Behaviour Change: Enabling Allied Health Professionals to have Healthy Conversations

The main aim of the project was to equip community based AHPs with the necessary skills and resources to enable them to have Healthy Conversations as part of their role in day to day interactions with clients and colleagues. In order to do that we needed to better understand how ready they were to engage with having Healthy Conversations as part of the wider public health agenda.

A national survey reported by the Royal Society of Public Health on Healthy Conversations and the AHPs (2015) demonstrated that although there was an overall willingness for AHPs to engage in Healthy Conversations there were several challenges to do this in practice. We wanted to explore the readiness and potential barriers to having Healthy Conversations for AHPs in Newcastle and then develop approaches that would facilitate the AHPs having Healthy Conversations in practice.

The main objectives were:

• To determine AHPs readiness to engage in Healthy Conversations
• To determine the extent to which AHPs already undertake health promotion with their patients either through Healthy Conversations or signposting.
• To identify the barriers and facilitators to having a Healthy Conversation
• To address the barriers to having a Healthy Conversation
• To evaluate the impact
• To present the findings to the wider health community

The way we live has a significant impact on our health.  Across the population levels of obesity continue to rise with 66.8% of men and 57.8% of women now overweight or obese (PHE, 2017).  By 2030 we will be 35% less active than in 1961.  Alcohol related deaths have doubled over the last 20 years and those with poor mental health will die on average 15-20 years earlier than those without (PHE, 2014).

Newcastle upon Tyne is one of the 20% most deprived areas in England and the health of its population is, overall, worse than the average health of the population in England. 

Life expectancy for both men and women is lower than the average for England with life expectancy being 12.4 years lower for men and 9.5 years lower for women in the most deprived areas of Newcastle, compared to the least deprived. 

In Newcastle in 2016 there were 472 deaths related to smoking, 2085 alcohol-related and 680 self-harm hospital stays, figures which are worse than the average figures for England (PHE, 2016).

Published in October 2014, NHS England’s Five Year Forward View set out a collective vision for the future of the National Health Service (NHS), recommending improvements for ill-health prevention and for public health. It recognised the need for workforce transformation to achieve this and the challenge to enable practitioners to support behaviour change (NHS England, 2014).

Having ‘Healthy Conversations’ is an approach health care staff can use at every opportunity and through interaction with patients and visitors promote healthy lifestyles and signpost them to further services. This approach being consistent with the Making Every Contact Count (MECC) approach recommended in NICE guidance https://www.nice.org.uk/guidance/ph49.

The Royal Society for Public Health and Public Health England had undertaken a joint project with the support of each of the Allied Health Professional (AHP) bodies to better understand the extent to which AHPs engage in Healthy Conversations. They found that while there was a willingness to engage in Healthy Conversations there were several challenges to doing this in practice (RSPH, 2015).

With a significantly reduced life expectancy and poorer reported health of the population in Newcastle it was relevant to look at the readiness and capacity for AHPs in NUTH to engage with having Healthy Conversations.  

To determine AHP readiness to engage in Healthy Conversations a questionnaire was developed based on that used in Healthy Conversations and the Allied Health Professionals’ (RSPH, 2015). The data was checked and analysed to produce a report on AHP views on health promotion activity, their practice in carrying out health promoting activity and views on having a Healthy Conversation. A summary of the main findings of the report, including the main barriers to having a Healthy Conversation, is presented with the results.

A ‘snap shot survey’ was used to determine the extent to which AHPs already undertake health promotion activity. AHPs were asked to record how many times during one working day they had a Healthy Conversation. They were asked to note the subject of the conversation and the level of conversation they had based on NICE guidance (PH 49, recommendation 9) which describes the delivery of very brief, brief, extended brief and high intensity behaviour change interventions and programmes. Any signposting information used was also recorded, with the intention of identifying what information could be recommended for future use and any areas that were lacking.

From the results it was clear that the main barriers to having a conversation included a lack of knowledge and confidence to having a conversation and a lack of signposting information. In an attempt to address the barriers a programme of training was developed, with colleagues from clinical psychology, and delivered in six group sessions to a total of 121 members of staff. The training covered the following:

• MECC and Healthy Conversations
• Underlying theory – COM-B model
• The content of Healthy Conversations
• How to start a Healthy Conversation
• How to end a Healthy Conversation

An electronic library of further training and signposting resources was developed and made available to all AHPs. A list of the main signposting sites and referral contacts was produced in a laminated format for use in community clinics where web access might be limited. Credit card sized ‘information for you’ cards were made for use by patients to keep a note of any signposting detail relevant to them.

To evaluate the impact of the training and resources all community based AHPs were asked to re-complete the Healthy Conversation questionnaire and the ‘snap shot survey’ for analysis.

The initial Healthy Conversations questionnaire reported:

• 80% of respondents agreed that carrying out health promoting activity was an important part of their professional role
• 70% agreed that their role provided opportunity to have Healthy Conversations

Whilst there was an overall willingness to engage in Healthy Conversations, respondents identified several challenges to doing this in practice including lack of knowledge, pressures on time, lack of easily accessible information to support signposting and not being able to directly refer.

The initial survey showed respondents had an average of 5.5 Healthy Conversations in 1 working day. Analysis of the type of conversation by profession showed that AHPs were more likely to have a Healthy Conversation related to the nature of the referral.

Repeat of the Healthy Conversations questionnaire in 2018 identified a continued overall willingness to have Healthy Conversations and agreement that health promotion is part of professional duty.

• 95% (15% more) agree that they are aware of how to carry out health promoting activity
• 63% (16% more) agree they have sufficient management support
• 85% (35% more) are aware of MECC
• 30% (18% more) agree they would find it easy to weave subjects into healthy conversations
• 57% (9% more) would feel confident discussing areas of health that did not relate to the condition their client was receiving care for
• 60% (14% more) had a clear plan of how to incorporate Healthy Conversations into their practice
• Knowing where to signpost patients for more information increased across all subject areas by up to 26%
• Confidence in having a Healthy Conversation increased in all subject areas (stress by 41%, healthy eating by 16% and substance misuse by 25%)
• Prompts from clients and reflecting on practice were seen as the key components to facilitating further Healthy Conversation

Respondents reported a significant increase in confidence and knowledge and do plan to have healthy conversations. An increase in the average daily number of healthy conversations equates to an extra 120 healthy conversations taking place every day without additional resource.

The project informs how the skills of AHPs can be further developed to potentially impact on improving the health and wellbeing of individuals and populations (AHPs into Action impact 1, priority 1).

Taking time to identify the main challenges to making change will allow development of  more bespoke interventions. In this case the intervention being a programme of training and resources to support the AHPs who identified lack of knowledge and resources as being barriers to having a Healthy Conversation.

Recognised models of behaviour change, such as COM-B (capability, opportunity, motivation and behaviour), can be used at an organisational level to underpin change in practice. 

Whilst interventions like training can influence capability it should be recognised that behaviour is part of an interacting system. Behaviour change takes time, it is an ongoing process that requires continued reflection and support to embed the change into practice.

Small changes in practice have potential to have great affect. If each AHP involved in the project has one extra Healthy Conversation per day it could impact on up to 600 extra people per week. AHPs have the opportunity to influence change.

Plans for Spread:

Results of the project will be shared with AHPs in NUTH at the quarterly AHP forum.

On line training resources and signposting information have been made available to the therapy services directorate in NUTH.

There are plans to roll out the face to face training and share the signposting resources with the wider AHP community across Therapy Services in NUTH over the next year.

There is further work required to support the AHPs involved in embedding their skills into practice. Plans to support this are on the agenda for the next project team meeting in April.

Next steps for the project are to identify and measure any impact on the health and wellbeing of the population attending AHP appointments in NUTH. Success stories will be one example whilst plans for further projects to demonstrate impact need to be developed over the next 4-6 months.

The project has been shared with other professions across NUTH and it has informed the Trust's public health strategy.