Characteristics of the sample of GPs
The 15 GPs in this sample consisted of seven males and eight females, representing an approximately equal number of single and group practices. The majority had previously been involved as participants in a related study , and had undertaken a short training session in motivational interviewing. During the recruitment process, these GPs had expressed an interest in the project. It is therefore recognised that this sample represents GPs who may be more interested in preventive care, or more specifically interested in identifying the barriers and enablers to delivering such care, than the general population of GPs.
Behaviours of GPs
The provision of preventive care in a health check consultation involves a number of possible behaviours by clinicians. Initial open coding of the interview transcripts assisted in the identification of the various behaviours. Not all behaviours were undertaken by all clinicians, and clinicians discussed the execution of them to different degrees. Added to that, some clinician behaviours were more evident for some SNAP factors than for others. Further analysis of the transcripts allowed the researchers to identify specific factors influencing these behaviours. These are presented in the following section, with supporting quotes presented in the appendix.
Assessment (relates to research question 1)
The assessment of lifestyle risk by clinicians included direct enquiry, ordering tests, and reviewing and updating patient records. Some GPs stated that patients expected risk factors to be assessed within a health check consultation, thus providing a sense of greater permission to address SNAP factors. Time was mentioned as a barrier to a detailed assessment. Differences in assessment for individual SNAP factors were also evident. GPs were unanimous in their opinion that reviewing smoking status was straightforward. There was more variation in their attitudes towards assessment of nutrition, alcohol and physical activity. Those GPs who had experience and interest in addressing drug and alcohol issues reported being consistent in assessing alcohol intake; others had increased this screening as a result of implementing the health check, and some others felt this screening was only possible during such a health check. Nutritional status and level of physical activity were often inferred by the clinicians from the patient's general appearance (eg overweight), or from physiological conditions such as hypertension or hypercholesterolaemia. The level of risk to the patient appeared to inform the intensity of the assessment. For example, if the patient already exhibited signs of poor nutrition (such as obesity), more intensive assessment of diet and physical activity would usually be undertaken.
The GPs' perception of their professional role also influenced the amount of assessment, with one GP admitting to not asking about specific dietary intake as he "was not a dietician" and doubted the effectiveness of general dietary recommendations.
Those GPs who did fully assess nutrition, or specifically asked about physical activity, were influenced by other factors. These included the capacity of the practice (eg a nurse who undertook assessments), or the expressed interest of the GP in these risk factors. Specific mention was also made of the usefulness of a computer-based template or patient education and assessment resources such as Lifescripts, which include paper-based templates for lifestyle assessment and individualised written prescriptions for behaviour change including goals and actions .
Motivating the patient (relates to research question 2)
GPs varied in their attempts to motivate their patients to change risk behaviour. This was discussed in the wider context of how much preventive care they were involved in generally, whether they felt effective as a motivator, and whether it was an expected role of GPs. Most had recently attended training in motivational interviewing, with some GPs believing their skills had increased. Others felt that motivational interviewing sounded good in theory, but the reality of practice demands made it difficult. Some expressed disappointment when they could not successfully motivate their patients, implying that this was part of their professional role. At the opposite end of the spectrum, others felt that once the patient had been educated regarding lifestyle risk factors, the responsibility then lay fully with the patient. The patient's intrinsic level of motivation was often discussed, rather than whether the GP could modify that level.
Motivating patients to stop smoking caused the most frustration. One GP stated he no longer attempted it, while others believed they just did not have the skills to succeed. Success was generally gauged by the patient quitting completely. Success was similarly judged for patients who engaged in heavy drinking, with abstinence as the goal. This was different from the other lifestyle factors where success was located on a continuum from incremental improvement to sustained achievement of dietary and/or exercise goals. General practitioners who recognized that success for weight reduction could include small weight losses voiced less frustration than those whose measure of success was the achievement of ideal weight goals. Some GPs also reported that a patient's education level influenced the motivation level of that patient.
Giving Advice and educating the patient (relates to research question 2)
Giving advice and educating the patient were viewed as a professional responsibility by all GPs, and reported as expected by the patients. How the advice was given varied considerably amongst the clinicians, from personalized negotiation with patients to didactic presentation. When GPs recognized cultural influences on dietary habits, they tried to incorporate those cultural aspects into their advice. Whether patients were given written information depended more on clinician preferences than patient choice. The majority of GPs felt printed material reinforced any message. Written information appeared more commonly used to support nutritional advice followed by physical activity. Written materials for alcohol and smoking cessation were reported as being used less often. Some GPs felt they lacked skills in the area of nutrition, and wished they had better knowledge. This may have influenced their choice in giving written information to their patients.
The amount of diet and physical activity advice was proportional to patient risk (such as having an identified weight problem).
Arranging follow-up appointments (relates to research question 2)
There was recognition that ongoing behavioural change usually required more support than a single visit, but had to be balanced with the reality of practice demands. The degree to which follow-up appointments were encouraged appeared to depend upon the GPs' orientation to preventive care in general. Different attitudes were also evident in practices that had an appointment system (compared with a 'drop-in' service) as follow-ups could more easily be arranged. Follow-up was also provided opportunistically when patients came in for other reasons. Smoking and alcohol were followed up more actively, while nutrition and physical activity were followed up only if the patient was already overweight or hypertensive.
The patient's level of motivation was often cited as an influencing factor. In addition, cost was a perceived barrier for patients to return to the surgery, with many GPs believing that patients were reluctant to pay for ongoing consultations regarding preventive care.
Referring to other personnel and agencies (relates to research question 2)
GPs exhibited a range of attitudes towards referring patients to other services and personnel, with some believing that health conditions should be managed predominantly by the GP. GPs appear to be more ready to refer for some SNAP risk factors than others, with smoking prompting the most enthusiasm for referral. This was consistent with the frustration many GPs experienced with smoking cessation.
Perceived patient resistance to out of pocket costs was often cited as a barrier to referral, with many GPs believing their patients would not take up referrals if they had to pay. The accessibility of services was also important. With the majority of 45–49 year olds being in employment, most found it difficult to access referrals in working hours, and many services were not available out of hours. Quitline (a free smoking referral telephone service) does not have these barriers and was by far the most common referral pathway.
Patient motivation was also mentioned as a barrier. Only one GP acknowledged that support services could actually help to motivate patients.
Referrals to dieticians for nutritional advice appeared to depend on the patient's level of risk. Some GPs felt the advice offered by a dietician would be no different to that offered by the GP, and thus referrals were of little value.
Many GPs voiced their lack of knowledge regarding the role of the exercise physiologist. One GP stated that she referred to physiotherapists because she had worked with them in hospitals, but had no idea what an exercise physiologist did. Without this knowledge, she was reluctant to refer as she could not vouch for their effectiveness. Referrals to gyms and exercise classes were considered by GPs, but concern was expressed about the cost to the patient.
Referral to self help groups such as Alcoholics Anonymous was rarely mentioned as few GPs felt their patients were drinking at levels which required this level of intervention.
Managing multiple SNAP factors (relates to research question 3)
When clinicians were presented with a hypothetical patient with multiple risk factors, and asked how they would proceed with intervention, there was a variety of responses reflecting a non-standardised approach. Some GPs mentioned that they would try and motivate patients to address alcohol problems first, especially if they were drinking at levels high enough to de-stabilize their lives in relation to work and relationships – in other words, if the level of risk was high. One GP mentioned that if the patient was educated, they would try and address all the SNAP factors in one go. Others focused on assisting the patient to deal with whichever risk factor the patient wished to tackle first as this had a greater chance of success.
This view that the intervention should be patient-led was the most common, with a consensus that potential greater success may be achieved by addressing whichever factor the patient was more ready to change first. If the patient was unsure how to proceed, and appeared motivated to address all factors, smoking was often considered first. Other GPs felt it might be more advantageous to start with diet and/or physical activity, as changes in these areas would result in the patient feeling better more quickly. One clinician mentioned that if all SNAP factors were present, a psychological assessment should be made first.
The method of addressing individual factors when multiple factors were present followed the same variety of responses as outlined previously, with behaviours reflecting a range of strategies.