Evaluating primary care behavioral counseling interventions: an evidence-based approach

Risky behaviors are a leading cause of preventable morbidity and mortality, yet behavioral counseling interventions to address them are underutilized in healthcare settings. Research on such interventions has grown steadily, but the systematic review of this research is complicated by wide variations in the organization, content, and delivery of behavioral interventions and the lack of a consistent language and framework to describe these differences. The Counseling and Behavioral Interventions Work Group of the United States Preventive Services Task Force (USPSTF) was convened to address adapting existing USPSTF methods to issues and challenges raised by behavioral counseling intervention topical reviews.The systematic review of behavioral counseling interventions seeks to establish whether such interventions addressing individual behaviors improve health outcomes. Few studies directly address this question, so evidence addressing whether changing individual behavior improves health outcomes and whether behavioral counseling interventions in clinical settings help people change those behaviors must be linked. To illustrate this process, we present two separate analytic frameworks derived from screening topic tools that we developed to guide USPSTF behavioral topic reviews.No simple empirically validated model captures the broad range of intervention components across risk behaviors, but the Five A's construct-assess, advise, agree, assist, and arrange-adapted from tobacco cessation interventions in clinical care provides a workable framework to report behavioral counseling intervention review findings. We illustrate the use of this framework with general findings from recent behavioral counseling intervention studies. Readers are referred to the USPSTF (www.ahrq.gov/clinic/prevenix.htm or 1-800-358-9295) for systematic evidence reviews and USPSTF recommendations based on these reviews for specific behaviors.     

Physical activity promotion in primary health care: Results from a German physician survey

Abstract

Background: Primary care physicians are positioned to play an important role in changing physical activity and other health behaviour of their patients. However, little is known about the practice of physical activity promotion in German primary care settings and the factors associated with physical activity promotion. Methods: 260 randomly selected physicians from the State Medical Association of Baden-Wuerttemberg, Germany, took part in this survey (response rate: 13.3%) and provided data on physical activity promotion (physical activity assessment and advice), attitudes towards health promotion and cooperation activities. Factors associated with physical activity promotion were identified using logistic regression. Results: The physicians who replied had positive attitudes towards health promotion. However, 26.9% reported they had inadequate knowledge to provide counselling and 36.7% felt they were unsuccessful in motivating their patients to increase physical activity. Physical activity assessment and advice occurred in 54.9% of the physicians. Compared to their counterparts, physicians in large cities (odds ratio (OR) 3.93; and 95% confidence interval (95%CI): 1.55–9.99), those convinced to offer their patients a great deal in the way of lifestyle counselling (OR 1.92; 95%CI: 1.09–3.40) and those cooperating with sports clubs (OR 1.75; 95%CI: 1.03–2.96) were more likely to provide physical activity promotion. Conclusion: There is a need for interventions to increase the frequency of physical activity promotion by primary care physicians. In particular physicians in rural regions should be assisted and cooperation activities with sports clubs or other health care providers should be encouraged.     

Methods of connecting primary care patients with community-based physical activity opportunities: A realist scoping review

Deemed a global public health problem by the World Health Organization, physical inactivity is estimated to be responsible for one in six deaths in the United Kingdom (UK) and to cost the nation's economy £7.4 billion per year. A response to the problem receiving increasing attention is connecting primary care patients with community-based physical activity opportunities. We aimed to explore what is known about the effectiveness of different methods of connecting primary care patients with community-based physical activity opportunities in the United Kingdom by answering three research questions: 1) What methods of connection from primary care to community-based physical activity opportunities have been evaluated?; 2) What processes of physical activity promotion incorporating such methods of connection are (or are not) effective or acceptable, for whom, to what extent and under what circumstances; 3) How and why are (or are not) those processes effective or acceptable? We conducted a realist scoping review in which we searched Cochrane, Medline, PsycNET, Google Advanced Search, National Health Service (NHS) Evidence and NHS Health Scotland from inception until August 2020. We identified that five methods of connection from primary care to community-based physical activity opportunities had been evaluated. These were embedded in 15 processes of physical activity promotion, involving patient identification and behaviour change strategy delivery, as well as connection. In the contexts in which they were implemented, four of those processes had strong positive findings, three had moderately positive findings and eight had negative findings. The underlying theories of change were highly supported for three processes, supported to an extent for four and refuted for eight processes. Comparisons of the processes and their theories of change revealed several indications helpful for future development of effective processes. Our review also highlighted the limited evidence base in the area and the resulting need for well-designed theory-based evaluations.     

上海市健康促进学校工作效果的定性评估

目的了解健康促进学校创建的效果以及实施过程中遇到的问题，以便更好地开展健康促进学校工作。方法采用小组访谈和问卷调查的方法收集资料，根据分析主题对资料进行编码并分析。结果健康促进学校工作对学校卫生工作有良好的推动作用。实施过程中存在技术层面和管理层面的问题，主要涉及项目设计、评价标准、技术指导和人员培训以及政策、经费和组织的保障、计划、实施、管理机制等。结论创建健康促进学校是提高学生身心健康的有效措施。健康促进学校应该与学校的主体工作相融合，建立长期、系统的技术指导和管理模式：     

New pathways for primary care: an update on primary care programs from the innovation center at CMS

Those in practice find that the fee-for-service system does not adequately value the contributions made by primary care. The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs. All programs coming out of the Innovation Center are tests of new payment and service delivery models. By changing both payment and delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, we may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide.     

Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.     

Prevalence of physical activity,screen time,and obesity among US children by the service type of special health care needs

BackgroundChildren with special health care needs (SHCN) may be at greater risk of obesity than children without SHCN. A new classification system categorizes SHCN among children by service type using the following categories: No-SHCN, medication use only, services use only, medication + service use, and functional limitations. Research is needed to examine obesity and obesity-related behaviors among children using the new classification system.ObjectiveTo determine the prevalence of inadequate vigorous physical activity (VPA), high screen time and obesity by SHCN category using the new classification system.MethodsMultivariate regression models were fitted for inadequate VPA, high screen time, and obesity to determine if there were differences in these outcomes by SHCN category, adjusting for multistage-sampling and survey-design effects using a nationally representative sample of children in the National Survey of Children's Health 2007.Results22.9% of the sample was classified as having SHCN: 9% medication use only, 5% medication + service use, 4% service use only, and 5% functional limitations. Children in the medication use only and medication + service use groups were not at increased risk for inadequate VPA, high screen time, or obesity. Children in the service use only and functional limitation groups had increased odds of high screen time and obesity, which disappeared after controlling for confounders. However, the higher odds of inadequate VPA remained significant in the service use only [OR (95% CI) = 2.00 (1.34–3.00)] and the functional limitations groups with 2.21 (1.55–3.15).ConclusionsPhysical activity promotion programs are needed for children with SHCN, especially children with functional limitations and those who require service use only and do not use prescribed medication.     

Promoting physical activity in women: evaluation of a 2-year community-based intervention in Sydney, Australia

Women are less likely than men to reach recommended levels of physical activity and have unequal access to active leisure time. Studies in Australia have consistently found that women are only half as likely as men to be adequately active. A community-based multi-strategic health promotion intervention, 'Concord, A Great Place to be Active', was implemented from 1997 to 1999. It aimed to increase the physical activity levels of women aged 20-50 years living in the Concord Local Government Area (LGA), an inner-western region of Sydney, Australia. A key feature of this intervention was a partnership between Concord Council (the local government) and the Central Sydney Health Promotion Unit (CSHPU). The project was evaluated using qualitative and quantitative methods. Key informant interviews and focus groups were conducted to inform the development of the intervention and to assess the impact of the project on Concord Council. Pre- and post-intervention telephone surveys of the target group were also conducted. Following the intervention, there was a statistically significant (6.4%) reduction in the proportion of sedentary women. Further, there were a number of positive enhancements in the Council's capacity to promote physical activity in the community. These findings demonstrate that a community-based intervention targeting a specific population can achieve positive changes in physical activity and that a local government has the capacity to be involved in and sustain physical activity interventions.     

The 2016 proposal for the reorganisation of urgent care provision in Belgium: A political struggle to co-locate primary care providers and emergency departments

Internationally the number of emergency department (ED) visits is on the rise while evidence suggests that a substantial proportion of these patients do not require emergency care but primary care. This paper presents the Belgian 2016 proposal for the reorganisation of urgent care provision and places it into its political context. The proposal focused on re-designing patient flow aiming to reduce inappropriate ED visits by improving guidance of patients through the system. Initially policymakers envisaged, as cornerstone of the reform, to roll-out as standard model the co-location of primary care centres and EDs. Yet, this was substantially toned down in the final policy decisions mainly because GPs strongly opposed this model (because of increased workload and loss of autonomy, hospital-centrism, etc.). In fact, the final compromise assures a great degree of autonomy for GPs in organising out-of-hours care. Therefore, improvements will depend on future developments in the field and continuous monitoring of (un-)intended effects is certainly indicated. This policy process makes clear how important it is to involve all relevant stakeholders as early as possible in the development of a reform proposal to take into account their concerns, to illustrate the benefits of the reform and ultimately to gain buy-in for the reform.     

A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil

INTRODUCTION: This study presents a methodology for the rapid assessment of the organization and performance of primary care services at district level. It compares results from an earlier provider survey in Petrópolis, Brazil with those obtained directly from users of two types of primary care services (newly developed Family Health Program services or 'PSF'--Programa de Saúde da Família--and traditional services) in the same municipality. The aim is to demonstrate the validity of the methodology and its potential use in measuring and improving district-level primary care services in developing countries. METHODS: The study adapted a previously developed questionnaire to measure essential dimensions of primary care. Users (n = 468) were randomly selected from each of the 40 primary care clinics in the district and administered a question survey. Responses were used to create nine measures: an overall composite 'total primary care index' and eight sub-indices each pertaining to an essential primary care dimension. RESULTS: Primary care services show considerable variation in user experiences. Users of the new (PSF) clinics reported higher overall assessments of the total primary care index and the sub-indices for gatekeeping, comprehensiveness, family focus and community orientation than did users of traditional services (P < 0.05). The total primary care score was internally consistent with a Cronbach's alpha of 0.8, and could be reduced to only one principal component. User assessments of primary care services were predicted by self-rated health (OR 1.72) and the site of care (OR 1.03). User and provider assessments of the total primary care index were not significantly different, disagreeing on only two sub-indices (gatekeeping and family focus, P < 0.05). CONCLUSIONS: The study presents a rapid and valid method of obtaining information about clinic-level variation in primary care organization and performance at district level. The total primary care index was not sensitive to demographic or socio-economic characteristics of clients, was internally consistent and appears valid given similar results obtained using two different data sources. With some adaptation the instrument could potentially be applied in other developing countries.     

Having a Personal Health Care Provider and Receipt of Colorectal Cancer Testing

PURPOSE We wanted to assess the relationship between having a personal health care provider and receiving colorectal cancer testing.