Navigating Complexity: Advancing Multiple Behaviour Change Approaches for Chronic Disease and Multimorbidity Management

Abstract

Background: The rising prevalence of multimorbidity presents major challenges for healthcare systems worldwide. Managing it is particularly complex, as healthcare professionals (HCPs) delivering patient-centred care must balance competing clinical priorities, navigate fragmented services, and address diverse patient needs. This management involves various clinical activities, including assessments and behaviour change interventions, aimed at goals like enhancing patient well-being and reducing hospital readmissions. These goals may align or conflict – for example, promoting physical activity could support dietary improvements but reduce time for thorough assessments. Understanding these interactions is essential to optimising care delivery, improving patient outcomes, and guiding future research. Aim: This PhD thesis aims to advance the theoretical understanding of multiple behaviour change approaches in chronic disease and multimorbidity management. The research seeks to support HCPs in providing care for individuals with multimorbidity by developing evidence-based recommendations for practice, research, and the design of digital technologies that account for their multiple clinical behaviours and goals. Methodology: A multi-methods approach was employed, incorporating three studies designed to provide a comprehensive understanding of the challenges and opportunities associated with supporting HCPs in delivering personalised care for multimorbidity. A systematic review with meta-analysis was first conducted to examine the effectiveness and components of interventions aiming to change more than one health-related behaviour in individuals with chronic conditions (Study 1 – Chapter 3), followed by a secondary analysis of its components and impact on intervention effectiveness (Chapter 4). A second systematic review was conducted to examine the components of interventions aiming to change more than one clinical behaviour of HCPs (Study 2 – Chapter 5). A qualitative study was conducted to explore HCPs’ experiences in delivering personalised care for multimorbidity, focusing on their management of multiple behaviours and goals, provision of behaviour change advice, and use of digital technologies to support their practice (Study 3 – Chapter 6). The studies were triangulated through a matrix table using a combination of top-down (Studies 1 and 2) and bottom-up (Study 3) approaches to generate robust recommendations for future research and practice. Findings: The first study identified 61 randomised trials of multiple health behaviour change interventions, identifying “physical activity, diet, and smoking” as the most commonly targeted behavioural cluster (33%). The meta-analyses showed small to substantial positive effects on behaviour change across health behaviours (d=.08-2.00; RR=1.03-2.25), except for smoking (d=-.02). Most interventions were atheoretical (55%), with goal setting (70%) and self-monitoring of behaviour (41%) being the most frequently used techniques. Face-to-face interventions appeared less effective for improving physical activity outcomes, and longer intervention duration was linked to better outcomes. Not using goal setting behaviour might be more effective for smoking cessation outcomes. The second study included 17 randomised trials of interventions targeting multiple behaviours of HCPs. Clinical behaviours were categorised into seven upper-level categories: provision of behaviour change advice, screening/assessment/measurement, prescription of medication, referrals, treatment, diagnosis and past medical history taking. Interventions were often brief (median= 5 days) and delivered via a combination of face- to-face and at-a-distance modes of delivery (41%). Most interventions were atheoretical (82%) and used the techniques set behaviour goal (90%), add objects to the environment and present information from credible influence (63% each). The third study involved 32 semi-structured interviews with nurses and medical doctors from Ireland and Portugal. Findings highlighted barriers and facilitators to the management of HCPs’ multiple behaviours and goals (e.g. prioritisation of goals n = 16), HCPs’ characteristics (e.g. experience n = 10), patients’ characteristics (e.g. motivation n = 7), and organisational structure (e.g. time constrains n = 25). Factors influencing behaviour change advice to patients related to HCPs’ characteristics (e.g. training n = 12), patients’ characteristics (e.g. social support n = 11), organisational structure (e.g. multidisciplinary teams n = 15), and vi) resources available (e.g. staffing challenges n = 8). Digital technologies were identified as beneficial in supporting clinical practice (e.g. overview of patients n = 7) but were often hindered by usability and interoperability issues. Triangulation of findings from the above studies led to key recommendations for optimising multimorbidity care, including fostering shared decision-making, enhancing HCPs’ training, and promoting multidisciplinary care. Effective behaviour change advice requires equipping HCPs with behaviour change techniques and strengthening institutional and community support. Future research should rigorously test interventions, establish clear outcome definitions, and adopt standardised frameworks to guide development and reporting. Digital technologies should focus on reducing administrative burden, enhancing care coordination and actively involving HCPs in their development. Discussion and conclusion: This research is the first to comprehensively examine the interaction between HCPs’ multiple clinical behaviours and goals within the context of multimorbidity. By integrating systematic and qualitative evidence, it advances the theoretical and practical understanding of multiple behaviour change in multimorbidity care. The study provides actionable recommendations for both research and practice, laying the foundation for developing more effective and sustainable interventions to support and enhance HCPs’ clinical practice.