By Stephen Sutton, University of Cambridge, England
Large-scale problems require large-scale solutions. Tackling the ‘Big 4’ behaviours (physical inactivity, tobacco use, excessive consumption of food and alcohol) requires scalable interventions that can reach large numbers of people to achieve a significant public health impact. One promising approach is to use brief interventions delivered by practitioners in healthcare settings. For example, in the UK, the National Institute for Health and Care Excellence recommends that primary care practitioners deliver tailored, ‘brief’ physical activity advice to inactive adults, and follow this up at subsequent appointments.
There is evidence for the effectiveness of brief interventions. However, a problem with interpreting this literature is that there are different definitions of ‘brief advice’ or ‘brief interventions’. For example, one review defined brief advice as “Less than 30 minutes in duration, or delivered in one session (allowing for research follow-up only as additional contact)”. Many such ‘brief’ interventions are too long to be included in routine primary care consultations. In our work, we have therefore focused on developing and evaluating ‘very brief’ interventions, defined as a single session lasting no more than five minutes, to address physical inactivity. These very brief interventions could be used in different healthcare settings, but we developed ours for the National Health Service (NHS) Health Check Programme in England. This invites adults aged 40 to 74 years who are not on a disease register to have a vascular health check every five years. Most of these checks take place in primary care and are carried out by practice nurses and healthcare assistants. They are an ideal opportunity to deliver a very brief behaviour change intervention to potentially millions of people.
To develop the interventions we used an iterative approach that combined evidence and expertise from multiple sources, including systematic reviews, a stakeholder consultation, a qualitative study, estimation of resource cost and team discussions. We specified the content of the very brief interventions in terms of behaviour change techniques. For example, our pedometer-based very brief intervention incorporated nine different behaviour change techniques, including Goal setting (behaviour), Action planning and Self-monitoring of behaviour. These were implemented by giving the participant a pedometer and Step Chart along with verbal instructions such as “Each week you can set yourself a step goal, for example 6,000 steps a day, and then each day you can write down how many steps you walked and see if you achieved your goal”. We also developed a three-hour training session and manual for practitioners.
Such technique-based very brief interventions should be distinguished from simple ‘advice giving’. Advice usually involves exhortations to change and information about the harms of physical inactivity or the benefits of being more active. While important, it may also be helpful to include techniques such as goal setting and self-monitoring that are designed to help people to change their behaviour.
We showed that it is feasible to include very brief interventions in Health Checks and that they are acceptable to practitioners and patients. Our initial findings on efficacy were quite promising. Based on objectively-measured physical activity using an accelerometer, the pedometer-based very brief intervention had an estimated 73% probability of being effective (i.e. of increasing physical activity relative to a no-intervention control condition). However, when we tested this very brief intervention in a larger trial (N = 1,007), it had only a small, non-significant, positive effect on objectively-measured physical activity at three months. Nevertheless, the economic evaluation suggested that there is a 60% probability that the intervention is cost-effective in the long term compared with an NHS Health Check alone. Thus, delivering the very brief intervention may be better than doing nothing.
It may be possible to increase the effectiveness of very brief interventions by incorporating additional intervention components. The challenge is to do this without greatly increasing their cost. One approach is to combine a very brief face-to-face intervention delivered by a healthcare practitioner with a ‘digital’ intervention that provides the patient with ongoing support for behaviour change. The combination of face-to-face and digital components may be more effective than either alone. We have used a version of this intervention model in our work on improving quit rates among smokers in primary care, in which the digital component consists of a 90-day programme of tailored text messages sent to the smoker’s mobile phone.
- There is evidence for the effectiveness of brief interventions to change behaviours such as smoking and physical activity. But many of these interventions are too long to include in routine consultations with patients.
- Consider instead using very brief interventions, defined as taking no longer than five minutes. The evidence for their effectiveness is weaker than for brief interventions. But delivering a very brief intervention is probably better than not intervening at all.
- Rather than just ‘giving advice’, think of very brief interventions as including one or more behaviour change techniques. For example, it may be helpful to ask the patient to monitor their behaviour or to make a specific action plan by writing down when, where and how they will increase their physical activity or avoid tempting snacks.
- ‘Signposting’ patients to useful resources (e.g. a smartphone app or a local walking group) is quick to do and may enhance the impact of the intervention. Arranging a follow-up appointment may also be helpful.
- Make every contact count. Every time you see a patient, you have a potential opportunity to say something about behaviour change. The additive effect of many practitioners using very brief interventions with many patients may have a significant public health impact.