Use of Behaviour Change Techniques

Eight of the studies provided enough detail to identify BCTs. Of the studies that provided enough information to identify BCTs, all of the interventions used at least one BCT. The mean number of BCT used in the interventions was 3.3 (range 1-5). Figure 5.2 below illustrates the frequency of BCTs used in the interventions.

174 Figure 5.2: Frequency of BCTs used in the interventions

The most frequently used BCTs were ‘behavioural practice’ (Corelli et al., 2005; Hudmon et al., 2004; Hudmon et al., 2005; Martin et al., 2003; Martin and Chewning, 2011; Plake, 2003), ‘instruction how to perform behaviour’ (Corelli et al, 2005; Hudmon et al., 2004; Hudmon et al., 2005; Patwardhan & Chewning, 2012), ‘feedback on behaviour’ (Corelli et al., 2005; Hudmon et al., 2004; Hudmon et al., 2005; Martin et al., 2003; Martin and Chewning, 2011; Plake, 2003) and adding objects to the environment (Corelli et al., 2005; Hudmon et al., 2004; Hudmon et al., 2005; Patwardhan &

Chewning, 2012). Other less frequently used BCTs were ‘goal setting’, ‘problem solving’, providing a ‘demonstration of the target behaviour’, providing a ‘material incentive’ (remunerating pharmacists for providing services) and ‘social support’ in the form of a follow up visit from a researcher post- intervention to assist pharmacists with any problems they had providing smoking cessation advice (Patwardhan & Chewning, 2012).

0 1 2 3 4 5 6

Behaviour change techniques

N u m b er o f in te rv en tio n s

175

5.5 Discussion

This systematic review of the literature identified ten studies published between 1996 and 2014 which evaluated the effect of interventions to prepare pharmacy students, pharmacists and pharmacy staff to facilitate lifestyle patient behaviour change. Despite extensive searches, as with other similar reviews of interventions aimed at nurses and doctors (Chisholm, Hart, Mann, Harkness and Peters 2012; Fillingham, Peters, Chisholm and Hart 2013) the number of studies relevant to this review was low.

A range of interventions to enable pharmacists to facilitate patient lifestyle change had been developed and evaluated; most studies used quantitative methods however qualitative and mixed methods were also utilised. There was considerable variation in the intervention content, delivery and duration. A variety of different methods were used to deliver the interventions, comprising of one or a combination of: didactic oral presentations; discussion of case studies; setting behavioural self-monitoring tasks; video presentations; and role-play with peers, standardised patients and patients. The primary outcome measures of the review were participants’ behaviour and patient outcome (as an indirect measure of participants’ behaviour). All eight of the interventions that measured pharmacist/pharmacy staff/pharmacy student behaviour found increased counselling ability (objectively or subjectively measured) or increased service delivery to patients post

intervention. The effect on patient outcome was inconclusive; one study found increased smoking cessation in patients whilst the other found no difference in patient smoking status between patients receiving smoking cessation services from pharmacists receiving the behaviour change intervention and pharmacists in the control group. In addition to behavioural outcome measures, three of the studies measured pharmacists’ confidence/self-efficacy in their counselling ability, all of which found a significant increase in confidence/self-efficacy as a result of the intervention. However, these findings should be interpreted with caution, as the evidence was not strong enough to be sure that the change was due to the intervention.

176 The findings from the qualitative evidence identified lack of time and insufficient remuneration as barriers to implementing the skills targeted in the interventions. These are commonly reported barriers to pharmacists engaging in public health activities (Anderson et al., 2003; Eades et al., 2011). Most of the studies reported that participants’ perceived a need for further training whilst two of the studies identified counselling in a commercial setting (with problems associated with lack of time and sufficient remuneration), and patients’ perceptions of their (lack of) need for counselling as barriers. Again this is congruent with previous findings within the literature (Anderson et al., 2003; Eades et al., 2011). Most of the studies reported that participants perceived the intervention they received positively.

The poor reporting of intervention content and lack of a reported theoretical basis for the development of the majority of the interventions makes it very challenging to draw conclusions about the effective components, or ‘active ingredients’ (Michie et al., 2013) of the interventions. As previously noted, all of the interventions bar one (Sinclair et al., 1998) resulted in increased

counselling ability, service provision or improved patient outcome. Unfortunately there was not sufficient information reported in the Sinclair et al. (1998) paper to identify BCTs, therefore a

comparison between the content of this intervention and the interventions that were effective is not possible. All of the interventions providing sufficient information about the intervention to identify BCTs (n=8) incorporated at least one behaviour change technique listed in the behaviour change taxonomy (Michie et al., 2013) however the number and combination of BCTs utilised in each study varied (mean number of BCTs used = 3.3, range: 1-5). The most commonly used BCTs were

‘behavioural rehearsal’ (n=5), ‘feedback on behaviour’ (n=4), ‘adding objects to the environment’ and ‘instruction how to perform behaviour’ (n=4).

Two of the studies used BCTs associated with reward (remunerating participants for providing services) according to the behaviour change taxonomy (Michie et al., 2013), but did not report them as a way of changing behaviour. This is important, particularly given that the results from the

177 a barrier to engaging in the behaviour, therefore rewarding participants for performing a target behaviour may change their behaviour and may make them more motivated to perform the behaviour. If ‘reward’ is not described as a BCT and therefore a component of the intervention, it may affect replication in future studies or how the intervention is implemented in practice that does not reward pharmacists for delivering the intervention. This is an important factor that was not considered in any of the studies.

The majority of the studies did not describe the use of theory to change the pharmacists, pharmacy students or pharmacy staffs’ behaviour in the development of the intervention. Many of the studies described using the ‘5 As’ approach which is based on the Transtheoretical Model (Prochaska & Diclemente, 1983) however they did not apply a theoretical approach to changing the provider behaviour. The types of intervention included in this review are changing provider behaviour in order to change patients’ health behaviours. This needs to be reflected in the development of the

intervention through the application of psychological theory and BCTs to change provider behaviour and a separate level of psychological theory and BCTs to inform the intervention delivered by the provider behaviour.

The quality of the studies included in the current review was generally poor, with the study designs introducing a high risk of bias. Reporting of the studies and description of the intervention content also tended to be poor. This may mean that there were other BCTs used in the interventions but they could not be identified due to insufficient information. The aforementioned factors meant that reliable conclusions about the effectiveness of the interventions could not be drawn. These findings fit with recent, related systematic reviews of health professional behaviour. Fillingham, Peters, Chisholm and Hart (2013) assessed the efficacy of educational interventions in undergraduate nurse training regarding obesity whilst Chisholm, Hart, Mann, Harkness and Peters (2012) assessed the efficacy of interventions to prepare medical students to facilitate lifestyle changes with obese patients. As with the current review, both Fillingham et al. (2012) and Chisholm et al. (2013) found only a small number of studies that met the inclusion criteria (n=8 and n= 12 respectively). Both

178 reviews also found that due to a failure to adopt procedures to control for bias, the studies were highly susceptible to bias and therefore the efficacy of the interventions could not be determined. Furthermore, both studies also found that the reporting of the interventions was poor, that many of the study conclusions did not support the results presented and that the majority of the

interventions were deemed atheoretical by the authors.

A lack of intervention transparency due to poor reporting is not uncommon, with a large evidence base showing that reporting of interventions in health research is inadequate (Hoffman et al., 2014). Consequently the factors that underpin behaviour change, termed the “active ingredients” of interventions cannot be reliably identified (Michie & Johnston, 2012). A recent analysis of all non- pharmacological interventions in RCTs reported in six leading medical journals in 2009 found that only 39% were deemed adequately described, increasing to 59% when study authors were contacted for further information (Hoffman, Erueti & Glasziou, 2013). Hoffman et al. (2014) recently published the ‘TIDieR’ guidelines, an extension of the commonly cited CONSORT guidelines which state that interventions should report enough detail for each group to allow replication, to improve the reporting and consequently the replicability of interventions. The guidelines state that studies should report: a precise intervention title; the rationale, theory and goals underpinning the intervention; a detailed description of all materials used; description of all details, processes or activities the intervention provider(s) carried out; the expertise, background and any specific training given to provider(s); how the intervention was delivered; the location where the intervention was delivered; when and how much of the intervention was delivered; if the intervention was tailored then what, why, when and how; if the intervention was modified (what, why, when and how); how intervention fidelity was assessed and the extent to which the intervention was delivered as planned (if assessed). Following such guidelines would allow the effectiveness of future interventions

designed to enable pharmacists to facilitate patient lifestyle behaviour change to be assessed.

Many of the problems associated with the studies originate from the use of study designs that do not incorporate a control group. Whilst the majority of the studies established baseline and post

179 intervention measures for participants, the absence of a control group means that the results of the study cannot reliably determine the effectiveness of the interventions. Some of the studies utilised a randomised control design, however poor reporting of complete outcome data, randomisation procedures and lack of blinding of participants and assessors to group allocation introduced a risk of bias. Future research is required to conduct rigorous studies of high methodological quality to reliably assess the effectiveness of interventions to enable pharmacists and pharmacy staff to facilitate patient lifestyle behaviour change and identify the components of effective interventions.