Using conversation analysis to review and improve brief weight loss interventions in primary care

National guidelines exhort GPs to give brief opportunistic interventions for weight loss which incorporate the offer of referral to an effective behavioural programme, such as a commercial weight management service (CWMS). These brief interventions have been shown to be effective. However, GPs rarely deliver these interventions, and have requested more support to facilitate delivery. Current guidelines provide little detail to support GPs because there is sparse evidence regarding how to deliver effective opportunistic interventions.
In this thesis I aimed to understand what conversational strategies used by GPs are likely to result in patient agreement-to-attend, and actual attendance at a CWMS referral, and use the findings to develop an information resource to support primary care clinicians. I used a mixed methods approach including: a systematic review of evidence from conversation and discourse analytic studies; conversation analysis of audio recorded data from the brief interventions for weight loss (BWeL) trial; and statistical analysis of BWeL patient outcome data.
In a systematic review to identify how healthcare professionals can best communicate with patients about health behaviour change I found ten papers. Results demonstrated a series of specific conversational practices which clinicians use when talking about health behaviour change, and how patients respond to these. 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 identified as potentially problematic.
In three studies using conversation and statistical analyses to examine data from the BWeL trial I examined how referrals to CWMS were structured, delivered, and received. In the first study I found that referrals were formatted as ‘news deliveries’. I identified three news delivery formats, and found that use of a ‘good news’ delivery format showed evidence of motivating patient agreement-to-attend, and actual attendance.
In the second study I focussed on patient responses to the announcement of news. I found that patients displayed positive or negative reception of the referral early in the sequence, before they had been explicitly asked if they would like to attend. I found that positive and negative reception displays following the announcement of news were associated with subsequent attendance (or not) at the referral. Additionally, orienting to these patient responses which were produced early in the consultation, showed evidence of maintaining the brevity of the intervention.
In the third study I examined when and how GPs articulated an association between a patient’s weight and their health, and how patients responded. I found that, although this strategy is recommended by guidelines, linking was no more effective than not-linking, but did seem likely to generate displays of resistance in many cases, and was associated with longer consultations.
This thesis demonstrates associations between conversational practices and longer-term patient action. This provides specific evidence for GPs on how to deliver effective opportunistic brief interventions for weight loss. Results from this thesis highlight the importance of careful attention to conversational features to identify effective communication which has potential to improve practice.

Keywords: health care
primary care
medical communication
health behaviours
behaviour change
conversation analysis
obesity
Advisor: Aveyard, P
Ziebland, S
Stokoe, L
Webb, H