Our results are structured around three themes. First, we show how motivation was practiced during the preventive health dialogues. Second, we illustrate how patients perceived the preventive focus on health behavior in general practice. Third, we focus on how both GPs and patients had certain expectations regarding the role of the GP, which affected the motivational work carried out during the health dialogues.
Practicing motivational work
We introduce the results with an ethnographic observation that shows a significant empirical example of how motivational work most typically was practiced in the preventive health dialogue in the TOF intervention. As we shall argue, motivational work in the health dialogues occurred as one-way communication, in which the GP controlled, instead of facilitated, interplay and dialogue with the patient.
The doctor looks at the screen and confirms that the diet is red (in the risk zone). He asks Kenn whether the health survey has got him thinking about anything. Kenn answers that, yeah, he knows. “Know what?” asks the doctor? Kenn explains that he knows he is overweight and eats too much. He eagerly explains how he’s currently experimenting with leaving candy out all the time to wean himself off eating the whole thing in one go. He talks about an experiment he saw on TV in which a kindergarten kept candy out all the time and only brought out carrots every so often, with the result that the children didn’t want to eat candy but instead rushed over to the carrots. The doctor listens. Kenn continues explaining how he had previously almost been underweight, but after he had stopped smoking, he had gained a bit more weight, a bit more, a bit more. The doctor does not comment on this but glances quickly around Kenn’s health profile and comments instead on his responses regarding smoking and alcohol. He returns to diet shortly thereafter. He asks whether Kenn is familiar with BMI – Body Mass Index – and says: “It should ideally be a maximum of 25 – yours is at 27. What about exercise?” Kenn says that it could be better and explains that he does gymnastics once a week and goes hunting during the season. The doctor asks whether it’s sort of classic men’s gymnastics, “The kind of thing where you don’t sweat?” he asks with a laugh in his voice. Kenn smiles and assures him that they really work hard. The doctor smiles, “Joking aside.” He looks at Kenn: ”It’s important to get your heartrate up and break a sweat. Do you have a bike?” he asks. “No, I just hate biking!” Kenn answers. The doctor does not respond but turns around in his chair and looks at the computer screen. “Then I need to ask you. In terms of increasing your efforts in terms of physical activity, would you maybe be interested in a service from the municipality?” Kenn looks a bit skeptical. “What is it?” he asks. The doctor explains that the municipality has a lifestyle service for adults with overweight and a place where you can learn about health. Kenn still looks skeptical. “Hmm… Let’s assume that I’m interested. I mean, that I’m looking for somewhere I can learn about obesity. As a smoker, I didn’t need it.” The doctor looks at the description of the municipality’s service and reads it aloud. A moment later, Kenn acquiesces: “Alright, let’s accept it … Then we’ll have done something at least. It’s not necessarily certain that it would happen here, internally.” The doctor fills out some boxes in the health profile. He points at the screen, where an image shows a scale of 1 to 10. “How motivated are you in terms of the municipality’s lifestyle team?” he asks. Kenn thinks. “It’s probably a 4 or a 5…” “OK,” answers the doctor, types in the number and clicks around on the screen. He prints out a description of the municipality’s service. While the printer is going, he asks, “So, how’s the strategy with the bowl of candy going?” Kenn smiles. “Surprisingly well!” he answers. “The total amount at least has gone down – also when it comes to heavy food.” The doctor responds, “Great!” and hands the information on the municipality’s service over to Kenn in printed form. “If you’re really hardcore, there’s also a nutritionist. It isn’t free, but then you’re setting the agenda.” Kenn does not seem particularly interested as the doctor writes the nutritionist’s contact details down for him. The doctor clicks further in the health profile and asks Kenn a couple of quick questions about medicine use, etc. Afterwards, the doctor talks about cholesterol totals, and he calculates Kenn’s 10-year risk and a current risk with the help of a special computer program. “Hey, it looks really good – 1% risk.” Kenn smiles. “OK, then, it really can’t be much better.” The doctor responds, “It looks really good overall – ideally, you should lose a few kilos! … I also think you need to work on getting motivated to give it a shot – I believe in you! … But should we say that’s that, then? Then you’ll continue the program with the municipality.” (GP 2, Patient 9)
In this example, the GP attempted to motivate to behavior change in different ways. The health dialogue started out with the doctor asking an open-ended question that caused the patient to account for his candy experiment. The patient thereby presented the GP with an opening regarding his motivation to change eating behaviors. Although the dialogue started with including the patient’ experience, the GP did not follow up on this information, but instead applied an action perspective: recommending the patient to start biking and try consulting a nutritionist, which resulted in a drop in the patient’s motivation. Overall, throughout the empirical material, we found motivational work to be characterized by guidance, which included information, suggestions, and advice on risk factors, such as: “It’s important to get your heart rate up and break a sweat. Do you have a bike?” (GP 2, Patient 9), “You should lose weight to lower your cholesterol level,” (GP 3, Patient 4) or “Try to get 30 minutes of exercise every day, get the heart rate up… go for a daily walk” (GP6, Patient 8). Although these examples are not only biomedically anchored, but also include ways of approaching patients everyday lives , the dialogues in general seldom included the patients’ experiences with behavioral changes, general life situation, or social circumstances directly, which could influence their motivation, ambivalence, and actions regarding health behavior.
Furthermore, the GPs reduced MI tools, such as scaling questions and goal setting, to a means of gaining numerical information instead of serving as a dialogue tool. The numeric standards and measurements constituted preventive work on which the GPs never followed up. That is, the GPs neither asked questions about the reason for the assessment nor questions about the patient’s specific motivations for changing behavior. As such, perspectives and experiences that the GPs could have utilized to activate and strengthen the patient’s motivation for change  remained empty information, and information about behavior was quantified and given in generic terms by the GP, isolated from any social influences [13, 26]. One explanation for the GPs approach to motivation could be the framework and the instructions of the TOF-intervention, which the GPs were to follow during the health dialogues. The following example from an observation of a health dialogue shows how the GP acted to meet the expectations of the intervention.
GP 1: “You are going on a smoking cessation course – now I’m just putting words in your mouth (laughs)”. The sound of the printer printing the offer. “Let’s agree on a goal. Let’s agree that you go from 10 to five cigarettes a day. We will write that you will stop smoking within a year – then they will be happy in there [TOF project group] …Complete smoking cessation we will write”. Patient 1 does not reply. GP 1 reads out loud:” How sure are you that you will reach your goal?”. GP 1 looks patient 1 in the eyes. Patient 1: “Unsure”. GP 1 reads out loud: “Does the patient understand and accept?”. GP 1 looks at patient 1. Patient 1: “….yes yes…[Laughs and shakes his head]. (GP 1, patient 1)
The performance of motivation in this study could be explained by the structure of the digital framework, which facilitated the GPs using the digital support system as a checklist rather than as a starting point of a dialogue. Furthermore, in the interviews with the patients, we found that when GPs did not follow the digital support system, patients felt that their stories and individual experiences were seen and heard. In this way, the digital support system, which was meant to ensure that all the patients’ identified adverse health behaviors were considered and addressed, diminished the GPs’ use of the elements of MI. Thus, we argue that the framework and the instructions of the intervention influenced the character of the interaction between GP and patient and in this way the motivational work.
We further argue that the approach to MI presented in the examples can be characterized as a treatment-oriented practice rooted in a biomedical perspective, characterized by a numeric objectification of bodily functions and symptoms based on classification systems for diagnosing somatic and mental diseases, one that less so include patients’ experiences, values, or everyday lives [27, 28]. Existing research shows that GPs’ focus on diagnoses and treatment affects whether prevention is introduced in the clinical encounter [6, 29]. These findings correlate well with the findings in this article. However, the clinical encounter is more complex than the GPs only thinking in biomedical terms and patients only about their everyday lives. As we will show in the next section, patients also adhere to the biomedical rationale.
Experiencing motivational work
In this section, we illustrate how patients experienced and perceived the preventive focus on health behavior in general practice and how this influenced the motivational work carried out in the health dialogues.
Generally, the patients stated that they had not previously considered seeking advice or guidance from their GP about lifestyle related issues. Several patients did not regard risk factors, such as obesity, as a disease and, as a result, they did not present it as a health problem to the GP. The ways in which patients separated lifestyle related issues from disease are reflected in the following interview extract:
“When I contact the doctor, it’s because I notice something particular. If there’s something unusual, or there’s something that’s changed, and I notice it, then I get in touch with the doctor. But not my lifestyle, no … Because I feel I’ve got that covered” (Patient 7).
According to a study by BP Mjølstad, AL Kirkengen, L Getz and I Hetlevik , the contents of conversations between GPs and patients are framed by an awareness of what is not appropriate to share with the GP, such as everyday life issues. These authors argue that this awareness is socially and culturally embedded in the Western society, where patients are taught to regard the body in a physical and biomolecular manner. This social embedment lessens the degree to which patients introduce experiences from their everyday lives in the assessment of symptoms in the encounter . In our study, patients understood health behavior as a private matter and therefore not an appropriate content for the conversations with the GP:
“If it’s about how I have to alter my lifestyle, then it’s really more on the home front where that kind of thing happens. I mean, if we’re sitting around the table and agree, well, ‘we’d better eat a bit more salad and more beet burgers,’ then that’s where it’s decided. Not with the doctor. It’s nice of her to try, but no” (Patient 6).
As illustrated by this quote, patients generally regarded lifestyle related issues as something they themselves were responsible for changing and as something that took place at home and not in the GP’s consultation room. Patients’ awareness of their health behavior was in this way also often connected to a biomedical understanding of health behavior as an individual affair, as opposed to other clinical health issues. Instead of agreeing to the preventive premise of the health dialogue and of the intervention guidelines, patients often brought other health problems into the conversation, for example eczema, tennis elbow, and birthmarks. Other studies additionally find that patients coproduce the implementation of lifestyle promotion in an active or passive way , by for instance anticipating how the GPs might assess their health behavior and by incorporating this in the dialogue . Which could help explain why patients shifted the focus and reproduced a treatment-oriented focus in the preventive health dialogues in our study. In a study examining shame and honor in the clinical encounter, shifting focus in preventive consultations has been identified as a means by which patients preserve or regain face when confronted with behavior that is deemed insufficient . Though based on the patients’ understandings of the clinical encounter and health behavior as presented above, we found that by shifting focus, the patients contributed to the health dialogue as one-way information provided by the GP, with a focus on objectified biomedical, classifications of bodily functions and symptoms.
Expectations of GPs’ role in prevention
In this section, we demonstrate how both GPs’ and patients’ expectations of the GPs’ role affected the motivational work carried out in the health dialogues.
Generally, the GPs expressed concern about becoming overbearing and scaring patients away when confronting them with advice about health behavioral change. Some GPs expressed skepticism about setting goals in the health dialogues and about patients’ willingness to change health behavior. One GP described an awareness of not “pursuing” the patients:
“[In terms of setting goals,] well… they talk it up a bit while they’re sitting here, and when they get home, then they forget about it? I mean, if they say: ‘Yeah, but it’s a 7.’ Then I don’t know whether they’re going to follow up on it. But I mean, I don’t want to force them into it either. I don’t want to pursue them. I don’t want to punish them. Nah. I have one with these really bad feet, and she can’t have surgery unless she quits smoking. […] So, I say, ‘But, well, can’t you quit smoking?’ She basically can’t do that – what’s she supposed to do? She can’t walk, she can’t smoke. So, I mean… (laughs) it’s hard. […] But you can say to them: ‘Well, I mean, that’s just how it is.’ – and then, well, we don’t need to talk about it anymore (GP 1).
Focusing the health dialogue on biomedical facts and treatment has in other studies been found to stem from GPs’ practical inability to carry out MI as well as lack of time and concerns about harming trust in the doctor-patient relationship [4, 8, 11, 31]. GPs have been found to balance authority and respect for patients’ autonomy by compromising on or sidestepping certain health issues to avoid harming their relationships with patients, which has consequences for prevention in the clinical encounter [4, 32]. This means that GPs’ professional commitment to treatment, professional authority, and respect for patients’ autonomy may dominate the motivational work and dialogue with patients in the health dialogues. This was also evident in our empirical material.
Additionally, the excerpt above illustrates that after conveying normative biomedical facts to patients, such as the risks of smoking, motivational work was understood to be completed. This implies a hidden assumption that what the GP says is in itself a motivational factor. The term “the doctor-drug”  is widely known and describes how the GP’s mere presence influences patients’ responses to illness and treatment. As such, GPs’ perception of their professional authority affects the social practices of motivation for health behavioral change that emerges from and is reinforced within the context of the clinical encounter . This correlates well with the findings in this study, as the GPs’ comprehension of their professional position and focus on individual-oriented treatment seemed to influence the ways in which GPs understood and performed their role in the preventive health dialogues. However, contextual circumstances, such as the framework of the pilot study, may have presented a barrier to the GPs’ inclusion of the patients’ perspectives. For example, use of the digital support system in the health dialogues was new to the GPs, which may have influenced the degree to which the GPs had the resources to focus on the patients’ perspectives. An increase in time spent looking at the computer screen has in other studies been found to affect patient-GP interaction by leading to more periods of silence and a decrease in dialogue and information sharing [34, 35]. As a result, and as shown previously, the digital support system functions as a checklist, which may cause GPs to read questions aloud and to enter patients’ answers without making use of the information in active interplay with the patients.
Nonetheless, it is worth noting that the patients in this study expected GPs to focus on medical treatment and not on health behavior and prevention.
“No one said anything about this being a lifestyle change project – because then I don’t actually think I’d have agreed to take part, because that’s not something I need. I thought it was supposed to be about my health” (Patient 6).
Patients perceived the GP as someone who treated illness and as someone who could attend to health problems that they could not handle on their own. We found that patients perceived issues related to health behavior, such as obesity and smoking, as self-inflicted, self-controlled, and not (yet) disease related. As a result, the contexts – the patients’ private lives versus the biomedical context framing the clinical encounter – affected whether the patients perceived and recognized health behavior as an appropriate health problem. Patients’ attention to not burden or waste GPs’ time [33, 37] may explain why patients anticipated and assessed health behavior as an individual affair.
The following example illustrates the divergence between the processual motivation to change health behavior on the one hand and the biomedical, rational treatment focus on the other hand.
“I know that I shouldn’t smoke, and I know that it’s not healthy, and I know all that. But I’m just not ready for it, right? I’ve tried quitting many times – and it just hasn’t worked yet. And I just think, ‘Well, but, as long as I keep it to under 10 cigarettes a day and am conscious of not increasing it, then I’ll probably decide on my own whether to quit smoking in a year, in three months, or whenever I do. … But the doctor, well, he wants me to set a date. And there, I just thought to myself, ‘I’ll be damned if he’s deciding that’” (Patient 1).
Quantifying and estimating the length of this process by pushing the patient to set a date for smoking cessation disregarded the patient’s previous experiences with attempting this, which resulted in a decline in motivation. A qualitative study of health behavior counselling in general practice demonstrated that although GPs and practice nurses showed awareness of the value of including patients in the preventive health dialogue, the provision of simple risk factor information was the predominant strategy . Our findings reveal that ensuring a patient-centered dialogue and enhancing intrinsic motivation for behavioral change was complicated partly by GPs quantification of prevention and providing risk factor advice isolated from the patients’ social context and partly by patients’ understandings and expectations of appropriate health problems to discuss with the GP. K Thomas, P Bendtsen and B Krevers  suggest that prevalent understandings of the implementation of health behavioral change in healthcare could be improved if patients were seen as co-producers rather than receivers. Findings in the present study, however, suggest that this would not shift focus away from information about health behavior in generic terms, given that the patients additionally demonstrated expectations about the content and structure of the health dialogue based on a biomedical rationale.
To summarize, we found that GPs’ and patients’ expectations regarding the structure and content of the health dialogue influenced the character of the motivational work. Our findings show that both GPs and patients in an interplay— influenced and reduced MI in the health dialogues to one-way information due to a treatment-oriented focus and expectations related to perceptions of prevention as an individual and private task.