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National Institute for Health and Clinical Excellence

Preventing type 2 diabetes: risk identification and interventions for individuals at high risk

Consultation on the Draft Guidance from 9th Nov 2011 – 9th Jan 2012

Comments to be received no later than 5pm on 9 th January 2012

Stakeholder Comments

Please use this form for submitting your comments to: [email protected]

1. Please put each new comment in a new row.2. Please insert the section number in the 1st column. If your comment relates to the draft

guidance as a whole, please put ‘general’ in this column

Name: Prof. Ronan O’Carroll as Chair ofOrganisation: UK Society for Behavioural Medicine (UKSBM)

Section number

Indicate section number or ‘general’ if your comment relates to the whole document.

Pg Comments

Please insert each new comment in a new row.

General The UK Society of Behavioural Medicine (UKSBM, http://uksbm.org.uk/) welcomes the opportunity to comment on the preventing diabetes draft guidance.UKSBM defines behavioural medicine as an interdisciplinary field that aims to increase the integration of behavioural and bio-medical knowledge to prevent, treat and manage disease. Human behaviour is a major determinant of health. Factors that influence health related behaviours and peoples’ adaptive responses to disease and illness are becoming better understood. This understanding is leading to behaviourally based interventions targeted at the level of the individual and at service delivery, with impacts on both. UKSBM has been set up to promote research into and the use of well-founded behavioural interventions. (Marteau, et al., 2006). Our focus is to increase awareness, at a science policy level, of the need to build strength and capacity in this area in order to meet the health needs of the population.

General UKSBM were surprised not to be invited directly by NICE to respond to this draft, and only became aware of the consultation at a late stage, hence this brief response. We request that UKSBM be added to your circulation list for consultations where behaviour and behaviour change are key.

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Please return the comments form to: [email protected] by 5pm on 9th

January 2012

NB: The Institute reserves the absolute right to edit, summarise or remove comments received on during consultation on draft guidance where, in the reasonable opinion of the Institute, they may conflict with the law, are voluminous or are otherwise considered inappropriate.

mailto:[email protected]


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General UKSBM would be happy to suggest experts in behavioural science and behavioural medicine for future NICE guideline development groups where behaviour change forms a central component.

General We very much welcome fact that a behavioural scientist (and member of UKSBM) was involved in the guidance development process.

General We very much welcome the focus on prevention and the use of evidence-based strategies to change behaviour and thus reduce the risk of type 2 diabetes.

General UKSBM also welcomes the fact that the draft emphasizes the need for evidence-based rigorous training and relatively intensive programmes to achieve the levels of lifestyle change required.

General Large sections of the guidelines are written in a style which is seemingly underpinned by a paternalistic, deficit model of care where patients are seen as passive agents of their own care. This is in contrast to current health care policy (Wanless, 2004; Department of Health, 2004; Department of Health, 2010), self-management programmes (Expert Patient Programme, 2011), and scientific evidence (Greenfield, et al., 1988; Wanyonyi, et al., 2011).

General Providing information, while simple, is necessary but not Please add extra rows as needed


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sufficient to achieve lasting behaviour change (Bonetti, et al 2009; Van Achterberg, et al 2011). It is likely that people will have a baseline of knowledge, and thus knowledge provision and advice will be most relevant only for those who do not already possess it. Furthermore, knowledge is itself a poor predictor of what people actually do (Michie, et al., 2003), and in general people recall very little of the knowledge that is provided. There is an over-reliance in the current guidance on the provision of information (i.e., ‘explaining’, ‘advising’, and ‘telling people’). We recommend that techniques for behaviour change should be presented in a more appropriate language acknowledging the active role of patients. Furthermore, we recommend supplementing information provision with more evidence-based behaviour change techniques, an example of which is described below.

Health professionals’ limited time with patients would be best served employing more effective techniques for helping people at risk of type 2 diabetes to engage in more physical activity, eat more healthily and adhere to prescribed medication where appropriate. For example, there is a compelling evidence base for prompting the formation of implementation intentions, i.e.,



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goal setting and action plans that explicitly specify when, where and how a health behaviour will be performed. A recent systematic review by Belanger-Gravel, Godin and Amirault (in press) showed that interventions to increase physical activity based on implementation intentions showed an overall small-to-medium effect on behaviour. A systematic review of interventions to promote healthy eating found similar effects, showing that interventions based on implementation intentions to promote healthy eating had a medium effect on behaviour, and interventions promoting the avoidance of unhealthy behaviour had a small-to-medium effect on behaviour (Adriaanse, et al., 2011).

These reviews provide compelling evidence in favour of the use of implementation intentions, and we strongly recommend that health professionals prompt patients, who are motivated to do more physical activity or to eat better, to form implementation intentions by writing them down during the consultation. Implementation intentions as a behaviour change technique is particularly effective in those who are motivated to change; the most recent Health Survey for England suggests that over two thirds of adults intend to do more physical activity, suggesting a



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highly motivated but under-active population. A motivated population would benefit from interventions that skill them to act on that motivation, for example, learning how to make implementation intentions.

Further, the Health Survey for England highlights common barriers to engaging in physical activity, including competing goals (work or family commitments), lack of resources (time, money) or physical health. Health professionals who help individuals to problem solve these barriers may further assist people in becoming more active.

Appropriately trained Health professionals are well placed to offer these simple, flexible and powerful behaviour change techniques, which would provide a more active, patient-centred consultation tailored to the needs and context of each patient.

General Cross-referencing to existing NICE guidelines should be done consistently and comprehensively, which would promote consistency across guidelines. Currently, sections refer to relevant previous guidelines somewhat arbitrarily.

General There is frequent referral to people as “them” and “they”, this creates an artificial separation between the guideline users and



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those that are meant to benefit. We recommend minimising such language and referring to the target population as “people” or “individuals” wherever possible.

General If people are obese, take little exercise and smoke (i.e. multiple risk factors) and are advised to make lifestyle changes, then staff advising need to be aware that mood may be an important barrier to change and repeated failure to make behavioural changes may increase distress.

General The guideline refers to a 'a local, evidence-based, quality-assured intensive lifestyle-change programme', however no such programmes may be widely available. The guideline should be explicit if NICE expects PCTs or their successor organisations to create new services that meets this specification, rather than assume that such services are already in existence.

Recommendation 2: Encouraging people to have a risk assessment.

10 Prompting individuals to form action plans that include a specification of when and where a behaviour is performed has a strong evidence base of effectiveness for attendance to health services (Sheeran & Orbell, 2000). Prompting people to form an action plan of when and where they will have a risk assessment may help to increase the likelihood that they will attend.

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“Prompt individuals to elaborate where and when they will schedule a risk assessment.”

Recommendation 3: Communicating the risks of type 2 diabetes and the benefits of prevention

11 Bullet point 5 needs cross referencing to the relevant section in the guideline on lifestyle change programmes.

Recommendation 5: Matching interventions to risk

13 Brief advice is most sensible when the person’s views and current level of knowledge are taken into consideration. See first comment to Recommendation 2 above


13 Bullet 1 might benefit from suggesting a more active role for individual within the conversation. Encouraging health care professional (HCPs) to give “advice on how to achieve these changes” is unrealistic given the limited insight HCPs have in the individual’s specific psychosocial circumstances. Furthermore, it discourages ownership of lifestyle change goals and, most importantly, is unlikely to lead to any behavioural change (Okun & Karoly, 2007).


13 Bullet 2: Rather than providing individuals with information on local services, health care professionals might want to consider eliciting what is already known about available services, explore if



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any of these services would meet the perceived need of the individual and then offer any additional information if the person is interested. Furthermore, while knowledge about access is important, common barriers to physical activity (e.g., as evidenced in the Health Survey for England) such as lack of time and money will require health professionals to anticipate these and to offer information about services that take into consideration these external barriers.


13 & 14

Bullet 3: as stated in our response to page 6 (above), the difference between brief advice and brief intervention is unclear. We suggest making explicit the difference between brief advice and brief intervention, stressing the need for patient involvement and explicit cross-referencing to more detailed descriptions of evidence-based behaviour change techniques that are currently only vaguely mentioned.

We suggest a careful rewording of bullet point 3:“For those with a high risk score which has not been confirmed by a blood test (FPG less than 5.5 mmol/l or HbA1c less than 42 mmol/mol [6.0%]), offer a brief intervention. Discuss the risks of developing type 2 diabetes and the benefits of lifestyle change by asking people what they already know about this topic. If



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needed, supplement people’s views with additional relevant information and clarify where perceptions might be inaccurate. In contrast to brief advice, also discuss people’s individual risk factors and prompt an elaboration of how these can be reduced by asking what people are willing to change and how to put these changes in place. Ask if any relevant services are known that can help and add relevant services not mentioned. Provide tailored support in line with the person’s preference for change. For example, give individuals details about walking programmes, slimming clubs or weight management groups that offer support for improving a healthy balanced diet and physical activity as well as evidence-based behaviour change techniques to help them lose weight.”

Provide a cross reference to what is meant with “evidence-based behaviour change techniques” on p.14

Recommendation 6: Quality-assured intensive lifestyle-change programmes

15 & 16

The structuring and content of the recommendations for lifestyle-change programmes could be optimised. We suggest a separation of programme content (i.e. behaviour change techniques) from the style of intervention delivery. There is a well-elaborated literature that describes and defines each potential behaviour change technique, which could directly inform



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this section (Abraham & Michie, 2008; Michie, Ashford, Sniehotta, Dombrowski & French, 2011; Michie, Hyder, Walia & West, 2011). We recommend using these definitions within the guidelines in order to promote consistency in the application of techniques. We recommend the use of the CALO-RE taxonomy of behaviour change techniques (Michie, Ashford, Sniehotta, Dombrowski & French, 2011) as a basis for the definitions used in this section, and the UKSBM would be happy to advise on the details if needed.

We suggest a careful rewording of the sub-section on intensive lifestyle-change programmes as follows:“Intensive lifestyle-change programmes should at the very least include the following behaviour change techniques:

Information provision: Reinforce awareness of the benefits of making lifestyle behaviour changes to achieve and maintain a healthy weight. Provide information that builds on what participants already know and limit the amount of information provided to allow sufficient time for participants to elaborate on how to act on this information.

Goal setting: Prompt participants to elaborate on achievable, personally relevant goals that they intend to achieve through



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lifestyle change. Action planning: Prompting people to specifically plan what

physical activity and/or healthy eating behaviour they intend to change, and specifically when, where and how. These could be written by the participants. Participants should start with planning when, where and how to reach achievable and sustainable intermediate goals and build over time towards long-term lifestyle change.

Coping planning: Prompting people to identify barriers to being more physically active and eating a healthier diet and linking these to self-generated ways of overcoming these.

Self-monitoring: Prompt participants to monitor their behaviour (e.g. through diary and/or pedometer).

Review goals and feedback on performance: Prompt reviewing of goals and achievements and provide feedback on performance.

Planning social support: Prompt participants to identify sources of support and how to include these in their behaviour change efforts. Encourage participants to involve a family member, friend or carer (if possible) who can offer emotional or practical support and help them to plan the necessary changes. For example, they may be able to join



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in with activities, make changes to the family’s diet or help to free up the participant’s time for preventive activities.

Relapse management: Prompt anticipation of relapse and ways of overcoming these.

Programmes should be delivered in the following way:

Using a person-centred and empathy building style building on the individual’s beliefs, needs and preferences.

Delivery by health professionals and practitioners with relevant knowledge and skills who have received externally accredited training, for example primary care professionals or public health advisers.

In a logical progression such as: discussing risk and the potential benefit of lifestyle changes, elaborating on people’s motivation to change a specific behaviour then action planning and coping planning, followed by self-monitoring, reviewing of goals and relapse prevention towards the end.

Offer more intensive support at the start of the programme by delivering core sessions frequently (for example, weekly or fortnightly). Reduce the frequency of sessions over time to encourage more independent lifestyle management.

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gradual changes to their lifestyle – and to reflect on and learn from their experiences. Also allow time during sessions for them to share this learning with the group.

Teach appropriate self-monitoring/assessment skills using established methods such as diary keeping.

Note:These lists include bullet 1 (p.16), bullet 2 & 3 (p.17) under programme delivery and bullet 2 (p.16) under behaviour change techniques.Two points within the draft guidance are omitted:

1. “Building confidence and self-efficacy by making gradual changes.” Building confidence is not a behaviour change technique, but a consequence of using techniques. Gradual changes are already included within the action planning section.

2. “Frequent contact with participants”. This is a repetition of previous sections (e.g. p.15 bullet 1 which outlines frequent contact in much greater detail).

Recommendation 6: Quality-assured

15 & 17

We suggest including a bullet point on design and optimisation of intervention programmes:



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intensive lifestyle-change programmes

“Where relevant expertise is lacking, providers of lifestyle-change programmes should involve relevant experts in the design and optimisation of offered services, such as health psychologists and dieticians”.

Recommendation 6: Quality-assured intensive lifestyle-change programmes

15 It is unclear who will be providing the quality assurance for the intensive lifestyle-change programmes. Greater clarity on this key issue would be welcome in the final document. We strongly recommend that behaviour change experts should be consulted on the evaluation of such programmes.

Recommendation 7: Dietary advice

18 Overall, we encourage the use of “taking into account individual needs, preferences and circumstances” more frequently throughout the guideline, in line with other NICE guidelines.

We suggest a slight rewording of bullet 1 to reflect the fact that individual needs, preferences and circumstances need to be elicited from people before these can be taken into account.

“Explore what people already know about the types and amounts of food that can reduce the risk of diabetes. If needed, supplement people’s views with additional relevant information and clarify where perceptions might be inaccurate. For example, if unknown, explain that reducing fat intake (particularly saturated



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fat intake) and increasing dietary fibre intake can help reduce the chances of developing diabetes”

Recommendation 7: Dietary advice

18 This section should cross reference the behaviour change techniques mentioned in Recommendation 6 as these behaviour change techniques are highly relevant to dietary behaviour change support.

Recommendation 8: Physical activity advice

19 Although we agree that people should be aware of the governmental recommendations for physical activity, we suggest an emphasis on increasing physical activity based on individuals’ current baseline activity levels, acknowledging that they will benefit from any increase in current levels of physical activity. Focusing on levels of physical activity that may be perceived as unattainable may decrease an individual’s confidence in their ability to change and should be strongly discouraged.

We suggest a careful rewording of bullet 1:“Explore what people already know about the benefits of physical activity and the problems associated with a sedentary lifestyle. If needed, supplement people’s views with additional relevant information and clarify where perceptions might be inaccurate. Mention that the government recommends a minimum of 150 minutes of moderate-to-vigorous intensity per week, but for



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individuals where this level is unrealistic emphasise that any increase in activity would be beneficial.”

Note:We suggest omitting the sentence: “Also explain that some people may need to do more, for example, to assist or maintain weight loss” as (a) this section deals with physical activity which might be performed for various reasons other than weight management and (b) weight management is covered in recommendation 9.


19 & 20

Bullet 2, p.19. We suggest a separate bullet for self-monitoring physical activity using a diary or a pedometer as this is not only a means of establishing baseline levels, but also an effective behaviour change technique, especially when used in conjunction with action planning (Bravata, et al., 2007). This could be integrated with bullets 2 and 3 (p.20).


20 This section should cross reference the behaviour change techniques mentioned in Recommendation 6 as these behaviour change techniques are highly relevant to dietary behaviour change support.We also recognise that ‘getting started’ in such programmes is often a major barrier to initiating behaviour change, as it may



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involve considerable changes in daily routines. We recommend that health professionals take the time to prompt the formation of action plans specifying when, where and how they will join such programmes and forming coping plans to deal with anticipated barriers to attending these programmes.


20 This section nicely cross-references other relevant NICE guidelines. It is not clear why such cross-referencing is only provided for this specific section and not others.

Recommendation 9: Weight management advice

21 & 22

Some of the recommendations on weight management could be seen to conflict with recommendations on intensive lifestyle support, for example, it could be construed that offering a "structured weight loss programme" such as Weight Watchers would be a sufficient response. Whilst recent results reported by Jebb et al. (2011) are impressive (mean 5kg weight loss at 12 months following GP referral to Weightwatchers), this level of weight loss may not be maintained in obese individuals, and more intensive, evidence-based interventions will be required. Furthermore, the problem of attrition in standard weight management programmes is well recognized and should be addressed in guideline. Finally, referral to Weight Watchers will not be acceptable for all patients.

Recommendation 9: 21 The guide states that primary care health teams should; “Advise Please add extra rows as needed


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Weight management advice

and encourage overweight and obese people to reduce their weight and sustain this weight loss, using evidence-based behavior change techniques”. Is there good evidence that primary care professionals can use evidence-based behavior change techniques to improve weight loss? We suggest this as an important research recommendation.

Recommendation 9: Weight management advice

22 Bullet 1: We recommend slight rewording of the item as the notion of ‘readiness’ has little support in the behaviour change literature (Bridle, et al., 2005).We suggest a slight rewording of bullet 1:“Provide people who are not interested in starting on a weight-loss or intensive lifestyle programme with information about where they can get support in case they change their mind at some point in the future”.

Recommendation 10: Diabetes prevention programmes for black, minority ethnic and vulnerable groups

22 It is unclear why this section is isolated from the others and not mentioned in other recommendations to which they would apply. We suggest that recommendations for BME and other vulnerable groups, including groups in lower SES areas, be integrated across all recommendations in these guidelines. This would appropriately highlight the potential need for tailoring and of priorities for particular groups.



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Furthermore, lumping risk factors together in a single recommendation point including ethnicity and mental health might be perceived as equating them, which is likely to be viewed as inappropriate. Much of the ‘what action should be taken’ points would be applicable across the population as tailoring options, and we do not see what is gained by highlighting particular risk groups in this separate section. We therefore recommend removing the particular groups highlighted in the ‘whose health will benefit?’ section as there is nothing gained from specifying these groups in this section given that the tailoring suggested could benefit any population or group. While these groups are at higher risk, the recommendation as currently worded is more about tailoring, which is broadly applicable. Thus, we recommend changing the title of the recommendation to:“Recommendation 10: Tailoring the delivery of diabetes prevention programmes”.

The specificity of some bullet points in this section, such as “Recognise and address (where possible) issues which mean someone gives their health a low priority” is unclear. This section should be streamlined, or better yet, integrated at appropriate



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places within the all other recommendations in these guidelines.Recommendation 11: Diabetes prevention programmes for people in long-stay institutions and residential care

24 What is the difference between “Adults at high risk of developing type 2 diabetes who live in institutional settings such as hostels, nursing and residential homes, prisons and remand centres” (Recommendation 10, p.22) and “Adults in institutional settings such as prisons, remand centres, hostels, nursing and residential homes”? Just the high-risk status? It is not clear at present why this population receive a separate recommendation.

Recommendation 12: Evaluation of intensive lifestyle-change programmes

25 & 26

In line with the MRC framework for the development of complex interventions (Craig, et al., 2008) we recommend including an element into this recommendation that explicitly mentions intervention optimisation. This could be included in the final section bullet, p.26:

“Ensure a suitably experienced health psychologist, the programme trainer or another suitably qualified person regularly monitors the quality of programme delivery (for example, the use of behaviour-change techniques and empathy-building skills) and ensures optimisation of programme where applicable and feasibility based on on-going programme evaluation”.

Recommendation 12: Evaluation of

25 & 26

Moreover, we suggest including weight management programmes within this section, as in reality these two will be



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intensive lifestyle-change programmes

similar, if not identical.

A potential title for this recommendation could be: “Evaluation and optimisation of intensive lifestyle-change and weight management programmes”.

Recommendation 12: Evaluation of intensive lifestyle-change programmes

25 We suggest a re-ordering of evaluation measures (cf. Hardeman, et al., 2005) as well as additional evaluation measures (indicated by *):

number and demographics of adults registered level of attendance self-reported confidence in ability to engage in more physical

activity, to reduce sedentary behaviours, to eat healthier and to avoid unhealthy eating*

suggestions for improvement of programme* changes in the amount of moderate to vigorous physical

activity undertaken each week using objective measures of behavior where available, or else validated self-reported measures of physical activity

changes in dietary intake, with a focus on total intake of fat, saturated fat and fibre

changes in FPG or HbA1c levels changes in weight, waist circumference or BMI



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monitoring and audit of the programme delivered against a recognised standard and comparison with other programmes

Recommendation 13 Use of medication

27 The effectiveness of medication will greatly depend on adherence. There is a large literature on adherence to medication and the role that the health professional has in promoting adherence to medication. One barrier to adherence is forgetting to cash prescriptions and subsequently taking medication inconsistently. Forgetting may be circumvented with the use of effective action plans of when, where and how to take the medication, along with self-monitoring whether medication had been taken, e.g., using a daily checklist. We recommend that health professionals prompt patients to form action plans during the consultation for when, where and how they will cash their prescriptions and take their medication. Some people take strategic decisions not to use their medicines based on their beliefs (accurately or otherwise) about efficacy, benefits and risks associated with the medicine. These beliefs should be elicited and, where possible, addressed in the consultation.



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Recommendation 17: Commissioning intensive lifestyle-change programmes

33 We support the proposal to commission evidence-based, quality-assured intensive lifestyle-change programmes that cover diet, physical activity and weight management, and which teach behaviour change techniques. However, again it is unclear who will be providing such services. We recommend that appropriately trained experts in behavioural medicine and/or health psychology supervise and evaluate the delivery of these services.

Recommendation 18: National public health programmes

34 We note the proposal to “set up a national accreditation body to benchmark, audit and accredit practice and share effective practice in diabetes prevention”. However, again it is not clear who will be this accreditation body will be? We believe that it is essential that such a body be multidisciplinary in nature. Will NICE or the Department of Health be holding an open invitation for bids to establish this body? If so, UKSBM may be interested in submitting a bid.


35 We strongly support the statement “This should include research to help establish and implement effective practice”. In our opinion, rigorous evaluation of outcome must be planned for and costed for at the outset, including intention to treat style analysis to cope with participant attrition.



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35 Bullet point 2 focuses on quality assured training programmes for intensive lifestyle-change interventions. Whilst this quality assurance is welcome, many of the intervention points described in the guidance, for example communication of risk information and advice giving, are likely to be delivered by workers who are not trained to deliver intensive behaviour change programmes. We recommend that quality assurance criteria be extended to cover training programmes for the delivery of these lower intensity interventions.

Recommendation 19: Training and professional development

36 & 37

Effective behaviour change interventions need to be delivered competently to maximise their potential for behaviour change. The workforce needs to have the competencies required to deliver interventions at the level at which they are working. The draft guidance essentially describes a stepped care model where high risk individuals receive intensive interventions and those at lower risk receive lower intensity interventions. Training programmes for behaviour change competencies need to reflect this stepped care model. The draft guidance does not describe a training hierarchy for the workforce that accurately reflects the various levels of working. We recommend the final guidance describes the competencies required for delivery of low, medium and high intensity behaviour change interventions. We urge



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NICE to consult and consider the Health Behaviour Change Competency Framework, commissioned for the Scottish Government by Dixon and Johnston (2011). This framework describes the competencies required to deliver low, medium and high intensity behaviour change interventions across all health behaviours relevant to the prevention of type 2 diabetes. Competencies within the framework have been mapped onto competencies within the Knowledge and Skills Framework enabling managers to easily assess the competencies and need for training of their current workforce.


36 & 37

Training programmes for working at each level of intensity will be required. We drawn NICE’s attention to Scotland’s national training programme for the delivery of brief interventions for the reduction of alcohol consumption. This training programme may provide a useful template for the development of training programmes for low intensity behaviour change interventions more generally (NHS-Education Scotland, 2010).


36 & 37

Throughout the guidance separate recommendations are made for each health behaviour required for the prevention of type 2 diabetes. However, there is little evidence that the efficacy of behaviour change techniques is behaviour specific (Michie, et al, 2008). It should be possible to develop generic behaviour



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change training to enable the workforce to deliver change across behaviours. This generic approach will benefit: patients, who will be able to follow a single referral pathway; the workforce, who will develop generic skills through a single hierarchical programme of training and the healthcare system through the consolidation of behaviour specific training programmes into a generic training programme thereby reducing costs.


36 & 37

Behaviour change theory and evidence can be summarised in the form of two routes to behaviour (Strack and Deutsch, 2004). Behaviour change can be achieved through a route that requires a person to be actively engaged in the process of change. This route requires the individual to develop and maintain their motivation to change and to acquire the skills required to enable them to consistently enact that motivation to change. This route requires effortful cognitive processing and interventions exploiting this route would employ techniques to increase motivation and action on motivation. The draft document focuses exclusively on this route to behaviour change, for example through the use of action planning and self-regulation techniques.

However, behaviour change can also be achieved through a less effortful route via prompts or cues to behaviour. This route does



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not necessarily require constant conscious active engagement by an individual. Analyses of behaviour change interventions currently being delivered through UK publicly funded programmes indicate that the effortful route is well represented by interventions currently available but that the prompted route is less so (Dixon & Johnston, 2011). This presents an opportunity to ensure that interventions exploit the prompted route more widely. However, training programmes will need to skill the workforce to deliver these techniques. Techniques that exploit the prompted or cues route are contained within the Generic Health Behaviour Change: a comprehensive competency framework document (Dixon and Johnston, 2011). The current neglect of techniques that exploit the prompted route may be of particular importance because they can be delivered at the public health level and do not necessarily require active engagement by individuals. As a result, they may be helpful in reducing social inequalities in health.



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UKSBM consultation process

This UKSBM consultation response was prepared by Ronan O’Carroll and Diane Dixon, with input from Paul Aveyard, Christine Bundy, Stephan Dombrowski, Martin Eccles, Liz Glidewell and Justin Presseau. The draft response was circulated to the UKSBM executive committee for comment, and was also made available on the UKSBM website from 31st December 2011 to 6th January 2012 for comment from the wider UKSBM membership. Comments from the UKSBM members were also invited at the UKSBM AGM, held at the University of Stirling on 13th December 2011.

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interventions. Health Psychology. 27: 379-387.Adriaanse, M. A., Vinkers, C. D. W., De Ridder, D. T. D., Hox, J. J., & De Wit, J. B. F. (2011).

Do implementation intentions help to eat a healthy diet? A systematic review and meta-analysis of the empirical evidence. Appetite. 56: 183-193.

Bélanger-Gravel, A., Godin, G., & Amireault, S. (in press) A meta-analytic review of the effect of implementation intentions on physical activity. Health Psychology Review.

Bonetti, D., Johnston, M., Pitts, N. B., Deery, C., Ricketts, I., Tilley, C., & Clarkson, J. E. (2009). Knowledge may not be best target for strategies to influence evidence-based practice: using psychological models to understand RCT effects. International Journal of Behavioural Medicine. 16: 287-293.



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Bravata, D.M, Smith-Spangler, C., Sundaram, V., Gienger, A.L., Lin, N., Lewis, R., Stave, C.D., Olkin, I., & Sirard, J.R. (2007) Using pedometers to increase physical activity and improve health: A systematic review. Journal of the American Medical Association. 298:2296-2304.

Bridle, C., Riemsma, R.P., Pattenden, J., Sowden, A.J., Mather ,L., Watt, I.S., & Walker, A. (2005) Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model. Psychology and Health. 20:283-301.

Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., & Petticrew, M. (2008) Developing and evaluating complex interventions: The new medical research council guidance. British Medical Journal. 337: 979-983.

Department of Health (2004) Choosing Health: Making healthy choices easier. London: The Stationery Office.

Department of Health (2010) Healthy Lives, Healthy People: Our strategy for public health in England. London: The Stationery Office.

Dixon, D. & Johnston, M. (2011) Health Behaviour Change Competency Framework: Competences to deliver interventions to change lifestyle behaviours that affect health. Available at http://www.healthscotland.com/learning/index.aspx

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medical care. Journal General Internal Medicine. 88:448–57.Hardeman, W., Sutton, S., Griffin, S., Johnston, M., White, A., Wareham, N.J., & Kinmonth, A.L.



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http://www.expertpatients.co.uk/

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