Patients' experiences of behaviour change interventions delivered by general practitioners during routine consultations: A nationally representative survey

Abstract Background Consistent with the ‘Making Every Contact Count’ UK public health policy, general practitioners (GPs) are expected to provide patients with behaviour change interventions opportunistically. However, there is a belief widely held among GPs that patients neither want or need such interventions. We aimed to understand the following: (a) the characteristics of people attending GP appointments, (b) patients' needs for health behaviour change, (c) perceptions of appropriateness and helpfulness of interventions, and (d) factors associated with recall of receipt of interventions. Methods Cross‐sectional nationally representative online survey of UK adults who had attended GP clinics in the preceding four weeks (n = 3028). Data were analysed using descriptive statistics and binary logistic regression. Results 94.5% (n = 2862) of patients breached at least one health behaviour guideline, and 55.1% reported never having had a conversation with their GP about health behaviours. The majority of patients perceived intervention as appropriate (range 84.2%‐87.4% across behaviours) and helpful (range 82.8%‐85.9% across behaviours). Being male (OR = 1.412, 95% CI 1.217, 1.639), having a long‐term condition (OR = 1.514, 95% CI 1.287, 1.782) and a higher number of repeat GP visits (OR = 1.016, 95% CI 1.010, 1.023) were among factors associated with recall of receipt of interventions. Conclusions Patients perceived behaviour change intervention during routine GP consultations as appropriate and helpful, yet there are variations in the likelihood of receiving interventions according to sociodemographic factors. GPs could adopt a more proactive approach to behaviour change in patient consultations with the broad approval of patients. Patient or public contribution The questionnaire was piloted among a convenience sample prior to distribution.


| BACKG ROU N D
Non-communicable diseases (NCDs; cardiovascular disease, cancers, chronic respiratory diseases and diabetes) kill 41 million people each year. 1 Health behaviours such as smoking, excessive alcohol intake, physical inactivity and unhealthy diet are all key risk factors of NCDs and place a heavy financial burden on the National Health Service (NHS). 2 The recent Health Survey for England showed that 87% of adults breached national guidance on health behaviour. 3 General practitioners (GPs) are often the first point of contact for patients consulting with the health service and are consequently well placed to offer brief interventions to support patients in improving their health behaviour. Public health strategies in the UK emphasize the need for preventive strategies as central to every patient contact. 4 However, research to date provides a mixed picture of the extent to which GPs are willing to deliver behaviour change interventions. Some research suggests that GPs are dissatisfied by delivering behaviour change interventions such as smoking cessation. 5 GPs may also feel they are actively discouraged from delivering interventions, in favour of addressing and managing the primary medical complaint. 6 In contrast, other research suggests that GPs consider interventions for smoking cessation 5  there is evidence that some GPs do deliver behaviour change interventions during routine practice, although the proportion of patients receiving such interventions is low. A recent national survey of health-care professionals showed that GPs perceived that, of all the patients they saw in a typical week, 44% would benefit from a behaviour change intervention. However, GPs reported delivering interventions to just 34% of those patients who they perceived would benefit. 9 Moreover, it is currently unknown how many patients attending GP appointments perceive they would benefit from a behaviour change intervention meaning that GPs currently make decisions based on their perceptions of patient need.
Findings from systematic reviews show that some GPs believe that: (a) patients may not want or need behaviour change interventions, and patients would perceive this information as inappropriate 10,11 ; and (b) patients may lack the motivation and desire for behaviour change and are unwilling and lack the motivation to modify their health behaviour. 12 Consequently, GPs appear to make conscious decisions about whether or not to deliver interventions to patients, which may be influenced by biases towards certain types of patients based on GPs' perceptions of patient risk, and how receptive GPs believe that patients will be to conversations about health behaviours. 5,8,13 It would therefore be valuable to examine the factors associated with recall of receiving health behaviour change interventions.
Despite the conflicting evidence in relation to GPs' perceptions about the value of behaviour change activities during routine practice, more research is needed focussed on patient perspectives. A recent qualitative study suggests behaviour change interventions are perceived by patients as appropriate and helpful during routine GP consultations, particularly where it would benefit long-term condition management. 14 Some research has examined patients' willingness to receive opportunistic behaviour change interventions within specific health contexts (eg behaviour change advice during cancer screening appointments 15

| Design and procedure
A cross-sectional survey design was used. Patients who had visited their general practitioner (GP) at least once in the previous four weeks for a routine appointment (characterized as a prescheduled appointment with a GP for any reason) were recruited via a survey panel (YouGov)

| Participants
Purposive sampling was used to recruit participants to take part in an online questionnaire. Initially, a sample designed to be representative of adults resident in the United Kingdom was asked a screening question: 'have you consulted a general medical practitioner (ie a GP doctor) within the last four weeks?'. Response options were as follows: 'yes, in a local GP clinic', 'yes, in a hospital or accident and emergency department', 'yes, other', 'no', or 'don't know'. The final sampling frame was based on the respondents answering 'yes, in a local GP clinic'.

| Measures
The questionnaire, as part of a larger programme of research examining perceptions of health and well-being, collected demographic information including age, gender, ethnicity and socioeconomic status.
Patients' current health and any existing long-term conditions that may be relevant to their visit were also examined. The EQ-VAS 16 was used for participants to provide a global assessment of their current health. Participants are asked to report their current health, using a visual analogue scale, on a scale of 0 (worst imaginable health), to 100 (best imaginable health). Participants were also asked: 'Was the purpose of your last doctor (GP) visit to discuss a chronic condition (generally, these progress slowly, over an extended period of time, for example arthritis, high blood pressure, osteoporosis)'. To examine perceptions of the receipt of health behaviour interventions during routine consultations, for smoking, diet, physical activity, alcohol intake and weight management, participants were asked to rate the following: (a) perceived helpfulness of receiving a behaviour change intervention, (b) perceived appropriateness of receiving a behaviour change intervention, (c) perceived expectation of receiving a behaviour change intervention and (d) perceived concern as a result of receiving a behaviour change intervention. Perceived helpfulness and appropriateness were based on questions previously used in the literature. 19 In relation to perceived helpfulness, participants were asked the question 'In general, how helpful or not do you think it is for doctors (GPs) to ask people about the following?' answered using the response options 'very helpful', 'helpful', 'neither helpful nor unhelpful', 'not helpful' and 'not at all helpful' in relation to each of smoking, diet, physical activity, alcohol intake and weight management. In relation to perceived appropriateness, participants were asked the question 'In general, how appropriate or not do you think it is for doctors (GPs)

TA B L E 1 Sample characteristics
to ask people about the following?' answered using the response options 'very appropriate', 'appropriate', 'neither appropriate nor inappropriate', 'not appropriate' and 'not at all appropriate' in relation to each health behaviour. Perceived concern was answered using a 0 (not at all concerned) to 10 (very concerned) rating scale, adapted from Klein. 20 Perceived expectation was answered using a 0 (never expect) to 10 (always expect) rating scale, developed by the research team in the absence of a standardized item measuring perceived expectation.

| Analyses
Descriptive statistics were used to quantify (a) the characteristics of patients attending a GP appointment, (b) how many patients would benefit from behaviour change advice according to patients' selfreported health behaviours, (c) ratings of experiences of discussing health behaviours during routine GP appointments and (d) ratings of acceptability (perceived helpfulness, appropriateness, expectation and concern) in relation to receiving behaviour change advice.

| Patients' experiences of discussing health behaviours during consultations in relation to current health behaviour status
Of the patients who had breached at least one national health behaviour guideline (94.5%; n = 2862), and would therefore benefit from behaviour change advice, 55.1% (n = 1578) reported never having had a conversation with their GP about health behaviours (Table 2). We therefore examined the extent to which GPs discussed the health behaviours that patients believed they needed to change ( Table 3). Regardless of which health behaviour guideline TA B L E 3 Health behaviour interventions received during last GP visit according to patients' current health behaviour status

| Patients' perceptions of receiving health behaviour change interventions
As shown in Table 4

| Patients' perceptions of receiving health behaviour change interventions (amongst patients who received interventions)
As shown in Table 5, among patients who actually received behaviour change interventions and who were breaching guidelines (smoking cessation, diet, weight loss, physical activity, and alcohol reduction), intervention was perceived as 'very appropriate' or 'appropriate' (range 79.3%-87.1%) and 'very helpful' or 'helpful' (range 80.3%-83.9%). These results are also comparable to the perceptions of patients who were within national guidelines for health behaviour, but were in any case asked to change their behaviour. Across all health behaviours, intervention was perceived as 'very appropriate' or 'appropriate' (range 77.6%-88%) and 'very helpful' or 'helpful' (range 76.2%-87.9%). Thus, even when GPs provided what might be considered unnecessary intervention (eg asking non-smokers to quit), it seems there was little offence taken on the part of the patient.

| Factors associated with recall of receipt of behaviour change interventions
3.7.1 | Age, gender, ethnicity and social grade

| Summary
This is the first study to (a) identify the characteristics of patients attending routine GP appointments, (b) assess patient need for behav-

| Implications for practice
Behaviour change interventions delivered by GPs have been shown to be effective in changing patients' behaviour. 19,25 Whilst there is ambivalence amongst GPs about delivering behaviour change interventions in routine consultations, 5,8 we found evidence that interventions are being delivered during some consultations, even if the proportion is low. Our findings show that smokers (compared with non-smokers) and people exceeding alcohol guidelines (compared with those who are not) were more likely to report receiving a behaviour change intervention during their last GP visit. However, the skills required to deliver behaviour change interventions opportunistically may not be a part of health-care professional core training or practice 5,26 ; education and training to deliver interventions must therefore take priority. 27 Specific reasons contributing to the likelihood of GPs delivering interventions may include a fear of offending the patient, 28 beliefs that patients lack the motivation for behaviour change 5 and perceptions that patients do not want or need behaviour change interventions. 10,11 Our study suggests that patients (a) are receptive and would welcome a discussion about behaviour change, and (b) where behaviour change was discussed with patients, this was rated favourably by patients, even in cases of less personally relevant health behaviours. Further, GPs underestimate the proportion of patients that would benefit from a behaviour change intervention, and there are considerable differences in patient need compared to the proportion of patients breaching health behaviour guidelines observed in the current study.

| CON CLUS IONS
Behaviour change interventions delivered by GPs during routine medical consultations enable interventions to have maximum reach and can be used effectively when incorporated into time-restricted consultations. 19 Our findings suggest that GPs underestimate the proportion of patients that would benefit from behaviour change interventions, which patients perceive as appropriate and helpful.
GPs could adopt a more proactive approach to behaviour change in patient consultations with the broad approval of patients.

ACK N OWLED G EM ENTS
This study was funded by a research grant obtained from Tesco

E TH I C S A PPROVA L A N D CO N S E NT TO PA RTI CI PATE
Ethical approval for the study was obtained from a university ethics committee (ref. 2017-0739-1780).

CO M PE TI N G I NTER E S TS
The authors declare that they have no competing interests.

AUTH O R S ' CO NTR I B UTI O N
CK and CJA conceived the study. CK was responsible for data curation and leading data analysis. CK, TE, JG, RC, and CJA contributed to design and methodology. CK and CJA led the first draft of the manuscript, and all study authors contributed to later drafts and agreed on the final version.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.