Assessing fidelity of design and training of Making Every Contact Count (MECC) in a mental health inpatient setting | BMC Public Health

Making Every Contact Count (MECC) is a public health strategy designed to promote behaviour change through brief healthy lifestyle conversations between healthcare staff and service users [29]. A recent Delphi study has established an updated consensus on the definition of MECC, capturing the evolution of MECC and increased scope since its inception [23]. The MECC approach was initially developed in Yorkshire and Humber as a response to NICE guidelines designed as a public health initiative to promote health behaviour change and provide a common framework for all NHS workforce to use [22, 26]. MECC promotes behaviour change by using opportunistic delivery of healthy lifestyle information relating to health issues, there are five core elements of MECC including smoking, healthy eating, physical activity, alcohol and mental health [13]. MECC guidance documents outline key components of MECC which impact both organisations, staff and individuals [30]. MECC guidance documents support organisations in developing leadership and strategy around the approach and through provision of training and information relating to the MECC approach, enable staff with competence and increase confidence to deliver MECC through healthy lifestyle conversations, and encourage individuals to improve their health and wellbeing [30]. In addition to the core MECC definition, a broader definition has also been recognised (referred to as MECC Plus) to recognise how core MECC training has been further developed to support conversations about the wider determinants of health and wellbeing, such as social and health inequalities (e.g., debt management and housing and welfare; see Public Health England [30]).The MECC implementation guide outlines a process for implementing MECC using an eight-step approach [17] outlined in Table 1, and provides a checklist of how this can be achieved [30].

Although MECC aims to be delivered at scale in the United Kingdom, a low awareness has been shown amongst healthcare professionals [16]. Despite healthcare professionals stating that patients would benefit from MECC behaviour change interventions, they were only able to deliver MECC interventions to half of the patients during consultations [16].

Haighton et al. [9] proposed that theoretically relevant behaviour change components should be introduced to interventions to improve MECC implementation. One way of doing this is through introducing a wider range of BCTs which are used as a method for ‘specifying, evaluating, and implementing behaviour change interventions’ (BCTTv1) that link with theoretical domains framework domains. The Theoretical Domains Framework was developed for implementation research to identify theories relevant to implementation and group constructs from these theories into domains [1]. They can be used to address barriers to MECC implementation for example including incentives through use of reward based digital tools for recording MECC [9]. Pre- and post-evaluations of MECC training using the Theoretical Domains Framework have shown that beliefs about capabilities, goals, and staff confidence in delivering behaviour change conversations increased following training [15]. These findings were consistent at follow-up (six to ten weeks post training) showing maintained improvements for healthcare staff delivering MECC.

To evaluate whether interventions are being delivered as intended, intervention fidelity assessments are made [8]. As well as intervention fidelity, treatment fidelity [2], is assessed using five domains: study design, provider training, treatment delivery, treatment receipt and treatment enactment [3]. Intervention fidelity assessments have been used in healthcare contexts such as the NHS diabetes prevention programme [11] to ensure that behavioural intervention programmes are reliable and valid. Fidelity of training programmes has previously been examined in health contexts assessing healthcare professionals’ delivery and treatment provision of specific interventions [12, 21]. However, in some contexts such as the voluntary and community sector fidelity can be difficult to examine due to challenges reporting MECC as there is a lack of standardised resources and monitoring systems and tools that can be externally accessed and used to record and monitor MECC conversations [10].

To assess the fidelity of MECC training, Lawrence et al. [18] examined how trainers adhered to the outlined methods of training. Evidence of fidelity was shown through the interaction of trainers and trainees to model key skills of training and enable trainees to be involved in training activities to increase knowledge and competence. Healthcare staff who have completed MECC training were found to adopt behaviour change approaches with service users and implement MECC skills more readily than non-trained staff [18]. Healthcare professionals consider MECC as an enabler to implementing behaviour change. However, it was also noted that there were inconsistencies in the training approach used across organisations [18]. Therefore, a more streamlined approach to training is needed to ensure consistent delivery of the MECC approach [4, 22].

Train the trainer models have been widely used in public health [24, 33], and have been found effective, which is valued by participants [24]. Using train the trainer models for public health allows a wide reach of training [33] through a process of trainers delivering training to staff who are then equipped with the skills and knowledge to enable the delivery of cascade training [6]. However, although train the trainer models are effective in increasing knowledge amongst healthcare professionals, cascading this training to other staff once trained has shown to be less effective [27]. For example, although train the trainer models in public health demonstrated efficiency, when training is then cascaded, fidelity assessments have found low adherence to the original programme content i.e., trainers deviate from planned/original training content [6]. More recently, online training has been developed in Northwest England to support healthcare staff to deliver MECC and increase knowledge of behaviour change techniques [5, 15]. After receiving online MECC training, healthcare staff showed an increase in self-efficacy, behavioural attitudes and outcome expectancies demonstrating that receiving MECC training boosted staff skills in supporting behaviour change [5].

In a mental health inpatient setting in Northern England a training package has been developed to improve staff confidence and skills to ensure consistent delivery of MECC across the trust. The training package includes the train the trainer model which involves the delivery of the MECC approach and how to cascade this training amongst peers. A bespoke training was also developed to include Core MECC training with the addition of A Weight Off Your Mind. A Weight Off Your Mind is a regional weight management plan developed in Northeast England to support people living with learning disabilities or severe mental illness with weight management. A Weight Off Your Mind focuses on Physical Activity and Diet to support service users of mental health settings achieve a healthy weight which can be facilitated through the delivery of MECC conversations. The bespoke MECC training adopts the ‘3As approach’ to brief interventions (‘Ask’; ‘Assist’; ‘Act’) often used in smoking cessation interventions [25] and which is adapted from the 5As approach [32] (Ask, Assess, Advise, Agree, Assist). The 5 A’s approach [32] is also an approach used to improve weight management in primary care and shortened to adhere to the brief element of MECC.

To evaluate the MECC training programme, a fidelity assessment was conducted. Intervention fidelity assesses the extent an intervention was delivered as intended [8]. A recent behavioural analysis of MECC interventions [9] highlighted that a low percentage of behaviour change techniques (BCTs) were used across national interventions designed to improve MECC implementation, indicating a potential lack of fidelity of design of MECC, and highlighting a need for interventions to include more behaviour change techniques to overcome barriers to MECC implementation.

Research aims

This study aimed to assess intervention fidelity in the design of MECC implementation within a mental health inpatient setting. Specifically, a document analysis was conducted to compare MECC provider materials with official guidance documents and a MECC behavioural analysis [9], to determine whether MECC delivery aligned with its intended design. Additionally, the study evaluated training fidelity within the MECC training package by examining whether both components – Train the trainer and Core MECC + A Weight Off Your Mind – were being delivered according to the training materials, including presentation slides and the core MECC training delivery guide.

Research objectives

The objectives of this study were:

1. 1.

   To examine fidelity of design of MECC implementation across a mental health inpatient setting. This objective was achieved by comparing the behaviour change techniques (BCTs) and implementation strategies outlined in provider and guidance MECC documents.

2. 2.

   To assess fidelity of training across the same mental health inpatient setting. This was done by analysing BCTs from training session transcripts and comparing them with training documents, including presentation slides and a training delivery guide. The analysis focused on the delivery of both train the trainer and Core MECC + A Weight Off Your Mind components.