24. Levy MD, Loy L, Zatz LY. Policy approach to nutrition and physical activity education in health care professional training. Am J Clin Nutr. 2014;99(5 Suppl):1194S–201S. https://doi.org/10.3945/ajcn.113.073544.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Kordi R, Moghadam N, Rostami M. Sports and exercise medicine in undergraduate medical curricula in developing countries: a long path ahead. Med Educ Online. 2011;16. https://doi.org/10.3402/meo.v16i0.5962.

  26. Joy EL, Blair SN, McBride P, Sallis R. Physical activity counselling in sports medicine: a call to action. Br J Sports Med. 2013;47:49–53. https://doi.org/10.1136/bjsports-2012-091620.

    Article  PubMed  Google Scholar 

  27. Sallis R, Franklin B, Joy L, Ross R, Sabgir D, Stone J. Strategies for promoting physical activity in clinical practice. Prog Cardiovasc Dis. 2015;57:375–86. https://doi.org/10.1016/j.pcad.2014.10.003.

    Article  PubMed  Google Scholar 

  28. Douglas F, van Teijlingen E, Torrance N, Fearn P, Kerr A, Meloni S. Promoting physical activity in primary care settings: health visitors’ and practice nurses’ views and experiences. J Adv Nurs. 2006;55:159–68. https://doi.org/10.1111/j.1365-2648.2006.03903.x.

    Article  PubMed  Google Scholar 

  29. Knox ECL, Musson H, Adams EJ. Knowledge of physical activity recommendations in adults employed in England: associations with individual and workplace-related predictors. Int J Behav Nutr Phys Act. 2015;12:69. https://doi.org/10.1186/s12966-015-0231-3.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Knox ECL, Esliger DW, Biddle SJH, Sherar LB. Lack of knowledge of physical activity guidelines: can physical activity promotion campaigns do better? BMJ Open. 2013;3:e003633. https://doi.org/10.1136/bmjopen-2013-003633.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Chatterjee R, Chapman T, Brannan MG, Varney J. GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. Br J Gen Pract. 2017;67:e668–75 http://www.ncbi.nlm.nih.gov/pubmed/28808077. Accessed 8 Feb 2018.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Chisholm A, Hart J, Lam V, Peters S. Current challenges of behavior change talk for medical professionals and trainees. Patient Educ Couns. 2012;87:389–94.

    Article  PubMed  Google Scholar 

  33. Albert FA, Crowe MJ, Malau-Aduli AEO, Malau-Aduli BS. Physical activity promotion: a systematic review of the perceptions of healthcare professionals. Int J Environ Res Public Health. 2020;17:1–36. https://doi.org/10.3390/ijerph17124358.

    Article  Google Scholar 

  34. Rollnick S, Butler CC, McCambridge J, Kinnersley P, Elwyn G, Resnicow K. Consultations about changing behaviour. BMJ Br Med J. 2005;331:961. https://doi.org/10.1136/BMJ.331.7522.961.

    Article  Google Scholar 

  35. Laverack G. The challenge of the ‘art and science’ of health promotion. Challenges. 2017;8:22. https://doi.org/10.3390/challe8020022.

    Article  Google Scholar 

  36. Hillsdon M, Thorogood M, White I, Foster C. Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care. Int J Epidemiol. 2002;31:808–15. https://doi.org/10.1093/ije/31.4.808.

    Article  PubMed  Google Scholar 

  37. Gagliardi AR, Faulkner G, Ciliska D, Hicks A. Factors contributing to the effectiveness of physical activity counselling in primary care: a realist systematic review. Patient Educ Couns. 2015;98:412–9. https://doi.org/10.1016/j.pec.2014.11.020.

    Article  PubMed  Google Scholar 

  38. Lundahl B, Moleni T, Burke BL, Butters R, Tollefson D, Butler C, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013;93:157–68. https://doi.org/10.1016/j.pec.2013.07.012.

    Article  PubMed  Google Scholar 

  39. Health Education England, Skills for Health and S for C. Person-Centred Approaches: Empowering people in their lives and communities to enable an upgrade in prevention, wellbeing, health, care and support. 2017. https://www.hee.nhs.uk/our-work/person-centred-care. Accessed 11 Jun 2022.

    Google Scholar 

  40. Moyers TB, Rowell LN, Manuel JK, Ernst D, Houck JM. The motivational interviewing treatment integrity code (MITI 4): rationale, preliminary reliability and validity. J Subst Abus Treat. 2016;65:36. https://doi.org/10.1016/J.JSAT.2016.01.001.

    Article  Google Scholar 

  41. Borrelli B. The assessment, monitoring, and enhancement of treatment Fidelity in public health clinical trials. J Public Health Dent. 2011;71:S52. https://doi.org/10.1111/J.1752-7325.2011.00233.X.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Public Health Agency of Sweden. On behalf of the EUPAP Consortium. EUPAP FYSS-short - physical activity in the prevention and treatment of disease. Sweden; 2019. www.fhi.se

  43. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374. https://doi.org/10.1136/BMJ.N2061.

  44. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. https://doi.org/10.1186/1748-5908-6-42.

    Article  PubMed  PubMed Central  Google Scholar 

  45. NICE. Behaviour change: individual approaches | guidance and guidelines | NICE. Natl Inst Heal Care Excell. 2014:49 https://www.nice.org.uk/guidance/ph49. Accessed 15 Feb 2018.

  46. Webb J, Foster J, Poulter E. Increasing the frequency of physical activity very brief advice for cancer patients. Development of an intervention using the behaviour change wheel. Public Health. 2016;133:45–56. https://doi.org/10.1016/j.puhe.2015.12.009.

    Article  CAS  PubMed  Google Scholar 

  47. Pallin ND, Webb J, Brown L, Woznitza N, Stewart-Lord A, Charlesworth L, et al. Online training resources to aid therapeutic radiographers in engaging in conversations about physical activity and diet: a mixed methods study. Radiography. 2022;28:124–32.

    Article  CAS  PubMed  Google Scholar 

  48. Smith R, Michalopoulou M, Reid H, Riches SP, Wango YN, Kenworthy Y, et al. Applying the behaviour change wheel to develop a smartphone application ‘stay-active’ to increase physical activity in women with gestational diabetes. BMC Pregnancy Childbirth. 2022;22:1–16. https://doi.org/10.1186/s12884-022-04539-9.

    Article  Google Scholar 

  49. Haase AM, Taylor AH, Fox KR, Thorp H, Lewis G. Rationale and development of the physical activity counselling intervention for a pragmatic TRial of exercise and depression in the UK (TREAD-UK). Ment Health Phys Act. 2010;3:85–91.

    Article  Google Scholar 

  50. Carney R, Cotter J, Bradshaw T, Yung AR. Examining the physical health and lifestyle of young people at ultra-high risk for psychosis: a qualitative study involving service users, parents and clinicians. Psychiatry Res. 2017;255:87–93.

    Article  PubMed  Google Scholar 

  51. Smith CA, McNeill A, Kock L, Shahab L. Exploring mental health professionals’ practice in relation to smoke-free policy within a mental health trust: a qualitative study using the COM-B model of behaviour. BMC Psychiatry. 2019;19:1–12. https://doi.org/10.1186/S12888-019-2029-3/TABLES/2.

    Article  Google Scholar 

  52. Michie S, Atkins L, West R. The behaviour change wheel book - a guide to designing interventions; 2014. p. 199. http://www.behaviourchangewheel.com/. Accessed 2 Aug 2018

    Google Scholar 

  53. Myers A, Quirk H, Lowe A, Crank H, Broom D, Jones N, et al. The active hospital pilot: a qualitative study exploring the implementation of a trust-wide sport and exercise medicine-led physical activity intervention. Plos One. 2021;16:e0257802. https://doi.org/10.1371/JOURNAL.PONE.0257802.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:1–17 https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-7-37. Accessed 8 Jun 2022.

    Article  Google Scholar 

  55. Atkins L, Francis J, Islam R, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci. 2017;12:77. https://doi.org/10.1186/s13012-017-0605-9.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Alexander KE, Brijnath B, Mazza D. Barriers and enablers to delivery of the healthy kids check: an analysis informed by the theoretical domains framework and COM-B model. Implement Sci. 2014;9:1–14. https://doi.org/10.1186/1748-5908-9-60/TABLES/6.

    Article  Google Scholar 

  57. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46:81–95. https://doi.org/10.1007/s12160-013-9486-6.

    Article  PubMed  Google Scholar 

  58. Michie S, Wood CE, Johnston M, Abraham C, Francis JJ, Hardeman W. Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data). Health Technol Assess (Rockv). 2015;19:1–188. https://doi.org/10.3310/hta19990.

    Article  Google Scholar 

  59. Gould GS, Bar-Zeev Y, Bovill M, Atkins L, Gruppetta M, Clarke MJ, et al. Designing an implementation intervention with the behaviour change wheel for health provider smoking cessation care for Australian indigenous pregnant women. Implement Sci. 2017;12:114. https://doi.org/10.1186/s13012-017-0645-1.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Reid H, Caterson J, Copeland RJ. What makes a good clinical conversation on physical activity? A scoping review exploring what is known to inform the development of physical activity resources to support healthcare professionals in routine practice. OSF Prepr. 2021. https://doi.org/10.31219/OSF.IO/WBPXA.

  61. Michie S, Abraham C, Eccles MP, Francis JJ, Hardeman W, Johnston M. Strengthening evaluation and implementation by specifying components of behaviour change interventions: a study protocol. Implement Sci. 2011;6:10. https://doi.org/10.1186/1748-5908-6-10.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Williams SL, French DP. What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour - and are they the same? Health Educ Res. 2011;26:308–22.

    Article  CAS  PubMed  Google Scholar 

  63. Pears S, Morton K, Bijker M, Sutton S, Hardeman W. Development and feasibility study of very brief interventions for physical activity in primary care. BMC Public Health. 2015;15:333. https://doi.org/10.1186/s12889-015-1703-8.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Knittle K, Nurmi J, Crutzen R, Hankonen N, Beattie M, Dombrowski SU. How can interventions increase motivation for physical activity? A systematic review and meta-analysis. Health Psychol Rev. 2018;12:211–30. https://doi.org/10.1080/17437199.2018.1435299.

    Article  PubMed  Google Scholar 

  65. Samdal GB, Eide GE, Barth T, Williams G, Meland E. Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses. Int J Behav Nutr Phys Act. 2017;14:42. https://doi.org/10.1186/s12966-017-0494-y.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Olander EK, Fletcher H, Williams S, Atkinson L, Turner A, French DP. What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2013;10:29. https://doi.org/10.1186/1479-5868-10-29.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Howlett N, Trivedi D, Troop NA, Chater AM. Are physical activity interventions for healthy inactive adults effective in promoting behavior change and maintenance, and which behavior change techniques are effective? A systematic review and meta-analysis. Transl Behav Med. 2018;9(1):147–57. https://doi.org/10.1093/tbm/iby010.

    Article  PubMed Central  Google Scholar 

  68. Webb J, Hall J, Hall K, Fabunmi-Alade R. Increasing the frequency of physical activity very brief advice by nurses to cancer patients. A mixed methods feasibility study of a training intervention. Public Health. 2016;139:121–33. https://doi.org/10.1016/j.puhe.2016.05.015.

    Article  CAS  PubMed  Google Scholar 

  69. Keyworth C, Epton T, Goldthorpe J, Calam R, Armitage CJ. Delivering opportunistic behavior change interventions: a systematic review of systematic reviews. Prev Sci. 2020;21:319–31. https://doi.org/10.1007/s11121-020-01087-6.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Robertson R, Jochelson K. Interventions that change clinician behaviour: mapping the literature. London: King’s Fund; 2006. https://www.nice.org.uk/media/default/about/what-we-do/into-practice/support-for-service-improvement-and-audit/kings-fund-literature-review.pdf. Accessed 30 Jan 2018

    Google Scholar 

  71. Bize R, Cornuz J, Martin B. Opinions and attitudes of a sample of Swiss physicians about physical activity promotion in a primary care setting opinions and attitudes of a sample of Swiss physicians about physical activity promotion in a primary care setting. Sport Sport. 2007;55:97–100 https://sgsm.ch/fileadmin/user_upload/Zeitschrift/55-2007-3/PhysActProm_Bizea.pdf. Accessed 22 Aug 2018.

    Google Scholar 

  72. Graham RC, Dugdill L, Cable NT. Health professionals’ perspectives in exercise referral: implications for the referral process. Ergonomics. 2005;48:1411–22. https://doi.org/10.1080/00140130500101064.

    Article  CAS  PubMed  Google Scholar 

  73. Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians: a national survey. Clin J Sport Med. 2000;10:40–8 http://www.ncbi.nlm.nih.gov/pubmed/10695849. Accessed 30 Jul 2018.

    Article  CAS  PubMed  Google Scholar 

  74. Burns KJ, Camaione DN, Chatterton CT. Prescription of physical activity by adult nurse practitioners: a national survey. Nurs Outlook. 2000;48:28–33. https://doi.org/10.1067/mno.2000.99101.

    Article  CAS  PubMed  Google Scholar 

  75. Sherman SE, Hershman WY. Exercise counseling - how do general internists do? J Gen Intern Med. 1993;8:243–8. https://doi.org/10.1007/BF02600089.

    Article  CAS  PubMed  Google Scholar 

  76. Walsh JM, Swangard DM, Davis T, McPhee SJ. Exercise counseling by primary care physicians in the era of managed care. Am J Prev Med. 1999;16:307–13 http://www.ncbi.nlm.nih.gov/pubmed/10493287. Accessed 22 Aug 2018.

    Article  CAS  PubMed  Google Scholar 

  77. Goodman C, Davies SL, Dinan S, See Tai S, Iliffe S. Activity promotion for community-dwelling older people: a survey of the contribution of primary care nurses. Br J Community Nurs. 2011;16:12–7. https://doi.org/10.12968/bjcn.2011.16.1.12.

    Article  PubMed  Google Scholar 

  78. McDowell N, McKenna J, Naylor PJ. Factors that influence practice nurses to promote physical activity. Br J Sports Med. 1997;31:308–13. https://doi.org/10.1136/BJSM.31.4.308.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. McKenna J, Naylor PJ, McDowell N. Barriers to physical activity promotion by general practitioners and practice nurses. Br J Sports Med. 1998;32:242–7 http://www.ncbi.nlm.nih.gov/pubmed/9773175. Accessed 22 Aug 2018.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  80. Steptoe A, Doherty S, Kendrick T, Rink E, Hilton S. Attitudes to cardiovascular health promotion among GPs and practice nurses. Fam Pract. 1999;16:158–63 http://www.ncbi.nlm.nih.gov/pubmed/10381023. Accessed 22 Aug 2018.

    Article  CAS  PubMed  Google Scholar 

  81. Kennedy MF, Meeuwisse WH. Exercise counselling by family physicians in Canada. Prev Med (Baltim). 2003;37:226–32 http://www.ncbi.nlm.nih.gov/pubmed/12914828. Accessed 22 Aug 2018.

    Article  Google Scholar 

  82. Eakin EG, Smith BJ, Bauman AE. Evaluating the population health impact of physical activity interventions in primary care—are we asking the right questions? J Phys Act Health. 2005;2:197–215. https://doi.org/10.1123/jpah.2.2.197.

    Article  Google Scholar 

  83. Patel A, Schofield GM, Kolt GS, Keogh JWL. General practitioners’ views and experiences of counselling for physical activity through the New Zealand Green prescription program. BMC Fam Pract. 2011;12:119. https://doi.org/10.1186/1471-2296-12-119.

    Article  PubMed  PubMed Central  Google Scholar 

  84. Hebert ET, Caughy MO, Shuval K. Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review. Br J Sports Med. 2012;46:625–31.

    Article  PubMed  Google Scholar 

  85. Yarnall KSH, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41 http://www.ncbi.nlm.nih.gov/pubmed/12660210. Accessed 30 Jul 2018.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Heath GW, Kolade VO, Haynes JW. Exercise is MedicineTM: a pilot study linking primary care with community physical activity support. Prev Med Rep. 2015;2:492–7.

    Article  PubMed  PubMed Central  Google Scholar 

  87. Keyworth C, Epton T, Goldthorpe J, Calam R, Armitage CJ. Perceptions of receiving behaviour change interventions from GPs during routine consultations: A qualitative study. PLoS One. 2020;15(5):e0233399. https://doi.org/10.1371/journal.pone.0233399. PMID: 32437462; PMCID: PMC7241720.

  88. Bull FC, Schipper EC, Jamrozik K, Blanksby BA. How can and do Australian doctors promote physical activity? Prev Med (Baltim). 1997;26:866–73. https://doi.org/10.1006/pmed.1997.0226.

    Article  CAS  Google Scholar 

  89. Phillips EM. A call to arms (and legs): exercise prescription for medical students. PM R. 2012;4:914–8. https://doi.org/10.1016/j.pmrj.2012.09.1159.

    Article  PubMed  Google Scholar 

  90. Brannan M, Bernardotto M, Clarke N, Varney J. Moving healthcare professionals - a whole system approach to embed physical activity in clinical practice. BMC Med Educ. 2019;19:84. https://doi.org/10.1186/s12909-019-1517-y.

    Article  PubMed  PubMed Central  Google Scholar 

  91. Anderson N, Ozakinci G. “It all needs to be a full jigsaw, not just bits”: exploration of healthcare professionals’ beliefs towards supported self-management for long-term conditions. BMC Psychol. 2019;7. https://doi.org/10.1186/s40359-019-0319-7.

  92. Moser EM, Stagnaro-Green A. Teaching behavior change concepts and skills during the third-year medicine clerkship. Acad Med. 2009;84:851–8. https://doi.org/10.1097/ACM.0b013e3181a856f8.

    Article  PubMed  Google Scholar 

  93. Chauhan BF, Jeyaraman M, Mann AS, Lys J, Skidmore B, Sibley KM, et al. Behavior change interventions and policies influencing primary healthcare professionals’ practice-an overview of reviews. Implement Sci. 2017;12. https://doi.org/10.1186/s13012-016-0538-8.

  94. Wattanapisit A, Tuangratananon T, Thanamee S. Physical activity counseling in primary care and family medicine residency training: a systematic review. BMC Med Educ. 2018;18:159. https://doi.org/10.1186/s12909-018-1268-1.

    Article  PubMed  PubMed Central  Google Scholar 

  95. Blakeman T, Bower P, Reeves D, Chew-Graham C. Bringing self-management into clinical view: a qualitative study of long-term condition management in primary care consultations. Chronic Illn. 2010;6:136–50. https://doi.org/10.1177/1742395309358333.

    Article  PubMed  Google Scholar 

  96. Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43:89–92.

    Article  CAS  PubMed  Google Scholar 

  97. Lobelo F, de Quevedo IG. The evidence in support of physicians and health care providers as physical activity role models. Am J Lifestyle Med. 2014;10:1559827613520120. https://doi.org/10.1177/1559827613520120.

    Article  Google Scholar 

  98. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Getting research findings into practice. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. Br Med J. 1998;317:465–8. https://doi.org/10.1136/bmj.317.7156.465.

    Article  CAS  Google Scholar 

  99. Yost J, Ganann R, Thompson D, Aloweni F, Newman K, Hazzan A, et al. The effectiveness of knowledge translation interventions for promoting evidence-informed decision-making among nurses in tertiary care: a systematic review and meta-analysis. Implement Sci. 2015;10:98. https://doi.org/10.1186/s13012-015-0286-1. PMID: 26169063; PMCID: PMC4499897.

  100. Smith WR. Evidence for the effectiveness of techniques to change physician behavior. Chest. 2000;118(2 SUPPL):8S–17S. https://doi.org/10.1378/chest.118.2_suppl.8S.

    Article  CAS  PubMed  Google Scholar 

  101. Bauchner H, Simpson L, Chessare J. Changing physician behaviour: editorial. Arch Dis Child. 2001;84:459–62. https://doi.org/10.1136/adc.84.6.459.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  102. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362:1225–30. https://doi.org/10.1016/S0140-6736(03)14546-1.

    Article  PubMed  Google Scholar 

  103. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8:iii–iv, 1–72 http://www.ncbi.nlm.nih.gov/pubmed/14960256. Accessed 15 Sep 2018.

    Article  CAS  PubMed  Google Scholar 

  104. Crick K, Hartling L. Preferences of knowledge users for two formats of summarizing results from systematic reviews: infographics and critical appraisals. Plos One. 2015;10:e0140029. https://doi.org/10.1371/journal.pone.0140029.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  105. Huijg JM, van der Zouwe N, Crone MR, Verheijden MW, Middelkoop BJC, Gebhardt WA. Factors influencing the introduction of physical activity interventions in primary health care: a qualitative study. Int J Behav Med. 2015;22:404–14. https://doi.org/10.1007/s12529-014-9411-9.

    Article  PubMed  Google Scholar 

  106. Wheeler PC, Mitchell R, Ghaly M, Buxton K. Primary care knowledge and beliefs about physical activity and health: a survey of primary healthcare team members. BJGP Open. 2017;1(2):bjgpopen17X100809. https://doi.org/10.3399/bjgpopen17X100809. PMID: 30564660; PMCID: PMC6169952.

  107. Eakin EG, Brown WJ, Marshall AL, Mummery K, Larsen E. Physical activity promotion in primary care: bridging the gap between research and practice. Am J Prev Med. 2004;27:297–303. https://doi.org/10.1016/j.amepre.2004.07.012.

    Article  PubMed  Google Scholar 

  108. Sassen B, Kok G, Vanhees L. Predictors of healthcare professionals’ intention and behaviour to encourage physical activity in patients with cardiovascular risk factors. BMC Public Health. 2011;11:246. https://doi.org/10.1186/1471-2458-11-246.

    Article  PubMed  PubMed Central  Google Scholar 

  109. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: new guidance prepared on behalf of the Medical Research Council by. UK; 2006. www.mrc.ac.uk/complexinterventionsguidance. Accessed 2 Aug 2018.

    Google Scholar 

  110. Colquhoun HL, Squires JE, Kolehmainen N, Fraser C, Grimshaw JM. Methods for designing interventions to change healthcare professionals’ behaviour: a systematic review. Implement Sci. 2017;12:30. https://doi.org/10.1186/s13012-017-0560-5.

    Article  PubMed  PubMed Central  Google Scholar 

  111. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55:305–12 http://www.ncbi.nlm.nih.gov/pubmed/15826439. Accessed 17 Apr 2018.

    PubMed  PubMed Central  Google Scholar 

  112. Stange KC, Woolf SH, Gjeltema K. One minute for prevention: the power of leveraging to fulfill the promise of health behavior counseling. Am J Prev Med. 2002;22:320–3. https://doi.org/10.1016/S0749-3797(02)00413-0.

    Article  PubMed  Google Scholar 

  113. Jowsey T, Pearce-Brown C, Douglas KA, Yen L. What motivates Australian health service users with chronic illness to engage in self-management behaviour? Health Expect. 2014;17:267–77. https://doi.org/10.1111/j.1369-7625.2011.00744.x.

    Article  PubMed  Google Scholar 

  114. Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336:1114–7. https://doi.org/10.1136/bmj.39553.670231.25.

    Article  PubMed  PubMed Central  Google Scholar 

  115. Nevins TE, Nickerson PW, Dew MA. Understanding medication nonadherence after kidney transplant. J Am Soc Nephrol. 2017;28:2290–301. https://doi.org/10.1681/ASN.2017020216.

    Article  PubMed  PubMed Central  Google Scholar 

  116. Balint E. The possibilities of patient-centered medicine. J R Coll Gen Pract. 1969;17:269–76 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2236836&tool=pmcentrez&rendertype=abstract. Accessed 7 Aug 2015.

    CAS  PubMed  PubMed Central  Google Scholar 

  117. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8 SUPPL):2.

    Google Scholar 

  118. Kennedy A, Bower P, Reeves D, Blakeman T, Bowen R, Chew-Graham C, et al. Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial. BMJ. 2013;346. https://doi.org/10.1136/bmj.f2882.

  119. Potthoff S, Presseau J, Sniehotta FF, Johnston M, Elovainio M, Avery L. Planning to be routine: habit as a mediator of the planning-behaviour relationship in healthcare professionals. Implement Sci. 2017;12. https://doi.org/10.1186/s13012-017-0551-6.

  120. Wood W, Quinn JM, Kashy DA. Habits in everyday life: thought, emotion, and action. J Pers Soc Psychol. 2002;83:1281–97. https://doi.org/10.1037/0022-3514.83.6.1281.

    Article  PubMed  Google Scholar 

  121. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7:50. https://doi.org/10.1186/1748-5908-7-50.

    Article  PubMed  PubMed Central  Google Scholar 

  122. Squires JE, Sullivan K, Eccles MP, Worswick J, Grimshaw JM. Are multifaceted interventions more effective than single-component interventions in changing health-care professionals’ behaviours? An overview of systematic reviews. Implement Sci. 2014;9:152. https://doi.org/10.1186/s13012-014-0152-6.

    Article  PubMed  PubMed Central  Google Scholar 

  123. Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. J Am Med Assoc. 2005;293:1223–38. https://doi.org/10.1001/jama.293.10.1223.

    Article  CAS  Google Scholar 

  124. NICE. Behaviour change: digital and mobile health interventions. NICE guideline 183. London: National Institute for Health and Care Excellence; 2020. www.nice.org.uk/guidance/ng183.

  125. Orrow G, Kinmonth A-L, Sanderson S, Sutton S. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ. 2012;344:e1389. https://doi.org/10.1136/bmj.e1389.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors would like to acknowledge the contribution of the clinical working groups and the staff and patients at Oxford University Hospitals NHS Foundation Trust for their support of the Active Hospital project, where many of these ideas were explored in clinical environments. We would like to acknowledge Justin Varney, Mike Brannan and Jamie Blackshaw from Public Health England and the Office for Health Improvement and Disparities for conceptualising and managing delivery the Moving Healthcare Professionals Programme as well as Sarah Ruane and Suzanne Gardner from Sport England for their ongoing leadership and support of the programme.

Funding

Sport England and the National Lottery provided a funding contribution to support staff costs of £3500 and covered publication fees as part of their support of the Moving Health Professionals Program. The funders did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. Moving Medicine, Faculty of Sport and Exercise Medicine, 6 Hill Square, Edinburgh, UK

    Hamish Reid & Natasha Jones

  2. Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK

    Hamish Reid & Robert Copeland

  3. Oxford University Hospital NHS Foundation Trust Nuffield Orthopaedic Centre, Oxford, UK

    Ralph Smith, James Baldock & Natasha Jones

  4. School of Medicine, Trinity College Dublin, 152-160 Pearse Street, Dublin, Ireland

    Wilby Williamson

  5. Imperial College Healthcare NHS Trust, Praed Street, London, GB, W2 1NY, UK

    Jessica Caterson

  6. School of Medicine, University of Nottingham, Medical School, Nottingham, NG7 2UH, UK

    Stefan Kluzek

Authors
  1. Hamish Reid
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  2. Ralph Smith
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  3. Wilby Williamson
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  4. James Baldock
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  5. Jessica Caterson
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  6. Stefan Kluzek
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  7. Natasha Jones
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  8. Robert Copeland
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Contributions

HR, NJ and RC conceptualised this framework analysis. HR planned and led the delivery of the study. HR, RS and JC reviewed and applied findings from published literature. HR, RS, WW, JB, SK and NJ developed and tested all aspects of the behavioural change framework, including clinical feasibility and implementation, with oversight from RC. All authors contributed to revisions of this manuscript, which was written by HR and RC. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Hamish Reid.

Ethics declarations

Ethics approval and consent to participate

All methods were carried out in accordance with relevant guidelines and regulations at the Research and Development department of Oxford University Hospitals NHS Foundation Trust. In accordance with local protocol, the project was submitted to the UK National Health Service (NHS) Research Authority and Medical Research Council decision-making tool, which confirmed that NHS Research Ethics Committee review was not required. Concurrent and related evaluation activity in the Active Hospital project at Oxford University Hospitals NHS Foundation Trust were reviewed and approved by the National Research Ethics Service Committee Nottingham 2 (ref. 18/EM/0145). All contributors and/or their legal guardians provided informed consent to participate following a detailed description of what the project entailed.

Competing interests

The authors declare that they have no competing interests.

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Reid, H., Smith, R., Williamson, W. et al. Use of the behaviour change wheel to improve everyday person-centred conversations on physical activity across healthcare. BMC Public Health 22, 1784 (2022). https://doi.org/10.1186/s12889-022-14178-6

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  • DOI: https://doi.org/10.1186/s12889-022-14178-6

Keywords

  • Physical activity
  • Healthcare professional
  • Conversation
  • Behaviour change wheel

BMC Public Health

ISSN: 1471-2458

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