The findings of this qualitative study are congruent with the findings of the quantitative evaluation, and demonstrated that in the short term, a once off training intervention can change PCP’s perception of the importance of delivering BBCC in the South African primary care context . Training helped PCPs to recognize the worth of their possible contribution, and provided them with the necessary skills to perform BBCC, which increased their confidence in performing BBCC in actual practice.
It echoes other studies that have found that trained PCPs are less sceptical and feel more confident in their ability to deliver BBCC in clinical practice [18, 19]. BBCC training can change the approach of PCPs to delivering BBCC by changing their underlying values and beliefs.
However, although training enhances PCP’s perceived efficiency and capacity to provide this counselling, implementing it into every day practice in the long term remains challenging . In this study, 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. Within this environment some found it challenging not to default back to the directive approach of counselling. It is clear that to incorporate BBCC into everyday care, a whole systems approach is needed, that involves the patient, provider, and service organisation at different levels [20, 21].
PCPs in the Cape Town public sector have been characterised by personal values of caring, respect, compassion and listening, all of which are well aligned with the approach to BBCC . In other words BBCC could enable these personal values to find expression in the context of the consultation. The training programme therefore enabled PCPs to develop skills and professional behaviour that were well aligned with these values. However, although training can enhance this personal alignment, this is not sufficient to embed BBCC in every day practice. Another aspect of personal alignment is in helping staff to change their own unhealthy behaviours, and be good examples of a healthy lifestyle as this has been found to enhance performance in BBCC .
It is clear from the findings that there is a significant malalignment of personal and organisational values. Although the organisation espouses values of caring, competence, accountability, integrity, responsiveness and respect; the organisational culture is actually experienced as one of not sharing information, control, manipulation, blame, and power . This organisational culture is not congruent with the patient-centred guiding style of BBCC and may provide an unsupportive and undermining environment . Changing such organisational culture will require leadership transformation and a concerted effort to make the espoused values and culture a lived reality. Improving relationships trust and communication amongst the staff and management may be an important issue to support BBCC. It may be necessary to provide managers with the evidence for BBCC and to engage with them in a discussion about it [20–23].
In addition to creating a more supportive and committed organisational culture for BBCC it is necessary to ensure that the organisational practices and processes are also congruent with a patient-centred approach. For example it may be necessary to provide educational resources, to recognise and reward the provision of BBCC, and to commit to training all relevant staff in behaviour change counselling skills. Although there are many competing organizational demands in the daily operation of primary care centres, ongoing support for PCPs to offer BBCC should be prioritised . Ultimately piloting BBCC in different clinics may be a step towards widespread implementation [18, 24, 25].
Nurses play a vital role in service delivery in primary care facilities and local and international findings demonstrate that nurses can be effective in providing BBCC . However, a local culture of surveillance in primary care is dictated by bureaucracies in an attempt to ensure accountability [21, 26]. Task orientation is entrenched in nursing practice because it enables nurse managers to measure and to some extent control nurse’s performance and because it enables distance between the nurse and the patient. This system of discipline and scrutiny in which nurses are regulated, may be internalised and lead to a similar approach to patients, which inhibits the caring holistic approach that is integral to BBCC . To create this caring culture in healthcare institutions, we may need a shift away from fragmentation of nurses work into tasks. Clinical governance, which focuses on measuring and improving the quality of care, should find ways of not just quantifying counselling in a tick-box approach, but of valuing and assessing the nature and quality of counselling.
Evidence has shown that although integration of a system of chronic care in primary care facilities with limited financial resources is feasible, weak national systems often make it difficult to implement and sustain these interventions [27, 28]. Although BBCC integrated into everyday routine primary care has been prioritized by the NDOH, this study demonstrates the gap between national aspirations and the realities of incorporating BBCC into everyday service delivery . Patient centred care should be the central ambition of chronic care development strategies and policies that work towards outcomes that matter to patients, and not just to programmes or disease-orientated guidelines.
The findings of this study suggests that training should be incorporated early on, preferably into undergraduate curricula of PCPs for both nurses and doctors, to ensure that behaviour change counselling skills are embedded from the start. Existing PCPs could be offered training as part of continued professional development programmes. Internationally, the importance of incorporating BBCC training into curricula for PCPs, has been recognised as a future step in the struggle against NCDs [29–31].
This study forms part of a bigger project, the ichange4health programme, which has helped to further develop the materials and train trainers from Departments of Family Medicine and Primary Care throughout South Africa . These trainers are now able to train medical students, general practitioners and other family physicians in their respective areas.
Training PCPs in behaviour change counselling skills can have broader application beyond the risky lifestyle behaviours associated with NCDs. For example consultations involving risky sexual behaviours, intimate partner violence and problems with adherence to chronic medication could benefit from such a skills set. Future research should look at developing a comprehensive approach to patient education and counselling that includes BBCC as one component.
One of the limitations of this study was the limited follow up period in clinical practice. If interviewees were interviewed at a later time, it could have led to different responses. Implementing and improving a new skill over time is unlikely in a culture where limited support and feedback on performance is available and therefore one might anticipate a gradual loss of motivation and positivity. Future research is intended to evaluate the effect of providing on going on-line support after training and evaluating retention of the approach to BBCC over a longer time period. As the he researcher had been primarily involved in training and interviewing the PCPs, there could have been obsequiousness bias in the responses given. Previous research conducted by the researcher on general practitioners’ poor management of overweight and/or obese patients, could have had a negative influence on her perception of the PCP’s efficacy in counselling . However, the fact that the interview process, analysis and interpretation were, supervised by the other co-authors would have mitigated this influence.