The development, implementation and evaluation of a training intervention for primary health care providers on brief behaviour change counselling, and assessment of the provider’s competency in delivering this counselling intervention.
Unhealthy behaviour is a key modifiable factor that underlies much of the South African (SA) burden of disease and primary care morbidity. Chronic diseases such as heart disease, type 2 diabetes, lung diseases and some cancers are linked to underlying behavioural issues such as tobacco smoking, alcohol abuse, physical inactivity and unhealthy eating. Evidence shows that brief behaviour change counselling by primary care providers can be effective in helping patients to change risky lifestyle behaviours. However, the capacity of South African primary care providers to educate and counsel patients on lifestyle modification is generally poor. The need for primary care provider training in lifestyle counselling, is stated as a critical objective in ‘re-orientating’ the primary health care system to effectively address NCDs in the National Strategic Plan for the Prevention and Control of NCDs and their risk factors in SA. The overall aim of this research was to develop, implement and evaluate the effectiveness of a training intervention for primary care providers in the South African setting, which is based on teaching best practice, behaviour change counselling (BBCC) methods that can be used for patients with risky lifestyle behaviours associated with non-communicable diseases (NCDs) The sequence of the abstracts of the four articles that were published from this research, gives an overview of the process. The abstracts of the four articles presented for the degree are given here. Abstract: Article 1 Title A situational analysis of current training for behaviour change counselling amongst primary care providers in the Western Cape, South Africa. Background The risk factors (smoking, alcohol abuse, physical inactivity and unhealthy diet) associated with non-communicable diseases (NCDs) have been confirmed internationally, and locally. Primary health care providers can play an important role in counselling patients. The need for health care provider training in evidence-based lifestyle interventions has been acknowledged by the National Department of Health in their strategic plan for NCDs. Local studies to assess practitioners’ capacity to counsel, suggest that it is inadequate. This may be a reflection of a lack of training in counselling skills. Aim A situational analysis of the current training courses for primary health care providers in the Western Cape. Setting Key informant interviews were conducted with the two programme managers involved in the training of clinical nurse practitioners at Stellenbosch University, as well as three programme managers and a family physician involved with the training of registrars in Family Medicine at Stellenbosch and Cape Town Universities. Focus group interviews were conducted with nine nurses working at a primary care clinic, situated in the Cape Winelands, and with a group of eight registrars in family medicine at the University of Cape Town. Methods This was a qualitative study that used both individual in-depth, and focus group interviews. Results Current training for practitioners in the Western Cape is not sufficient to achieve competence in counselling. Conclusion Revising the approach to current training is necessary to improve primary care providers’ counselling skills. Abstract: Article 2 Title Development of a training programme for primary care providers to counsel patients with risky lifestyle behaviours in South Africa Objective This study aimed to re-design the current training for primary care providers (PCPs) in South Africa, around a new model for brief behaviour change counselling (BBCC) that would offer a standardised approach to addressing patients’ risky lifestyle behaviours associated with non-communicable diseases (NCDs). Methods The ADDIE model provided a systematic approach to the Analysis of learning needs, the Design and Development of the training programme, its Implementation and initial Evaluation. Results This study designed a new approach to BBCC, which was based on a conceptual model that combined the 5 As (ask, alert, assess, assist and arrange) with a guiding style derived from motivational interviewing. The 8 hour training programme was developed, for either clinical nurse practitioners or primary care doctors. Conclusion To our knowledge, this training programme is the first attempt at developing and implementing best practice BBCC training in our context, targeting a variety of PCPs, and addressing risk factors for NCDs. Practice implications Family physicians from Departments of Family Medicine throughout South Africa were trained as trainers. These trainers are now training medical students, general practitioners and family physicians in their respective areas. The authors have also presented the training programme in other countries such as Botswana and Namibia. Abstract: Article 3 Title Evaluation of a training programme for primary care providers to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa Objective To evaluate the effect on clinical practice of training primary care providers(PCPs) in an approach to brief behaviour change counselling (BBCC), which integrates the 5 As (ask, alert, assess, assist, arrange) with a guiding style derived from motivational interviewing in the South African context. BBCC was focused on the four risky behaviours (unhealthy eating, tobacco smoking, physical inactivity, harmful alcohol use) for non-communicable diseases. Methods A before-and-after design, recorded BBCC skills at baseline, again directly after training and finally 6-weeks later. We evaluated each recording for adherence to the guiding style and delivery of the 5 As using the Motivational Interviewing Treatment Integrity tool (Version 3.1.1), and a tool based on the 5 As training design. Results 123 recordings were collected from 41 PCPs. Results showed a significant improvement in adoption of the guiding style (e.g. global score at baseline 2.0 (2.0-2.6) and in clinical practice 3.0 (2.7-3.3) P<0.001) and completion of the 5 A steps (e.g. assist score at baseline 1.26 (1.12-1.4) and in clinical practice 1.75 (1.61-1.89) p<0.001. Conclusion Training PCPs in this approach to BBCC is effective at changing their clinical practice in the short term. Practice implications The training programme should be integrated into the curricula of PCPs, and used in continuing professional development. Abstract: Article 4 Title Qualitative evaluation of primary care providers experiences of a training programme to offer brief behaviour change counselling on risk factors for non-communicable diseases in South Africa Background The global epidemic of non-communicable disease (NCDs) has been linked with four modifiable risky lifestyle behaviours, namely smoking, unhealthy diet, physical inactivity and harmful alcohol use. Primary care providers (PCPs) can play an important role in changing patient’s risky behaviours. It is recommended that PCPs provide individual brief behaviour change counselling (BBCC) as part of everyday primary care. This study is part of a larger project that re-designed the current training for PCPs in South Africa, to offer a standardized approach to BBCC based on the 5 As and a guiding style. This article reports on a qualitative sub-study, which explored whether the training intervention changed PCPs perception of their ability to offer BBCC, whether they believed that the new approach could overcome the barriers to implementation in clinical practice and be sustained, and their recommendations on future training and integration of BBCC into curricula and clinical practice. Methods This was a qualitative study that used verbal feedback from participants at the beginning and end of the training course, as well as twelve individual in-depth interviews with participants once they had returned to their clinical practice. Results Although PCP’s confidence in counselling improved, and some thought that time constraints could be overcome, they still reported that understaffing, lack of support from within the facility and poor continuity of care were barriers to counselling. The current organisational culture was not congruent with the patient-centred guiding style of BBCC. Training should be incorporated into undergraduate curricula of PCPs for both nurses and doctors, to ensure that skills are embedded from the start. Existing PCPs should be offered training as part of continued professional development programmes. Conclusions This study showed that although training changed PCPs perception of their ability to offer BBCC, and increased their confidence to overcome certain barriers to implementation, significant barriers remained. It is clear that to incorporate BBCC into everyday care, not only training, but also a whole systems approach is needed, that involves the patient, provider, and service organisation at different levels.