Quantitative survey findings following MECC training in a mental health setting in the Northeast England suggested that staff perceived improvements in capability and motivation to deliver MECC, with the most notable increase observed in confidence. Confidence increased consistently over time, including among matched participants, suggesting growing self-efficacy with practice. In contrast, perceived social opportunity significantly declined at follow-up (alongside a marginal decline in perceived physical opportunity) in the wider sample, possibly reflecting challenges in sustaining environmental support. These findings were reflected in the qualitative data, where trained staff described greater confidence, enhanced communication skills, and improved ability to tailor conversations to patient needs. Both data sources highlight the role of training in developing psychological capability and reflective motivation, particularly through increased confidence, and strengthened therapeutic relationships. Although reflective motivation slightly declined among matched participants, possibly due to increased awareness of practical limitations. Automatic motivation increased over time, suggesting emerging habits or increased familiarity with delivery. Perceived importance and usefulness of MECC declined significantly at follow-up, which again may indicate that initial enthusiasm was difficult to sustain without continued organisational support. Our qualitative findings show that organisational support and role clarity further facilitated engagement, while persistent barriers, such as time constraints, inconsistent recording systems, and the impact of wider social determinants, were consistently noted across both trained and non-trained groups, mirroring the quantitative decline in physical and social opportunity and reflecting challenges encountered during implementation.

This study highlights how structured MECC training enhances staff capability and confidence to engage in weight-related conversations. Trained staff demonstrated a more systematic, patient-centred approach, employing targeted communication strategies, clear signposting to resources, and increased awareness of when and how to initiate sensitive discussions. In contrast, non-trained staff tended to rely on generalised health promotion strategies and often lacked the confidence or tools to tailor conversations to individual needs. This contrast underscores the value of formal training, particularly in supporting sensitive, context-specific behaviour change communication. The observed differences in staff capability likely reflect training outcomes, linked to the structured and consistent delivery of the MECC programme. A recent fidelity evaluation of MECC in this setting confirmed high adherence to core behaviour change techniques, showing that both the Train the Trainer and Core MECC + AWOYM packages were delivered as intended [21]. Similar training improvements have been reported elsewhere; for example, Bull et al. [22] found that behavioural science interprofessional skills training significantly increased practitioner confidence, competence, and intention to use behaviour change techniques in community health and social care settings.

Despite generally positive perceptions of MECC training, participants made suggestion for both content and broader implementation strategies. Staff (both trained and non-trained) expressed a need for more support in delivering culturally sensitive and individually tailored conversations, particularly when discussing weight-related issues with individuals from diverse backgrounds. These concerns are also echoed by service users themselves. A recent study with service users living with serious mental illness reported limited communication about medication-related weight gain and emphasised the need for more therapeutic, culturally appropriate engagement [23]. Similar gaps were observed in the community: adults taking antidepressants noted that current support often felt generic and disconnected from the psychological and practical challenges they faced [24]. While Kemp et al. [21] confirmed high adherence to core behaviour change techniques in MECC training delivery, wider implementation across the region remains fragmented [5], with delivery often occurring between rather than within organisations, limiting the consistency and routine application of training. Ethnographic research in inpatient mental health settings [25] illustrates how cultural tensions, under-resourcing, and institutional norms further complicate staff’s efforts to promote health behaviours. Consequently, future MECC training may benefit from going beyond generic communication skills to include structured opportunities to practice more sensitive conversations, as suggested by Meade et al. [26] and Nichol, Rodrigues, et al. [6]. It may also be valuable to consider local contextual and cultural adaptations, including approaches already in use such as tailoring MECC delivery to mental health settings [5, 27-28].

Staff consistently highlighted structural and organisational barriers that constrained effective MECC delivery. The use of standardised recording systems could improve continuity of care and follow-up, while socioeconomic disadvantage often made it difficult for service users to act on lifestyle advice, challenges also reflected in secure mental health settings, where fragmented services, obesogenic environments, and poor food provision undermined health promotion efforts [25, 29]. These findings align with feedback from both inpatient [23] and community-based service users [24], who reported that medication side effects, limited cultural awareness, and inconsistent support limited the impact of MECC conversations. Recent evaluations of MECC implementation across Integrated Care Systems (ICS) in England further support this picture, identifying barriers at macro (e.g. funding), organisational (e.g. time, staffing), and individual levels [30]. Meade et al. [15] also found that even when healthcare professionals intend to deliver MECC, environmental constraints, emotional burden, and prioritisation challenges reduce follow-through. Their subsequent qualitative work [26] reinforced the importance of enabling environments, highlighting how factors such as consultation settings, resource visibility, and management support play a pivotal role in embedding MECC into routine care. Together, these findings suggest that beyond enhancing staff capability and motivation, effective MECC implementation depends on coordinated, equity-focused systems that recognise the structural realities of both service users and providers (physical and social opportunity).