Communication practices for delivering health behaviour change conversations in primary care: A systematic review and thematic synthesis

Clinical guidelines exhort clinicians to encourage patients to improve their health behaviours. However, most offer little support on how to have these conversations in practice. Clinicians fear that health behaviour change talk will create interactional difficulties and discomfort for both clinician and patient. This review aims to identify how healthcare professionals can best communicate with patients about health behaviour change (HBC). Methods We included studies which used conversation analysis or discourse analysis to study recorded interactions between healthcare professionals and patients. We followed an aggregative thematic synthesis approach. This involved line-by-line coding of the results and discussion sections of included studies, and the inductive development and hierarchical grouping of descriptive themes. Top-level themes were organised to reflect their conversational positioning. Of the 17,562 studies identified through systematic searching, ten papers were included. Analysis resulted in 10 top-level descriptive themes grouped into three domains: initiating; carrying out; and closing health behaviour change talk. Of three methods of initiation, two facilitated further discussion, and one was associated with outright resistance. Of two methods of conducting behaviour change talk, one was associated with only minimal patient responses. One way of closing was identified, and patients did not seem to respond to this positively. Results demonstrated a series of specific conversational practices which clinicians use when talking about HBC, and how patients respond to these. Our results largely complemented clinical guidelines, providing further detail on how they can best be delivered in practice. However, one recommended practice - linking a patient’s health concerns and their health behaviours - was shown to receive variable responses and to often generate resistance displays. Conclusions Health behaviour change talk is smoothly initiated, conducted, and terminated by clinicians and this rarely causes interactional difficulty. However, initiating conversations by linking a person’s current health concern with their health behaviour can lead to resistance to advice, while other strategies such as capitalising on patient initiated discussions, or collaborating through question-answer sequences, may be well received

Determinants of GPI-PLC Localisation to the Flagellum and Access to GPI-Anchored Substrates in Trypanosomes

<div><p>In <i>Trypanosoma brucei</i>, glycosylphosphatidylinositol phospholipase C (GPI-PLC) is a virulence factor that releases variant surface glycoprotein (VSG) from dying cells. In live cells, GPI-PLC is localised to the plasma membrane where it is concentrated on the flagellar membrane, so activity or access must be tightly regulated as very little VSG is shed. Little is known about regulation except that acylation within a short internal motif containing three cysteines is necessary for GPI-PLC to access VSG in dying cells. Here, GPI-PLC mutants have been analysed both for subcellular localisation and for the ability to release VSG from dying cells. Two sequence determinants necessary for concentration on the flagellar membrane were identified. First, all three cysteines are required for full concentration on the flagellar membrane. Mutants with two cysteines localise predominantly to the plasma membrane but lose some of their flagellar concentration, while mutants with one cysteine are mainly localised to membranes between the nucleus and flagellar pocket. Second, a proline residue close to the C-terminus, and distant from the acylated cysteines, is necessary for concentration on the flagellar membrane. The localisation of GPI-PLC to the plasma but not flagellar membrane is necessary for access to the VSG in dying cells. Cellular structures necessary for concentration on the flagellar membrane were identified by depletion of components. Disruption of the flagellar pocket collar caused loss of concentration whereas detachment of the flagellum from the cell body after disruption of the flagellar attachment zone did not. Thus, targeting to the flagellar membrane requires: a titratable level of acylation, a motif including a proline, and a functional flagellar pocket. These results provide an insight into how the segregation of flagellar membrane proteins from those present in the flagellar pocket and cell body membranes is achieved.</p></div

Cysteine mutants mis-localise to the endosome and/or cytoplasm.

<p>(A) Cell lines modified to contain a single copy of the wild type (CCGAC) or cysteine mutant <i>GPI-PLC</i> all modified with a C-terminal eYFP tag were imaged using the native fluorescence of the eYFP tag after being immobilised. Each image is representative of the distribution observed in the majority of cells. Scale bar represents 2 µm. (B) Wild type (GPI-PLC +/+) and the same cell lines as (A) were hypotonically lysed for 5 minutes on ice and the lysate (I) separated into supernatant (S) and pellet (P) fractions and analysed for the distribution of GPI-PLC-eYFP by Western blotting. The detection of PFR is a control for the cytoskeleton present in the pellet and DHH1 for cytoplasmic proteins. The arrows indicate the presence of GPI-PLC-eYFP in the supernatant fraction. 2×10⁶ cell equivalents were loaded in each track and the blots were cut for presentation purposes.</p

Cysteine mutants are enzymically active but unable to access VSG on hypotonic lysis.

<p>Cell lines modified to contain a single copy of the wild type (CCGAC) or cysteine mutant <i>GPI-PLC</i> all modified with a C-terminal eYFP tag were assayed for hydrolysis of the VSG GPI-anchor. (A) Expression level of GPI-PLC-eYFP wild type and mutant transgenes detected by Western blots probed with anti-GPI-PLC or anti-DHH1 as a loading control. 2×10⁶ cell equivalents were loaded in each track. (B) Western blot lysates of cells expressing GPI-PLC wild type and mutants before and after 20 min incubation in 0.5% triton X-100. The GPI-PLC activity was detected by probing with anti-CRD and anti-BiP was used as a loading control. Two clones are shown for each transgene. (C) One clone expressing each transgene was lysed hypotonically and incubated for 20 minutes at 37°C. Pellet (P) and supernatant (S) fractions were separated at 0 and 20 minutes and analysed by Coomassie staining gels. The white arrows indicate the VSG released. 2×10⁶ cell equivalents were loaded in each track.</p

An intact FPC is necessary for the maintenance of GPI-PLC flagellar concentration.

<p>The ‘single marker’ bloodstream form RNAi cell line was modified to contain a <i>GPI-PLC-eYFP</i> transgene at the endogenous locus and then modified FPC component BILBO1 or the FAZ component FLA3. The images are representative of the native fluorescence from the eYFP in immobilised post-induction cells with one attached (old) and one detached (new) flagellum. The arrowheads indicate the new flagellum. Scale bar represents 2 µm.</p

Summary of subcellular localisation and GPI-anchor hydrolysis for wild type and mutant GPI-PLC (n.d - no data).

<p>Summary of subcellular localisation and GPI-anchor hydrolysis for wild type and mutant GPI-PLC (n.d - no data).</p

GPI-PLC is not sensitive to trypsin digest in live cells.

<p>A cell line modified to contain one copy of the wild type <i>GPI-PLC</i> gene and one copy modified with a C-terminal eYFP tag (GPI-PLC-eYFP/+) was treated with exogenous trypsin and samples were removed over a time course for analysis by SDS-PAGE and Western blotting. A parallel time course after 0.5% triton X-100 addition was used as a control for trypsin sensitivity. (A) Coomassie stained gel of a trypsin digest time course of <i>GPI-PLC</i>-eYFP/+ cells. Note the almost complete digestion of VSG by 3 minutes. (B) Western blots with relative quantitation below, setting the zero time point at 100. Quantitation used an Odyssey Infrared Imaging System and associated software. However, the expression levels of GPI-PLC-eYFP were too low for reliable detection using fluorescent secondary antibodies and were instead detected by chemiluminescence; this was not quantitated. ISG65 was mostly digested within 3 minutes. GPI-PLC-eYFP and GPI-PLC were stable over the time course but were digested within 3 minutes when detergent was included as were the flagellar proteins PFR1 and 2 and the cytoplasmic protein DHH1. 2×10⁶ cell equivalents were loaded in each track.</p

What happens when patients say “no” to offers of referral for weight loss? - Results and recommendations from a conversation analysis of primary care interactions

ObjectiveGuidelines recommend that clinicians should offer patients with obesity referrals to weight management services. However, clinicians and patients worry that such conversations will generate friction, and the risk of this is greatest when patients say no. We examined how doctors actually respond to patient refusals, and how patients reacted to clinicians in turn.MethodsConversation analysis of 226 GP-patient interactions recorded during a clinical trial of weight management referrals in UK primary care.ResultsSome clinicians responded to refusals by delivering further information or offering referral again. These actions treated patient refusals as unwelcome, and acted to pursue acceptance instead. However, pursuit did not lead to acceptance. Rather, pursuing acceptance lengthened consultations and led to frustration, offence, or anger. Clinicians who accepted refusals and closed the consultation avoided friction and negative emotional displays.ConclusionPatient refusals have the potential to create negative consequences in the consultation and clinician responses were key in avoiding these. When clinicians acknowledged the legitimacy of patient refusals, negative consequences were avoided, and the conversation was briefer and smoother.Practice ImplicationsWhen patients refuse the offer of a free weight management referral, GPs should accept this refusal, rather than trying to persuade patients to accept.</div

GP-delivered brief weight loss interventions: a cohort study of patient responses and subsequent actions, using conversation analysis in UK primary care

Background Guidelines encourage GPs to make brief opportunistic interventions to support weight loss. However, GPs fear that starting these discussions will lead to lengthy consultations. Recognising that patients are committed to take action could allow GPs to shorten brief interventions. Aim To examine which patient responses indicated commitment to action, and the time saved if these had been recognised and the consultation closed sooner. Design and setting A mixed-method cohort study of UK primary care patients participating in a trial of opportunistic weight management interventions. Method Conversation analysis was applied to 226 consultation audiorecordings to identify types of responses from patients that indicated that an offer of referral to weight management was well received. Odds ratios (OR) were calculated to examine associations between response types and likelihood of weight management programme attendance. Results Affirmative responses, for example ‘yes’, displayed no conversational evidence that the referral was well received and showed no association with attendance: ‘yes’ (OR 1.2, 95% confidence interval [CI] = 0.37 to 3.95, P = 0.97). However, ‘oh’-prefaced responses and marked positive responses, for example ‘lovely’, showed conversational evidence of enthusiasm and were associated with higher odds of commercial weight management service attendance. Recognising these could have saved doctors a mean of 31 seconds per consultation. Conclusion When doctors make brief opportunistic interventions that incorporate the offer of help, ‘oh’-prefaced or marked positive responses indicate enthusiastic acceptance of the offer and a higher likelihood of take-up. Recognising these responses and moving swiftly to facilitate patient action would shorten the brief intervention in many cases

Talking delicately: Providing opportunistic weight loss advice to people living with obesity

Obesity is a major worldwide public health problem. Clinicians are asked to communicate public health messages, including encouraging and supporting weight loss, during consultations with patients living with obesity. However, research shows that talking about weight with patients rarely happens and both parties find it difficult to initiate. Current guidelines on how to have such conversations do not include evidence-based examples of what to say, when to say it and how to avoid causing offence (a key concern for clinicians). To address this gap, we examined 237 audio recorded consultations between clinicians and patients living with obesity in the UK in which weight was discussed opportunistically. Conversation analysis revealed that framing advice as depersonalised generic information was one strategy clinicians used when initiating discussions. This contrasted to clinicians who made advice clearly relevant and personalised to the patient by first appraising their weight. However not all personalised forms of advice worked equally well. Clinicians who spoke delicately when personalising the discussion avoided the types of patient resistance that we found when clinicians were less delicate. More delicate approaches included forecasting upcoming discussion of weight along with delicacy markers in talk (e.g. strategic use of hesitation). Our findings suggest that clinicians should not avoid talking about a patient's weight, but should speak delicately to help maintain good relationships with patients. The findings also demonstrate the need to examine communication practices to develop better and specific guidance for clinicians. Data are in British English.</p