The Behavior Change Wheel [
Low numbers of patients with type 2 diabetes are currently being referred to weight management [
This step was informed by work carried out locally in Glasgow by Rhonda Wilkie (MSc project, unpublished). Eleven patients who had not taken up the offer of a place in weight management were interviewed about their reasons for not doing so. A major theme was the initial discussion with a primary care health professional about weight and weight management (
“I avoid going to my GP [general practitioner] as the first thing I hear is [that] I should lose weight, which upsets me as my GP knows how much I’ve struggled...I have given up asking for help”
“Ahh, she [GP] told me that I would be expected to attend for 2 years, every 2 weeks and eh, I wouldn’t be allowed to drop out, I had to guarantee that I would stay on the program for 2 years...she did tell me it was a class of 16 or 17 people all discussing it.” (incorrect information)
“One bus, two trains and whatever transport I required from Queens park station to unit...if I had been referred nearer to home, (ie) Johnstone or Paisley, I certainly would have made the effort. Only I felt it ridiculous that a 71-year-old woman with health problems would be expected to travel to a different place to get to from her residence” (incorrect information)
“Em, I think they [GP] just described Orlistat or whatever the drug is called and gave me a letter away with me. He didn’t go into what the service was or what you could do...
“Lack of support from GP – I felt it was a way of dismissing my weight concerns, he delegated his responsibility by giving me a phone number...I have no support from my GP”
The target behavior selected was making “informed” referrals to weight management of patients with type 2 diabetes and high BMI (≥25 kg/m2) during annual diabetes review and supporting patients thereafter. It was felt that the impact of any behavior change is high, and there is a promising likelihood of being able to modify the behavior. There is also the additional benefit of spill-over to patients who have obesity but not type 2 diabetes and to other behavior change conversations such as smoking cessation. The ability to measure such a behavior change is high as the Glasgow and Clyde Weight Management Service uses electronic referrals meaning it is possible to see how many referrals are made, and “informed” can be inferred through uptake and attendance.
The target behavior, making “informed” referrals to weight management of patients with type 2 diabetes in primary care, needs to be performed by GPs and practice nurses, in the GP practice, during annual diabetes reviews, and during routine appointments if appropriate. The clinicians need to make more referrals to weight management, approach the subject sensitively and discuss it more often, encourage patients to take up referral and attend, and bring up the topic with patients more than once if required. They need to do this with every relevant patient (once a year per patient), working as a team between GP and nurse to decide who will do it.
This step was informed by qualitative interviews carried out as part of a health needs assessment by Public Health, NHS Greater Glasgow and Clyde, between October and December 2012. A total of 25 individuals were interviewed face to face and 2 by telephone. Participants included General Practice (Practice Nurses), Dietetics, Diabetes, Occupational Health, Cardiac Rehabilitation, Community Health (Health Improvement Team), Carers Service, Leisure Providers, and Rehabilitation.
The components of the Capability, Opportunity, Motivation, and Behavior (COM-B) model, identified behaviors, and the need for change.
| COM-B components | What needs to happen for the target behavior to occur? | Is there a need for change? | Supporting quote(s) |
| Physical capability | None |
No change needed |
N/Aa |
| Psychological capability | Know local pathways and what else needs to be done prior to referral (eg, medication checks) To inform the patient of what is going to happen to them, referrers should know components of effective weight management |
Yes, our qualitative research shows that referrers do not know local pathways or the components of effective weight management. N/A |
“I don’t feel I’ve got the skills...it is such a specialist field...to lose weight is a big change. Sometimes the only enjoyment these people have in their life is actually food and to try and turn that on its head and see how they can support themselves, I don’t feel...I have the skills to do that effectively.” “I think further training would be better, even going to weight management classes to see what’s involved so I could then tell the patient...it’s alright me sitting with a patient and saying ‘you’ve got to lose weight’...just more about healthy eating, more in depth and if I was referring someone more information so I could then tell the patient, the more information the better.” |
| Physical opportunity | Have access to relevant patient materials to supplement referral discussions Have access to referral forms for weight management Have time to discuss the topic and make referral |
Yes, currently such materials do not exist locally. No, referrals are done electronically via the standard referral system. Personal computers with this system are available in all consulting rooms in primary care and referrers will be used to using this system. Yes, make the discussion format as simple as possible to decrease the time required. Referral system is already quick and simple to use. |
N/A N/A “Often patients I deal with have so many issues at one point in time, they couldn’t possibly think about dealing with weight management. I think that maybe means that we end up forgetting about it.” |
| Social opportunity | Make it part of the routine diabetes consultation carried out by all the practice team and the wider diabetes network Triggers to prompt discussion about weight and referral |
Yes, would need to get everyone who sees patients with type 2 diabetes in the practice all discussing weight and making referrals. Ideally other practices (eg, within the quality improvement clusters) will also be doing this. No, there is already a prompt in the diabetes Chronic Disease Management Framework for behavior change, which includes recording discussions on weight management and referral to services. |
N/A N/A |
| Reflective motivation | To want to discuss weight management and refer patients, feel that it is an essential part of their job, having confidence that they can discuss weight, and that it would be good for their patients |
Yes, our qualitative research shows that there are issues with referrers’ motivation based on their beliefs towards weight management, their perceived role and belief in their abilities. |
“I have no idea, that’s the truth…I’m limited in what I know. I can sit and discuss diet but priority in my role, I don’t know.” |
| Automatic motivation | Develop a habit of doing it |
Yes, given referral rates are so low, it is clearly not yet a habit to discuss weight and refer patients during annual diabetes review. |
N/A |
| Behavioral diagnosis of the relevant COM-B components | Psychological capability and reflective motivation are deemed to be the most important, with some changes required in physical opportunity, social opportunity and automatic motivation. Getting to the point where GPs and nurses want to discuss weight management and know how to discuss it and how to refer patients is key to addressing the problem |
N/A |
N/A |
aN/A: not applicable.
The affordability, practicability, effectiveness/cost-effectiveness, acceptability, side-effects/safety, equity (APEASE) criteria were considered to select intervention functions. It was considered that education and training, and to a lesser degree environmental restructuring, would cover the range of behaviors identified in Step 4. Education was considered affordable, practical, and acceptable with a history of this intervention working in similar contexts. There are practical skills on the discussion of weight management that can be taught, and it is possible to develop patient materials that the referrers could have easily available.
Using APEASE criteria, policy categories were considered for each of the selected intervention functions. Communication/ marketing and service provision (education), guidelines and service provision (training), and guidelines and environmental/ social planning (environmental restructuring) all fulfilled APEASE criteria.
We identified five behavior change techniques matching the three intervention functions that were deemed necessary to improve the making of “informed” referrals to weight management of patients with type 2 diabetes in primary care: (1) information about health consequences, (2) prompts/cues, (3) demonstration of the behavior, (4) instruction on how to perform a behavior, and (5) adding objects to the environment.
Individual level and group face-to-face training and an individually accessed e-learning website were the only modes of delivery that met APEASE criteria. E-learning websites would allow the intervention to be delivered to many people and is a commonly used, acceptable mode of delivery in a health care setting. Face-to-face training allows for more in-depth skills training to be given.
The Small Talk Big Difference (STBD) intervention comprises:
a 1-hour Internet-based eLearning package covering the links between obesity, type 2 diabetes, and the benefits of weight management, the treatment of diabetes in patients with obesity, specific training in raising the issue of weight, local services and referral pathways, overview of weight management components/ evidence base, and the role of the referrer (
training on raising the issue, with focus on three key components:
Ask: seeking permission from the patient to discuss their weight
Assess: determine if the patient thinks it important they manage their weight and how confident they feel about achieving weight loss; if the patient does not think it important or is not confident, provide further support and information and aim to discuss again in future
Assist: make a referral to weight management and provide the patient with details of what will happen next and any requirements from the patient at this stage
Internet-based training, which includes reference to recently published studies, case studies, and an interactive conversation with multiple choice questions to select the appropriate responses; learning will be assessed using end of module multiple choice questions
a patient pamphlet covering the benefits of weight management in diabetes and what to expect during a weight management program
a discussion tool with helpful facts and charts that can be used to guide a discussion about weight in a patient with type 2 diabetes
a practice implementation checklist
optional 2.5-hour face-to-face training building on the Internet-based module by using experiential learning to teach motivational interviewing techniques
Welcome page from Small Talk Big Difference module showing the 4 available modules.
Screenshot from welcome video on Small Talk Big Difference eLearning platform.
Screenshot from module on benefits of weight management in Small Talk Big Difference eLearning platform.
Screenshot from interactive video on communication skills in Small Talk Big Difference eLearning platform.
Our aims are to (1) evaluate the effectiveness of an Internet-based training program and practice implementation toolkit with or without face-to-face training for primary care staff in terms of patient attendance at NHS-funded adult weight management services, and (2) gain clinician feedback about an Internet-based training program, practice implementation toolkit, and face-to-face training on raising the issue of weight management with patients with type 2 diabetes.
A randomized trial design will be used for this evaluation with GP practices randomly assigned to one of the two arms described. We will notify clinicians of the STBD package and evaluation through primary care management, training forums, and communications. If interested, the practices will be able to opt in to the STBD evaluation via email. Once a practice has expressed interest, they will then be randomized to one of the two arms and either receive immediate access to the Internet-based training and print materials or receive access 4 months later (with awareness that their referral rates will be monitored).
The inclusion criteria for participants requires that they be GP practices in NHS Greater Glasgow and Clyde that have a contract for local enhanced services for long-term conditions (ie, diabetes) and have a unique clinical database (ie, not shared with another practice). Practices classified as “17c” (those with a separate NHS contract for long-term conditions) and those practices with a database shared with another practice (8 practices in area) are excluded.
As this is an evaluation study of a voluntary training program offered to GP practices as part of the usual program of NHS Health Improvement training, individual consent will not be required. By logging in to the Internet-based training website, practices will be agreeing to participate in the evaluation of the effectiveness of the training. No practices, staff, or patients will be identified during the evaluation. This information is in the letter instructing practices how to log into the training website. Patient data will be used to evaluate the outcomes of the training program, but this will be at the level of the intervention (ie, by GP practice) using health record linkage. The patient data and practice ID will be anonymized and accessed via the NHS Greater Glasgow and Clyde IT Safe Haven, so no individual patient consent will be sought.
All practices will be informed about the available training via communications from clinical directors and other routine NHS communication sources, which will explain the purpose of STBD and provide contact details to use if they are interested in completing the training. Those practices that do opt in will be randomized to one of the two arms of the evaluation. Practices gaining immediate access to the Internet-based training will be emailed with instructions on how to access the site (Arm 1). They will also be sent a practice kit containing the print materials designed to support implementation of STBD within their practice. Those practices randomized to Arm 1 will be sent options for the supplementary face-to-face training sessions and instructions on how to book a place through NHS Greater Glasgow and Clyde Health Improvement. Practices that express an interest and are randomized to Arm 2 (ie, delayed access to the STBD training), will be notified by email that their instructions for access will be available in 4 months. They will be made aware that their referral data over the next 4 months will be analyzed as part of the evaluation. A reminder letter/email/ phone call will be sent/made to any practice that opts in and does not access or complete the Internet-based training module after 4 weeks.
It will be made clear within correspondence with practices that completion of the training is entirely voluntary and that data for referrals, weight management, and diabetes outcomes will be examined to evaluate the impact of the new Internet-based training, but neither individual practitioners nor practices will be identified in any output.
The schedule and timeline for the trial are outlined in
Trial schedule and timeline.
| Activity | Owner | Outcome | Estimated timeline |
| Ad placed within primary care communication channels and forums | University of Glasgow and NHSa Greater Glasgow and Clyde | Notify practice of training. Opt-in of practices to evaluation | Oct 2017 |
| Randomization | University of Glasgow | Randomized practices that opt in to Arm 1 or 2 using Castor Electronic Data Capture | Oct 2017-Apr 2018 |
| Practices notified of arm for evaluation | University of Glasgow | Practices informed if they are immediate or delayed access to training by email | Oct 2017-Apr 2018 |
| Arm 1: Practices sent patient materials, posters, and invited to complete Internet-based training with or without face-to-face training | NHS Greater Glasgow and Clyde Health Improvement | Practices randomized to Arm 1 or 2 invited to complete training | Oct 2017-May 2018 |
| Notification of completion of Internet-based training (Arm 1) | University of Glasgow | Website analytics notifies research team of Internet-based training completion by practice code | Oct 2017-Sept 2018 |
| Reminder notice/phone call | University of Glasgow | Practices not having completed the Internet-based training will be sent a reminder and also the practice will be phoned once | Nov 2017-May 2018 |
| Provision of face-to-face training (Arm 1) | NHS Greater Glasgow and Clyde Health Improvement | Notification of attendees provided to NHS team | A study-specific face-to-face training session available every 2 months Oct 2017-Jun 2018 |
| Access to referral data | NHS Safe Haven | Statistician has remote access to anonymized data via a virtual private network | Oct 2018 |
| Comparison of change in referral rate (Arms 1 vs 2) | Statistician | Report of results | Dec 2018 |
aNHS: National Health Service.
Practices will be randomized to immediate or delayed intervention using the Internet-based random allocation software (Castor Electronic Data Capture) using permuted random block sizes of 4.
The primary outcome is change in primary care referral rate to an adult NHS weight management service. Using data from the weight management database held by NHS Greater Glasgow and Clyde, the ratio of referrals over 3 months before and after the STBD intervention (allowing 1 month for completion) will be calculated. Secondary outcome measures include change in referral, including uptake ratio, local enhanced service template completion (weight management discussed); change in local enhanced service template completion; completion of lifestyle weight management phase (completion defined as 80% attendance); weight change (kg and %) in lifestyle weight management phase for those attending >1 session; and weight change (kg and %) at 1 year for all patients (data from annual diabetes review). Tertiary outcomes include diabetes medications at time of referral, that is percentage on weight gaining medications (sulphonylureas, thiazolidinediones, insulin), and percentage on weight neutral/reducing medications (GLP-1 agonists, metformin, DPP-IV inhibitors, SGLT2 inhibitors). Exploratory analyses (before and after) will be carried out to look at the effect of completion of training; change in referral rate analysis of those who completed Internet-based training only; when training done was completed by GP only, by practice nurse only or both; and change in referral rate in those where one practice member completed Internet-based plus face-to-face training.
A feasibility study was completed during which five practices (from a range of current referral rates to weight management services and deprivation areas in NHS Greater Glasgow and Clyde) were provided with access to the STBD e-learning program in June 2016. A GP and practice nurse from each attended a 2.5-hour face-to-face training session, and the practices were provided with the implementation toolkit. The referral rate to uptake was assessed for the 3 months prior to the STBD training (March-May 2016), 3 months post- STBD training (October-December 2016), and the same 3 months in 2015 (October-December 2015). We saw an increase in referrals of 50% compared to same period the year before (n=8 and 15 referrals respectively) and 88% compared to previous 3 months (n=10 and 15 referrals respectively) after the STBD intervention. Two practices did not make any referrals in the immediate time period analyzed prior to the intervention. As a result of this, together with the small number of feasibility practices, it was difficult to make a formal power calculation. The effect compared to same period 12 months before was 1.5 (SD 1.21); effect compared to 3 months previous was 1.88 (SD 0.38). A sample size of 80 per group would give 80% power to detect a difference of 0.5 in the change in referral rate based on a hypothetical SD of 1.12.
Comparisons between study arms will be by independent two-sample
The evaluation will end 15 months after the practices are invited to participate, to allow time for training, changes in practice, and patient attendance at services.
We have prepared a custom electronic case report form for the purposes of randomizing the practices to immediate or delayed access to STBD training at the point of opting in. The remaining data for use in this evaluation will be from routine health records (ie, weight management and diabetes care). Access to these data will be via the NHS Greater Glasgow and Clyde Safe Haven (already approved by the Local Privacy Advisory Committee). The data will be fully anonymized and accessed via a virtual private network. Access will be only for the duration of the analysis of the data for the evaluation.
The STBD training and patient materials packages were developed over 2 years. The contents of the materials were developed by the NHS clinical team including a consultant physician, a GP, a consultant psychologist, specialist dietitian, and a health improvement specialist. Review has been extensive with patient materials reviewed by 7 patient volunteers (with type 2 diabetes and co-existing obesity), the training materials were reviewed by 3 specialist dietitians and 3 health improvement specialists, and then by 8 GPs who are based outside of NHS Greater Glasgow and Clyde. All materials were extensively reviewed by medical and marketing staff from AstraZeneca and Merck Sharp & Dohme to ensure they complied with the Association of British Pharmaceutical Industry code of practice. Evaluation plans had oversight from the evaluation team within NHS Greater Glasgow and Clyde Public Health. After the pilot study was conducted, the e-learning was independently reviewed and approved for continuous professional development points from both the Royal College of Nursing and the Royal College of General Practitioners.
Favorable ethical opinion was received from London – Bromley Research Ethics Committee. Sponsorship and management approval were received from NHS Greater Glasgow and Clyde. NHS Greater Glasgow and Clyde and Glasgow University Insurance and Indemnity will apply.