Randomized controlled trial of physical activity counseling for older primary care patients

BACKGROUND: Regular physical activity reduces the risk for chronic diseases among older adults. Older adults are likely to be seen by primary care clinicians who can play a role in promoting physical activity among their patients. DESIGN: In this randomized controlled trial (1998-2003; data analyzed 2004-2005), we compared the effects of brief advice to exercise from a clinician supplemented by telephone-based counseling by health educators (extended advice) to brief advice from a clinician alone (brief advice). SETTING/PARTICIPANTS: A total of 100 primary care patients (63.2% female, 14.7% minority, mean age=68.5 years) participated in the trial. INTERVENTIONS: The extended-advice intervention consisted of clinician advice plus exercise counseling via telephone provided by research staff, and the brief advice condition consisted of clinician advice alone. Both interventions focused on promoting moderate-intensity physical activity. MAIN OUTCOME MEASURES: Self-reported physical activity using the 7-Day Physical Activity Recall instrument and objective activity monitoring using Biotrainers were assessed at baseline, and at 3 and 6 months. RESULTS: Participants in the extended-advice arm reported significantly greater participation in moderate-intensity physical activity than the brief-advice group at 3 months (+57.69 minutes vs 12.45 minutes; 3.84 kcal/week vs 0.83 kcal/week) and 6 months (+62.84 minutes vs 16.60 minutes; 4.19 kcal/week vs 1.1 kcal/week). Objective activity monitoring also showed significantly increased physical activity among extended-advice versus brief-advice participants at both time points (+50.79 vs -11.11; +42.39 vs -24.18, respectively). CONCLUSIONS: These data indicate that clinician advice with follow-up counseling can promote adoption of moderate-intensity physical activity among older, primary care patients.     

Identifying and helping alcohol abusers attending general health care services

Studies conducted in Canada and elsewhere show a high prevalence of alcohol-related problems among general practice patients, users of accident and emergency services, and patients in some community-based and hospital-based outpatient and residential settings. However, many users of general health care services with alcohol problems are not recognized as such. Also, even when identified, alcohol abusers are not always treated for alcohol abuse per se. Interest in prevention and in early identification of alcohol problems is also low among many health care professionals. Alcohol problems can be prevented and treated. Health care professionals should thus try to identify clients with alcohol-related problems and those at risk. These clients should then be provided with appropriate information and advice and, if necessary, referred to a specialized addiction service. The routine use of simple, structured questions concerning drinking will facilitate the identification process.     

Alcohol-related discussions in primary care: a report from ASPN. Ambulatory Sentinel Practice Network

BACKGROUND: Problem drinking is common, and a 15-minute intervention can help some patients reduce drinking to safe levels. Little is known, however, about the frequency and duration of alcohol-related discussions in primary care. METHODS: Nineteen clinicians in the Ambulatory Sentinel Practice Network (ASPN) collected data about alcohol-related discussions for 1 week following their usual office routine (Phase 1) and for 1 week with the addition of routine screening for problem drinking (Phase 2). Of those, 15 clinicians collected data for a third week after receiving training in brief interventions with problem drinkers (Phase 3). Clinicians collected data on standard ASPN reporting cards. RESULTS: In Phase 1 the clinicians discussed alcohol during 9.6% of all visits. Seventy-three percent of those discussions were shorter than 2 minutes long, and only 10% lasted longer than 4 minutes. When routine screening was added (Phase 2), clinicians were more likely to discuss alcohol at acute-illness visits, but the frequency, duration, and intensity of such discussions did not change. Only 32% of Phase 2 discussions prompted by a positive screening result lasted longer than 2 minutes. After training, the duration increased (P <.004). In Phase 3, 58% of discussions prompted by a positive screening result lasted longer than 2 minutes, but only 26% lasted longer than 4 minutes. CONCLUSION: Routine screening changed the kinds of visits during which clinicians discussed alcohol use. Training in brief-intervention techniques significantly increased the duration of alcohol-related discussions, but most discussions prompted by a positive screening result were still shorter than effective interventions reported in the literature.     

Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force

OBJECTIVE: The purpose of this study was to examine the effectiveness of counseling to promote a healthy diet among patients in primary care settings. DESIGN AND DATA SOURCES: We conducted a MEDLINE search from 1966 to December 2001. STUDY SELECTION: We included randomized controlled trials of at least 3 months' duration with measures of dietary behavior that were conducted in patient populations similar to those found in primary care practices. We excluded studies that reported only biochemical or anthropomorphic endpoints, had dropout rates greater than 50%, or enrolled patients based on the presence of a chronic disease. DATA EXTRACTION: One author extracted relevant data from each included article into evidence tables. Using definitions developed by the research team, two authors independently rated each study in terms of its effect size, the intensity of its intervention, the patient risk level, and the use of well-proven counseling techniques. DATA SYNTHESIS: We identified 21 trials for use in this review. Dietary counseling produces modest changes in self-reported consumption of saturated fat, fruits and vegetables, and possibly dietary fiber. More-intensive interventions were more likely to produce important changes than brief interventions, but they may be more difficult to apply to typical primary care patients. Interventions using interactive health communications, including computer-generated telephone or mail messages, can also produce moderate dietary changes. CONCLUSIONS: Moderate- or high-intensity counseling interventions, including use of interactive health communication tools, can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appears to produce small changes in dietary behavior, but its effect on health outcomes is unclear.     

Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care

BACKGROUND: Over the last 10 years 'exercise referral schemes' have been popular even though the evidence for effectiveness of any one-to-one intervention in primary care is deficient. We report the results of a primary care based one-to-one intervention that compared the effect of two communication styles with a no-intervention control group on self-reported physical activity at 12 months. METHODS: In all, 1658 middle-aged men and women were randomly assigned to 30 minutes of brief negotiation or direct advice in primary care or a no-intervention control group. The main outcome was self-reported physical activity at 12 months. Secondary outcome measures included change in blood pressure and body mass index. RESULTS: Intention-to-treat analysis revealed no significant differences in physical activity between groups. Brief negotiation group participants who completed the study increased their physical activity significantly more than controls. There was no change in body mass index in any group. The brief negotiation group produced a greater reduction in diastolic blood pressure than direct advice. CONCLUSION: If patients whose health may benefit from increased physical activity seek advice in primary care, 20-30 minutes of brief negotiation to increase physical activity is probably more effective than similar attempts to persuade or coerce. However, blanket physical activity promotion in primary care is not effective. The most effective way of increasing physical activity in primary care has yet to be determined.     

Stepped care for depression and anxiety: from primary care to specialized mental health care: a randomised controlled trial testing the effectiveness of a stepped care program among primary care patients with mood or anxiety disorders

Background

There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments.

Methods/design

The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation.

Discussion

This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.

Trial Registration

ISRCTN 93681536     

Receiving an alcohol enquiry from a physician in routine health care in Sweden: a population-based study of gender differences and predictors

Research has shown that the provision of brief interventions in the health care system is effective for reducing hazardous drinking. Using a telephone-administered questionnaire, this study provides a population-based investigation on the extent to which physicians address patients' alcohol habits in the Swedish health care system, whether there are gender differences in the extent to which patients receive questions about alcohol, and predictors for receiving such questions. Data were obtained from monthly telephone surveys with around 72,000 people in 2006-2009. Having received an alcohol enquiry was defined as having been asked about one's drinking habits by a physician in any health care visit in the last 12 months. Fourteen percent of the total population had received an alcohol enquiry, but there were considerable gender differences: for hazardous drinkers, 13% of the women and 17% of the men had received an alcohol enquiry; among those with sensible alcohol consumption, 10% of women and 15% of men had received an alcohol enquiry. Patients were more likely to have received an alcohol enquiry if they had self-reported alcohol-related problems, were hazardous drinkers and/or daily smokers. Some of the alcohol enquiry predictors differed by gender; social class was an important predictor for women but not for men.     

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors

Background

To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).

Methods

A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18?years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High?≥?8 points of contact/hours; Moderate >3 and <8; Low?≤?3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported.

Results

52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.

Conclusion

Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

     

Concurrent Alcohol Use or Heavier Use of Alcohol and Cigarette Smoking Among Women of Childbearing Age with Accessible Health Care

This study was conducted to provide nationally representative findings on the prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age with accessible health care. For the years 2003–2005, a total of 20,912 women 18–44 years of age who participated in the National Health Interview Survey (NHIS) reported that during the study period, there was a place where they would usually go for health care when sick or in need of advice about their health. The prevalence and distribution of concurrent alcohol use or heavier use of alcohol and cigarette smoking reported by such women was calculated. Logistic regression analysis was used to evaluate the “most often visited health care place” among concurrent users who reported having seen or talked to a health care provider during the previous 12 months. Among surveyed women with accessible health care, 12.3% reported concurrent alcohol use and cigarette smoking, and 1.9% reported concurrent heavier use of alcohol and cigarette smoking during the study period. Of women who reported either type of concurrent use, at least 84.4% also indicated having seen or talked to one or more health care providers during the previous 12 months. Such women were more likely than non-concurrent users to indicate that the “most often visited health care place” was a “hospital emergency room or outpatient department or some other place” or a “clinic or health center,” as opposed to an “HMO or doctor’s office.” Concurrent alcohol use or heavier use of alcohol and cigarette smoking among women of childbearing age is an important public health concern in the United States. The findings of this study highlight the importance of screening and behavioral counseling interventions for excessive drinking and cigarette smoking by health care providers in both primary care and emergency department settings.     

Concordance of patient beliefs and expectations regarding the management of low back pain with guideline recommendations – a cross-sectional study in Germany

Pharmacological and behavioural treatments for alcohol use disorders (AUDs) are effective but the uptake is limited. Primary care could be a key setting for identification and continuous care for AUD due to accessibility, low cost and acceptability to patients. We aimed to synthesise the literature regarding differential models of care for the management of AUD in primary health care settings. We conducted a systematic review of articles published worldwide (1998-present) using the following databases; Medline, PsycINFO, Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials and Embase. The Grey Matters Tool guided the grey literature search. We selected randomised controlled trials evaluating the effectiveness of a primary care model in the management of AUD. Two researchers independently assessed and then reached agreement on the included studies. We used the Cochrane risk of bias tool 2.0 for the critical appraisal. Eleven studies (4186 participants) were included. We categorised the studies into ‘lower’ versus ‘higher’ intensity given the varying intensity of clinical care evaluated across the studies. Significant differences in treatment uptake were reported by most studies. The uptake of AUD medication was reported in 5 out of 6 studies that offered AUD medication. Three studies reported a significantly higher uptake of AUD medication in the intervention group. A significant reduction in alcohol use was reported in two out of the five studies with lower intensity of care, and three out of six studies with higher intensity of care. Our results suggest that models of care in primary care settings can increase treatment uptake (e.g. psychosocial and/or pharmacotherapy) although results for alcohol-related outcomes were mixed. More research is required to determine which specific patient groups are suitable for AUD treatment in primary health care settings and to identify which models and components are most effective. PROSPERO: CRD42019120293 .     

Nurse-assisted smoking counseling in medical settings: minimizing demands on physicians

BACKGROUND. In an effort to find more practical smoking intervention models for primary-care settings, three physician-and-nurse team approaches to patient counseling were compared with brief physician advice alone. METHODS. Subjects were 3,161 adult smokers surveyed while waiting to see 1 of 40 primary-care physicians. Physicians delivered a brief stop-smoking prompt to 2,707 (86%) of these smokers and referred them to an on-site smoking counselor (e.g., nurse) who randomly provided a two-page pamphlet (advice-only control) or one of three brief nurse-assisted interventions: (a) self-quit training, (b) recruitment to a group program, or (c) a combination intervention. Smokers usually (87%) agreed to see the counselor. RESULTS. After 3 months, subjects in the three nurse-assisted conditions were more likely to report a serious quit attempt (50% vs 39%, P less than 0.001) than were physician-advice-only subjects. Quit rates at 3 months were also higher (P less than 0.001) in the nurse-assisted self-quit (12.9%), recruitment (14.1%), and combination (13.0%) conditions, compared with those for brief physician advice only (7.6%). CONCLUSION. If long-term efficacy is confirmed, these nurse-assisted counseling approaches will serve as practical smoking intervention models for most medical-care delivery settings.     

Managing alcohol problems and risky drinking

While overall alcohol consumption and alcohol-related automobile deaths have declined, rates of alcohol dependence, liver cirrhosis, and alcohol-related problems remain high among adults, and binge drinking continues as a major health risk for high school and college students. Some individual-level downstream interventions have been evaluated with sufficient rigor to recommend widespread dissemination, and widened availability of new pharmacotherapies could further increase effectiveness. Midstream population-based programs, such as screening and brief interventions in hospitals and managed care organizations, may have greater public health impact than tertiary treatment because of early identification and low cost. Upstream programs and policies that place limits on alcohol availability (e.g., higher legal purchasing age) have the greatest potential to reduce morbidity and mortality at the least cost to society.     

General practice nurses' knowledge of alcohol use and misuse: a questionnaire survey

Nurses in general practice (termed practice nurses) are an under-utilized resource for the detection and management of patients with alcohol misuse. However, little is known about their knowledge and attitudes towards alcohol use and misuse. We therefore conducted a postal questionnaire survey of 132 practice nurses in Liverpool (UK). The results of our survey (response rate 77%) show that a knowledge and skills gap exists in the delivery of effective advice on alcohol-related issues. Indeed, our results suggest that only one in two women and one in three men are receiving correct advice on sensible limits of alcohol consumption, this despite the fact that alcohol histories are taken. Further training was requested by most nurses to develop their screening and health promotion roles, and to become involved in the management of patients with alcohol-related problems in primary care. We suggest practice nurses should be encouraged to become involved in screening for, and management of, alcohol-related problems. However, it is important to ensure that the nurses receive appropriate training and have adequate back-up facilities from doctors and other workers involved in the care of patients with alcohol-related problems.     

Effectiveness of brief intervention on non-dependent alcohol drinkers (EBIAL): a Spanish multi-centre study

OBJECTIVE: The project was designed to compare the effectiveness of brief intervention (BI) versus simple advice (SA) in the secondary prevention of hazardous alcohol consumption. METHODS: A randomized controlled trial with a 12-month follow-up was conducted. A total of 74 community-based primary care practices (328 physicians) located in 13 Spanish autonomous regions were recruited initially. Out of 546 men screened, only 229 were randomized into BI (n = 104) and SA (n = 125); 44.6% of practices finalized the study. The interventions on the BI group consisted of a 15-minute counselling visit carried out by physicians which included: (i) alcohol quantification, (ii) information on safe limits, (iii) advice, (iv) drinking limits agreement, (v) self-informative booklet with drinking diary record and (vi) unscheduled reinforcement visits. The SA group spent 5 minutes which included (i), (ii) and (iii). RESULTS: There were no significant differences between both groups at baseline on alcohol use, age, socioeconomic status and CAGE score. After the 12-month follow-up there was a significant decrease in frequency of excessive drinkers (67% of BI group reached targeted consumption, versus 44% of SA; P < 0.001) as well as weekly alcohol intake reduction (BI reached 52 versus 32% in SA; P < 0.001). A trend to improve outcome with the number of reinforcement visits was found with BI. The only predictor of success was the initial alcohol consumption level. CONCLUSIONS: Brief intervention is more effective than simple advice to reduce alcohol intake on adult men who attend primary care services in Spain.     

Validation of the primary care alcohol severity measure

Alcohol-related disorders are common in primary care settings; many primary care physicians are ill-equipped to manage patients with alcohol-related disorders. The objective of this prospective cohort study was to develop and validate a patient-based measure, the Primary Care Alcohol Severity Measure, to determine which primary care patients with alcohol-related disorders would benefit from referral to alcohol treatment services. Four Boston-area Department of Veterans Affairs ambulatory care clinics were chosen as study sites. Two hundred seventy-eight male patients, mean age 55.5 years, 89.9% Caucasian, 42.5% married, all with CAGE Questionnaire scores greater than or equal to 2 and drinking within past year, participated in the study. We developed a multidimensional, 30-item measure that contained 2 subscales that assessed 2 symptom clusters of alcohol-related disorders: Physical and Behavioral. Each subscale's score was higher (more severe) for patients with a current Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised diagnosis of alcohol dependence or abuse: P < .01 for the physical subscale and P < .0001 for the behavioral subscale. Patients with more physical symptoms had poorer physical and mental health status, whereas patients with more behavioral symptoms had poorer mental health status. Scores on the 2 subscales, along with age and history of prior treatment, predicted the use of alcohol treatment services in the following year: c = 0.90 in logistic regression. The Primary Care Alcohol Severity Measure is a valid measure of alcohol severity in primary care patients and predicts the use of alcohol treatment services. It is relatively brief and easy to use, requiring only standard medical history items and patient reports of behavioral symptoms. It may be a useful tool to improve the quality of care for primary care patients with alcohol-related disorders.     

Screening and brief intervention for hazardous drinking in an HMO: Effects on medical care utilization

This study examined whether a brief intervention to reduce hazardous alcohol consumption among primary care patients reduced use of medical care. In a parent, randomized controlled trial, at-risk drinkers identified in HMO outpatient waiting rooms were randomly assigned to receive usual care or brief clinician advice plus a 15-minute motivational counseling session. The current study (n=514) examined the groups' use of outpatient and inpatient medical services during two years after intervention. Although the intervention reduced alcohol consumption at six-month follow-up, intervention and control groups made similar numbers of outpatient visits (M=17.7 vs. 18.3, respectively;p=.47), were equally likely to be hospitalized (21.2% vs. 22.0%;p=.81), and, among those hospitalized, had similar lengths of stay (4.7 vs. 6.6 days;p=.37). Although brief interventions to reduce hazardous drinking may potentially reduce medical care utilization, more evidence is needed to substantiate their practicality and cost-effectiveness.     

Opinions on alcohol-related issues among professionals in primary, occupational, and specialized health care

— The objective of this study was to analyse differencesin health care personnel's knowledge, skills, and attitudesin relation to alcohol-related matters by a postal questionnairebetween primary, occupational, and specialized health care.Heavy drinking was considered to be common among patients atall health care levels, and particularly in specialized healthcare. However, early recognition and treatment of heavy drinkerswas considered more appropriate in primary and occupationalhealth care, than in specialized health care. Alcohol consumptionwas found to be an easy subject to discuss at all health carelevels. In addition, 90% (165/183) of the respondents thoughtthat patients had a positive or neutral attitude towards questionson their alcohol consumption. Of the respondents, 32% (58/182)considered discussing alcohol-related matters unacceptable and81% (121/149) believed that they could not influence patients'drinking using brief intervention; there was no significantdifference between different settings. Additionally, motivationalskills of doctors and nurses were found to be poor at all healthcare levels. Our study shows that, although discussing alcoholconsumption is easy, better motivational skills and more positiveattitudes are needed in primary, occupational, and specializedhealth care. Professionals need further education at all healthcare levels, but particularly in specialized health care.     

Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis.

BACKGROUND: Earlier meta-analyses have not made a distinction between very brief (5- to 20-min) interventions and extended (several visits) brief interventions. METHODS: Literature searches identified seven publications, comprising 14 data sets, meeting the inclusion criteria: sampling from primary care populations, random allocation to intervention and to control groups, and follow-up time 6-12 months. RESULTS: For very brief interventions, the change in alcohol consumption was not significant among men nor among women. For extended brief interventions, the pooled effect estimate of change in alcohol intake was -51 g of alcohol per week (95% confidence interval -74, -29) among women. Among men the estimate was of similar magnitude, but significant lack of statistical homogeneity implied that the summary estimate was not meaningful. Significant statistical heterogeneity was observed when data on very brief interventions among men and women were pooled. That was the case also for gamma-glutamyltransferase activity. CONCLUSIONS: Extended brief interventions were effective among women. Other brief interventions seem to be effective sometimes, but not always, and the average effect cannot be reliably estimated. The reasons for the lack of uniform effectiveness should be explored.