'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.

Cheryl Hunter,Peter Salmon,Jessica Drinkwater,Alexandra Stenhoff,Elspeth A Guthrie,Susanne Langer,Carolyn A Chew‐Graham

doi:10.1111/hex.12304

Abstract

BackgroundHealth outcomes for long‐term conditions (LTCs) can be improved by lifestyle, dietary and condition management‐related behaviour change. Primary care is an important setting for behaviour change work. Practitioners have identified barriers to this work, but there is little evidence examining practices of behaviour change in primary care consultations and how patients and practitioners perceive these practices.ObjectiveTo examine how behaviour change is engaged with in primary care consultations for LTCs and investigate how behaviour change is perceived by patients and practitioners.DesignMultiperspective, longitudinal qualitative research involving six primary health‐care practices in England. Consultations between patients with LTCs and health‐care practitioners were audio‐recorded. Semi‐structured interviews were completed with patients and practitioners, using stimulated recall. Patients were re‐interviewed 3 months later. Framework analysis was applied to all data.ParticipantsThirty‐two people with at least one LTC (chronic obstructive pulmonary disease, diabetes, asthma and coronary heart disease) and 10 practitioners.ResultsBehaviour change talk in consultations was rare and, when it occurred, was characterized by deflection and diffidence on the part of practitioners. Patient motivation tended to be unaddressed. While practitioners positioned behaviour change work as outside their remit, patients felt uncertain about, yet responsible for, this work. Practitioners raised concerns that this work could damage other aspects of care, particularly the patient–practitioner relationship.ConclusionBehaviour change work is often deflected or deferred by practitioners in consultations, who nevertheless vocalize support for its importance in interviews. This discrepancy between practitioners’ accounts and behaviours needs to be addressed within primary health‐care organizations.

Highlights

Health outcomes for long-term conditions (LTCs) can be improved by lifestyle, dietary and condition managementrelated behaviour change
This paper examines one aspect of primary care consultations: practices of behaviour change
This study demonstrates a disjunction between how practitioners enact behaviour change in consultations and their expressed commitment to its importance for long-term condition management

Summary

Introduction

Health outcomes for long-term conditions (LTCs) can be improved by lifestyle, dietary and condition managementrelated behaviour change. Primary care is considered the optimum health-care setting to manage people with LTCs,[12,14] and LTC management accounts for a large proportion of the workload.[15] Primary care is community-based, accessible and able to offer continuity of care and of patient– practitioner relationships – key requirements for managing patient needs over time.[16,17] Several initiatives in the United Kingdom, such as the NHS and Social Care Long-term Conditions Model[1] and the Quality and Outcomes Framework (QOF),[18] aim to improve quality of care and health outcomes for patients through system changes in primary care As part of these system changes, there is a focus on patient self-management, supported by initiatives such as the Expert Patient programme.[19] The chronic care model suggests that 70–80% of people can self-manage their conditions with support from health-care services.[20] This support includes information provision, lifestyle and dietary advice, and behaviour change interventions around issues such as smoking and alcohol use

Results

Discussion

Conclusion