Study 4.i: content analysis of core training competencies relating to lifestyle behaviour change skills for health-care professionals

This study aimed to assess the extent to which LBC skills are included in the postgraduate training curricula of dermatologists, dermatology specialist nurses (DSNs), GPs and general practitioners with a special interest (GPSIs) in dermatology.¹⁴⁷

Study 4.ii: in-depth qualitative interview study of health-care professionals to examine how they conceptualise and manage psoriasis, including gauging attitudes to providing lifestyle behaviour change support as part of patient care

This qualitative study aimed to assess the experiences of dermatologists, specialist nurses and GPs in managing psoriasis and, in particular, providing strategies and referral routes to support lifestyle change (e.g. weight reduction, increased physical activity, reduction in smoking or alcohol use) for patients and the barriers to conducting this work in practice.

Study 4.iii: observational study of the prevalence, nature and quality of lifestyle behaviour change information available to patients with psoriasis in clinic settings

This study aimed to investigate whether or not the setting of the patient waiting room currently promotes appropriate LBC information for psoriasis patients by providing up-to-date information linking lifestyle with disease (general and specific) and high-quality links to support LBC.

Study 4.iv: survey of dermatology specialist nurses to assess views on behaviour change skills training needs

This study aimed to assess the views of DSNs on training needs in relation to supporting behaviour change in people with psoriasis. The aim was to enable planning of the level and type of training required for dermatology specialist staff who are likely to have fewer opportunities to undertake skills support in the area of LBC.

It was intended that findings from all four studies would inform the development of effective new approaches (IMPACT programme workstream 5 interventions) to help front-line staff assess and manage psoriasis more holistically and overcome any barriers to supporting patients’ LBCs.

Methods

Results

In the 11 curriculum documents analysed, 67 instances of terms related to LBC and health promotion were found. Most were found in the GP curriculum (62.7%), followed by the specialist nurse curriculum (20.9%) and dermatologist curriculum (16.4%). There were no instances in the curriculum of GPSIs in dermatology. The majority of terms were related to awareness-raising alone, with no instances linked to the skills required for long-term behaviour change facilitation (Figure 10).

FIGURE 10

Core curricula mapped to the Prevention and Lifestyle Behaviour Change competence framework by professional group. Reproduced from Keyworth et al. © 2014 British Association of Dermatologists. Reproduced with permission of John Wiley & (more...)

Of the 67 occurrences found in the curricula, around one-third related to being aware of opportunities to introduce LBC; approximately one-fifth related to being able to identify and signpost to LBC support (however, behaviour change techniques known to enable these competencies were not included); half the instances were unable to be mapped to the Prevention and Lifestyle Behaviour Change competence framework¹⁴⁸ and none of the core curricula related to provision of long-term support and LBC facilitation. In summary, the core practitioner training documents showed few clearly specified learning outcomes or recommendations relating to LBC knowledge, skills and attitudes. There were few references to recognised LBC techniques (see Keyworth et al.¹⁴⁷ for supporting data).

Conclusion

Study 4.i highlighted the lack of systematic training for practitioners who may be managing patients with psoriasis to develop appropriate skills and knowledge. Post-qualification health-care professional curricula could be improved by including more explicit LBC skills training.

Data collection and analysis

Health-care professionals were first contacted in writing through their professional organisations or via public general practice lists with snowball sampling as a second step when recruitment proved challenging (i.e. health-care professionals did not readily respond to invitations via their organisations and responded better when known peers facilitated invitations personally). In this way, individual participants were able to identify other potential interviewees to approach. This study was approved by the University of Manchester’s REC (reference number: 12017).

A topic guide developed from the literature guided semistructured interviews with health-care professionals managing people with psoriasis. Participants were asked about their attitudes and knowledge in relation to supporting lifestyle changes for people with psoriasis as part of psoriasis management, as well as their experiences of practice and strategies used, with a focus on their:

• levels of knowledge (including on alcohol consumption, smoking/smoking cessation, obesity, low activity levels, CVD risk, low mood associated with psoriasis)
• attitudes to lifestyle change support or advice-giving (clinical and managerial priorities, actual and perceived staff roles)
• understanding of barriers to engaging in behavioural change support for patients (environmental, social/cultural norms, low mood)
• perceptions of barriers for practitioners (knowledge, ‘embeddedness’ of LBC, training/skills, preservation of therapeutic relationship, patient burden)
• attitudes to the use of patient information (leaflets, booklets, or known referral routes to services such as smoking cessation)
• actual behaviours used to address LBC.

In recognition of the potentially sensitive nature of the interview questions, all interviews were undertaken by experienced interviewers trained in asking questions to probe adequately and sensitively to get beyond socially desirable answers. Interviews were audio-recorded, transcribed and analysed using principles of framework analysis,¹²⁸ with a model of evidence-based factors known to influence behaviour change¹⁴⁹ and the Self-Regulatory/Common Sense Model (SRM/CSM) of illness representations¹⁵⁰ as frames to consider the data.

Results

In total, 23 in-depth interviews were conducted with clinicians (seven consultant dermatologists, six DSNs, five GPSIs in dermatology and five regular GPs in primary care).

Findings highlighted that, although most clinicians recognised the importance of LBC in psoriasis management, they did not see it as part of their professional role to support patients with behaviour change. Lack of time and prioritising other aspects of care such as diagnosis and medications management were cited as underlying reasons, in addition to a belief that addressing alcohol use, smoking or weight loss was a potential threat to harmonious relationships with patients. Clinicians were pessimistic about patients’ motivation to change as well as their own influence in helping patients make behavioural changes. Table 7 presents illustrative data extracts to support the analysis (see Nelson et al.¹¹³).

TABLE 7

Clinicians’ perspectives on supporting LBC in psoriasis

In addition, practitioners held a range of different ‘personal models’ of psoriasis. Most reported working with incoherent models in mind, for example holding a ‘sophisticated’ understanding of psoriasis as a complex condition while paradoxically managing the condition in a ‘linear’ skin-focused way. Practitioners who reported working to an incoherent personal model also reported frustration in relation to managing psoriasis and satisfaction only when patients’ skin improved. Table 8 presents illustrative data extracts to support the analysis (see Chisolm et al.¹⁵¹).

TABLE 8

Examples of health-care providers’ personal model types relating to psoriasis

For the most part, limited knowledge and skills in ‘whole-person’ management, including LBC skills, underpinned these beliefs and attitudes. Nonetheless, some clinicians identified a need for training to enable them to manage psoriasis as a complex, long-term condition involving comorbidities and to support patients with LBCs.

Conclusions

There are low levels of both knowledge and skills among professionals about managing psoriasis as a complex, long-term condition, including addressing LBCs. There is also a lack of structured support in both primary and secondary care for this work. Training to broaden professionals’ conceptualisations of psoriasis and incorporate evidence-based LBC skills in consultations could enable better patient assessment and management.

Data collection and analysis

Health centres were randomly selected from a full, publicly available list. In a non-participant observation study, exploratory observational methods were used to record the prevalence and quality of leaflets and posters signposting LBC (whether general or dermatology specific) in health centre waiting areas for patients with psoriasis in both primary and secondary care. A structured observation schedule was developed to guide data collection (see Chisholm et al.¹⁵¹). Ethics approval was obtained from the University of Manchester REC (reference number: 12017). Content analysis was used to identify frequency, characteristics and standard of materials. A series of quality indicators guided rating of the materials’ quality in terms of visual condition and visibility/accessibility to patients.

Results

From the 24 health centres observed, 262 sources of lifestyle information were identified. These were mainly categorised into generic posters/displays not specific to psoriasis (n = 113) and generic leaflets/flyers not specific to psoriasis (n = 98). Information was of poor quality, as well as being poorly displayed, and there was no evidence of high-quality psoriasis-specific information being made available to patients.

Conclusions

Study 4.iii found that little emphasis is given to the role of lifestyle as a health risk in patients with psoriasis. Evidence about the use of environmental cues to prompt behaviour change could inform the design and display of lifestyle information.

Methods

Results

Analysis of 77 participant responses indicated that DSNs generally expressed confidence in being able to address lifestyle change with patients with psoriasis. However, only 19% reported having knowledge of evidence-based techniques that could be used in consultations. On a scale from 1 to 7, with 7 being the highest level of confidence, the mean scores given by DSNs were between 4.3 and 4.0 for addressing smoking cessation, alcohol reduction, physical activity, diet and weight loss. There were differences in the degree to which respondents believed that different health-care professionals had a role to play in addressing LBC with patients with psoriasis: primary care-based practice nurses (100%); GPs (95%); DSNs (90%); dermatologists (73%) and GPSIs (70%).

Conclusions

Findings from this survey suggest that LBC skills training needs careful planning to tailor interventions in the most appropriate ways and deliver them in the most appropriate settings. Uptake of training may be low if health-care professionals fail to identify the relevance of acquiring such skills.