Authors: Justin Webb, Physical Activity Engagement Manager, Macmillan Cancer Support; Jo Foster, Physical Activity Programme Lead, Macmillan Cancer Support; Edward Poulter, retired, member of expert advisor panel, Macmillan Cancer Support

Being physically active has been shown to have multiple benefits for people living with cancer.[1] Despite this only 23% are active to the chief medical officer guidelines[2] and 31% are completely inactive.[3] Although the evidence is strong to support the benefits of physical activity for cancer patients, awareness amongst healthcare professionals is not universal and some actively discourage physical activity thinking rest is best.[4,5]

Nurses are uniquely situated to offer physical activity advice to cancer patients. It is suggested that patients prefer lifestyle interventions to be delivered by a nurse rather than a doctor.[6]

NICE recommends that health, wellbeing and social care staff should be encouraged to use a very brief intervention to motivate people to make a change.[7]

This case study outlines the development of an intervention to improve the frequency of delivery of very brief advice on physical activity by nurses to cancer patients using the Behaviour Change Wheel (BCW) to guide intervention development.[8]

Introduction

©Macmillan Cancer Support, Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). MAC15362 Printed using sustainable material. Please recycle.

To improve delivery of physical activity very brief advice by cancer care nurses – a case study on the use of the Behaviour Change Wheel.

References1. Macmillan Cancer Support. The importance of physical activity for people living with and beyond cancer – a concise evidence review. London: Macmillan Cancer Support; 2011. 2. Department of Health. Start active, stay active. London: Stationery Office; 2011. 3. Department of Health. Improving Outcomes: A strategy for cancer. Second annual report. London: Stationery Office; 2012. 4. Macmillan Cancer Support. Online survey of 400 health professionals who deal with cancer patients. Unpublished; 2011. 5. Stone P, Ream E, Richardson A, Thomas H, Andrews P, Campbell P, Dawson T, Edwards J, Goldie T, Hammick M, Kearney N, Lean M, Rapley D, Smith AG, Teague C, Young A (2003) Cancer-related fatigue – a difference of opinion? Results of a multicentre survey of healthcare professionals, patients and caregivers. Eur J Cancer Care (Engl). 2003;12:20-27. 6. Laws RA, Kirby SE, Powell Davies GP, Williams AM, Jayasinghe UW, Amoroso CL, Harris MF. Should I and can I?: A mixed methods study of clinicians beliefs and attitudes in the management of lifestyle risk factors in primary health care. BMC Health Services Research. 2008; 8:1-10. 7. National Institute of Health and Care Excellence. Behaviour change: individual approaches. PH49. London: National Institute of Health and Care Excellence; 2014. 8. Michie S, Atkins L, West R. The Behaviour Change Wheel. A guide to designing interventions. London: Silverback publishing; 2014. 9. Michie S, van Stralen M, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. [online] 2011; 6:42. Available from: http://www.implementationscience.com/content/6/1/42 [Accessed 12th June 2014] 10. Bourne C, Batehup L, Lynall A. Towards an understanding of what challenges cancer health professionals face in raising lifestyle issues with patients, and pointers for the development of an intervention framework to support practice change. Unpublished; 2013. 11. National Institute of Health and Care Excellence. Physical activity: brief advice for adults in primary care. PH44. London: National Institute of Health and Care Excellence; 2013. 12. Leeman J, Baernholdt M, Sandelowski M. Developing a theory-based taxonomy of methods for implementing change in practice. J Adv Nurs. [online] 2007; 58(2):191-200. Available from: DOI: 10.1111/j.1365-2648.2006.04207.x [Accessed 13th June 2014] 13. Wang S K, Hsu H. Use of the Webinar Tool (Elluminate) to Support Training: The Effects of Webinar-Learning Implementation from Student-Trainers’ Perspective. Journal of Interactive Online Learning. [online] 2007; 7(3):175-194. Available from: http://www.ncolr.org/jiol/issues/pdf/7.3.2.pdf [Accessed 12th August 2014] 14. Albright CL, Cohen S, Gibbons L, Miller S, Marcus B, Sallis J et al. Incorporating Physical activity advice into primary care physician-delivered advice within the activity counseling trial. American Journal of Preventive Medicine. [online] 2000; 18(3); 225-234. Available from: http://www.sciencedirect.com/science/article/pii/S0749379799001555 [Accessed 14th August 2014]. 15. Carroll JK, Antognoli E, Flocke SA. Evaluation of physical activity counselling in primary care using direct observation of the 5As. Annuals of Family Medicine. [online] 2011; 9(5): 416 – 422. Available from: http://www.annfammed.org/content/9/5/416.full [Accessed 14th August 2014] 16. Meriwether RA,Lee JA. Physical activity counselling. American family Physician. [online] 2008; 77(8): 1129-1136. Available from: http://www.aafp.org/afp/2008/0415/p1129.html [Accessed 14th August 2014]. 17. National centre for smoking cessation and training. Very brief advice on smoking. [online] Available from: http://elearning.ncsct.co.uk/vba-launch [Accessed 25th September 2014].

Step 1: Defining the problem

31% of people living with cancer are inactive. Only 23% are active to recommended levels.

Awareness of the benefits of physical activity amongst healthcare professionals is not universal.

Delivery of advice on physical activity could be improved.

Step 2: Select target behaviour

This intervention seeks to change the frequency of delivery of very brief advice on physical activity to cancer patients by nurses. This is an interdependent behaviour to the behaviour of improving the physical activity levels of cancer patients.

Step 3: Specify behaviour

Who? Nurses.

What? Delivery of very brief advice signposting for further advice and support.

When, where, how often and with whom? During all cancer patient appointments.

Step 4: What needs to change?

A behavioural diagnosis was made by synthesising the work of Bourne et al,[10] NICE evidence statements[11] and field work conducted by Macmillan.[4]

Capability – psychologicalKnowledge of what to say, the skills on how to say it and the memory and attention to remember to deliver very brief advice.

Opportunity – physicalThe resources to signpost more support. Time is a limited resource so a very brief intervention is required.

Opportunity – socialSupport within the workplace.

Motivation – reflectiveThe belief and understanding that this is part of their role and the right thing to do.

The confidence to deliver the advice.

Steps 5 to 8

The intervention functions of education; persuasion; training; environmental restructuring; modelling and enablement were selected.

The policy categories of communications/marketing; and service provision incorporating guidelines were selected.

10 behaviour change techniques from the behaviour change technique taxonomy version 1 (BCTTv1) met the APEASE criteria and were selected.

Communications/marketingA digital mass media campaign can drive awareness to the training intervention once the feasibility of the intervention is confirmed. The evidence suggests that such campaigns are good at raising awareness of interventions.[12]

Service provision incorporating guidelinesBoth face-to-face and online training met the APEASE criteria. These modes of delivery are likely to be familiar to nurses.

Interpersonal communication is effective during the adoption of interventions.[12] Therefore the online training will be delivered using online seminar technology allowing for real-time interpersonal communications in an online learning environment. This method has been shown to be effective.[13]

Easy to remember frameworks improve memory of interventions. Assess, advise and refer has been developed as a framework to deliver physical activity advice.[14] Similar versions exist such as the 5A’s of access, advise, agree, assist and arrange.[15,16] These have been developed outside of the UK.

The National Centre for Smoking Cessation and Training (registered in England and Wales) has adopted ask, advise and act to deliver very brief advice on smoking cessation. As of 1st August 2014, 111,763 have completed their online training.[17]

This ask, advise and act framework has been adopted for delivery of very brief advice on physical activity to cancer patients as it is appropriate and it may be familiar to nurses already.

Results

Final intervention content Intervention function BCTTv1 code

Est delivery time – 45 minutes

Introduction – aims of the training Education 9.1

Participant expectations

Incidence and prevalence of cancer within the UK Education 9.1Evidence for physical activity and cancer Education 9.1, 5.1, 5.6

Video: Professor of oncology Education, Persuasion, 9.1, 5.1, 5.6, talking about the importance Modelling 4.1, 5.2 of physical activity

CMO guidelines for physical activity Education 9.1, 5.1

Guidance on the levels of physical Education 9.1, 5.1, 5.6 activity for cancer patientsSafety considerations Education, Training 9.1, 5.1

Video: Patient story – how physical Persuasion 9.1, 5.6, 5.2 activity has helped

Observed levels of physical activity Education 9.1 amongst cancer patients

Research on the impact of Education 9.1, 5.1, 5.6 sedentary behaviour

Details of the teachable moment Education, Persuasion 9.1, 5.2 that may exist following a cancer diagnosis

Research on the positive effect Education, Persuasion 9.1, 5.2 of unsolicited advice on physical activity in patients with severe medical problems

Introduce and present the ask, Training 9.1, 4.1, 7.1 advise and act framework and how to use it

Audio clip: The behaviour in action Training, Modelling 9.1, 6.1

Resources available to support Education, Training 9.1, 4.1, 6.1,behaviour change in cancer patients

Working through relevant sections Enablement 12.5

Details of other relevant resources Restructuring the and how to access or order them environment

Participants given/sent an ask, Enablement, 12.5, 7.1 advise and act coaster and Restructuring example script postcard the environment

Participants to pledge what they Enablement 1.1, 1.9 will do differently using the term “I will....” focusing on a behavioural outcome

Returned by email or post eight weeks post intervention

Summary and close Education, EnablementOpportunity for questions

Short quiz to test knowledge Immediate feedback given Education 5.1, 5.6, 4.1

Method

Conclusion

Training on the delivery of very brief advice for physical activity currently does not exist for healthcare professionals within the UK.

The behaviour change wheel has enabled a systematic and theory-driven approach to the development of an intervention designed to enhance delivery of very brief advice on physical activity by nurses interacting with cancer patients.

NICE call for research in this area.[11] A mixed methods feasibility study is suggested to examine the acceptability, practicability, implementation and efficacy (limited) of this training intervention before a larger-scale pilot randomised control trial.

Further informationContact Justin Webb at jwebb@macmillan.org.uk

Stage 1: Understand the behaviour

1. Define the problem in behavioural terms

2. Select target behaviour

3. Specify the target behaviour

4. Identify what needs to change

Stage 2: Identify intervention options

Identify:

5. Intervention functions

6. Policy categories

Stage 3: Identify content and implementation options

Identify:

7. Behaviour change techniques

8. Mode of delivery

[9: p7]

The APEASE criteria of affordability, practicability, effectiveness and cost effectiveness, acceptability, side effects and safety, equity[8: p23]

were used to evaluate all steps in stages 2 and 3.

Adapted from Michie, Atkins and West, 2014. [8: p25]

References for the literature cited within the intervention content are available on request.