Assessing multiple risk behaviors in primary care. Screening issues and related concepts

Barriers and facilitators to screen for and address social needs in primary care practices in Maryland: a qualitative study

Background

Social needs screening can help modify care delivery to meet patient needs and address non-medical barriers to optimal health. However, there is a need to understand how factors that exist at multiple levels of the healthcare ecosystem influence the collection of these data in primary care settings.

Methods

We conducted 20 semi-structured interviews involving healthcare providers and primary care clinic staff who represented 16 primary care practices. Interviews focused on barriers and facilitators to awareness of and assistance for patients' social needs in primary care settings in Maryland. The interviews were coded to abstract themes highlighting barriers and facilitators to conducting social needs screening. The themes were organized through an inductive approach using the socio-ecological model delineating individual-, clinic-, and system-level barriers and facilitators to identifying and addressing patients' social needs.

Results

We identified several individual barriers to awareness, including patient stigma about verbalizing social needs, provider frustration at eliciting needs they were unable to address, and provider unfamiliarity with community-based resources to address social needs. Clinic-level barriers to awareness included limited appointment times and connecting patients to appropriate community-based organizations. System-level barriers to awareness included navigating documentation challenges on the electronic health record.

Conclusions

Overcoming barriers to effective screening for social needs in primary care requires not only practice- and provider-level process change but also an alignment of community resources and advocacy of policies to redistribute community assets to address social needs.

Assessing efficacy of a web-based smoking cessation tool - QuitAdvisorMD: Protocol for a practice-based, clustered, randomized control trial

Background

Smoking remains the leading cause of preventable death, yet physicians inconsistently provide best-practices cessation advice to smokers. Point-of-care digital health tools can prompt and assist physicians to provide improved smoking cessation counseling. QuitAdvisorMD is a comprehensive web-based counseling and management digital health tool designed to guide smoking cessation counseling at the point-of-care. The tool enables clinicians to assess patient readiness to change and then deliver stage-appropriate interventions, while also incorporating Motivational Interviewing techniques. We present the research protocol to assess the efficacy of QuitAdvisorMD to change frequency and quality of smoking cessation counseling and its effect on patient quit rates.

Methods

A practice-based, clustered, randomized controlled trial will be used to evaluate QuitAdvisorMD. Cluster design will be used where patients are clustered within primary care practices and practices will be randomized to either the intervention (QuitAdvisorMD) or control group. The primary outcome is frequency and quality of clinician initiated smoking cessation counseling. Secondary outcomes include, 1) changes in physician knowledge, skills and perceived self-efficacy in providing appropriate stage-based smoking cessation counseling and 2) patient quit attempts. Analyses will be conducted to determine pre- and post-test individual clinician outcomes and between intervention and control group practices for patient outcomes.

Conclusion

Results from this study will provide important insights regarding the ability of an integrated, web-based counseling and management tool (QuitAdvisorMD) to impact both the quality and efficacy of smoking cessation counseling in primary care settings.

Health Risk Behaviour Inventory Validation and its Association with Self-regulatory Dispositions

We put forward a validation of the first instrument to measure the big four health risk behaviours (World Health Organization, Global status report on non-communicable diseases 2014, WHO, 2014) in a single assessment, the Health Risk Behaviour Inventory (HRBI) that assesses physical inactivity, unhealthy diet, smoking and alcohol in Italian- and English-speaking samples. Further, we investigate the instrument's association with self-regulatory dispositions, exploring culture and gender differences in Italian and US subgroup samples. Overall, 304 English- and 939 Italian-speaking participants completed the HRBI and the self-regulatory questionnaire. We explored the factorial structure, convergent validity, invariance and association with self-regulatory dispositions using structural equation modelling.The HRBI has a robust factorial structure; it usefully converges with widely used healthy lifestyle measures, and it is invariant across the categories of age, gender and languages. Regarding self-regulatory dispositions, the promotion focus emerges as the most protective factor over physical inactivity, unhealthy diet, smoking and alcohol, whereas the prevention focus is associated mainly with smoking and alcohol reduction. Results are consistent across genders and US subgroup-Italian samples. The HRBI is a valid instrument for assessing the big four health risk behaviours in clinic and research contexts, and among self-regulatory measures, the promotion and prevention foci have the greatest efficacy in eliciting positive health behaviours.

Patient perspectives on tablet-based technology to collect risk factor information in primary care

BACKGROUND

Primary care provides an opportunity to introduce prevention strategies and identify risk behaviours. Algorithmic information technology such as the Risk Factor Identification Tool (RFIT) can support primary care counseling. This study explores the integration of the tablet-based RFIT in primary care clinics to support exploration of patient risk factor information.

METHODS

Qualitative study to explore patients' perspectives of RFIT. RFIT was implemented in two primary care clinics in Manitoba, Canada. There were 207 patients who completed RFIT, offered to them by eight family physicians. We conducted one-on-one patient interviews with 86 patients to capture the patient's perspective. Responses were coded and categorized into five common themes.

RESULTS

RFIT had a completion rate of 86%. Clinic staff reported that very few patients declined the use of RFIT or required assistance to use the tablet. Patients reported that the tablet-based RFIT provided a user-friendly interface that enabled self-reflection while in the waiting room. Patients discussed the impact of RFIT on the patient-provider interaction, utility for the clinician, their concerns and suggested improvements for RFIT. Among the patients who used RFIT 12.1% smoked, 21.2% felt their diet could be improved, 9.3% reported high alcohol consumption, 56.4% reported less than 150 min of PA a week, and 8.2% lived in poverty.

CONCLUSION

RFIT is a user-friendly tool for the collection of patient risk behaviour information. RFIT is particularly useful for patients lacking continuity in the care they receive. Information technology can promote self-reflection while providing useful information to the primary care clinician. When combined with practical tools and resources RFIT can assist in the reduction of risk behaviours.

Using Information Technology to Assess Patient Risk Factors in Primary Care Clinics: Pragmatic Evaluation

BACKGROUND

Tobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review.

OBJECTIVE

This study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics.

METHODS

This is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation.

RESULTS

Clinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups.

CONCLUSIONS

Clinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients' context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care.

Health Risk Behaviors and Resilience Among Low-Income, Black Primary Care Patients: Qualitative Findings From a Trauma-Informed Primary Care Intervention Study

This study describes an intervention with low-income, Black primary care patients and their experience in changing a health risk behavior. Participant themes, including behavioral coping, personal values, accomplishments and strengths, barriers and strategies, and social support, are understood in relationship to health behavior theories. Two structured interviews were conducted 1 month apart. Content analysis was used to analyze responses from 40 participants. Participants were well equipped with resilience-based coping, self-efficacies, and informal social networks despite economic and social disadvantages. Findings from this study have the potential to improve behavioral health coping and reduce racial inequities in health prevalent for this population.

The Social Distance Scale (v1): A Screening Instrument to Assess Patient Adherence to Prevention Strategies during Pandemics

BACKGROUND

This paper describes the development of a brief self-report screening measure of adherence to social distancing and self-protective behaviors in pandemic situations. Items measured behaviors currently established as primary strategies to prevent and reduce the spread of the COVID-19 infection.

METHODS

An item pool of 29 questions was generated with the aim of estimating the frequency of specific behaviors and were written to avoid confounding the description of behavioral actions with evaluative judgements. Responses were collected from 401 young adults using an anonymous online survey.

RESULTS

An Exploratory Factor Analysis was conducted with the purpose of item reduction and subscale development. A 14-item Social Distance Scale emerged, consisting of four subscales: Isolation from Community (IC), Work from Home (WH), Family Contact (FC), and Protective Behaviors (PB). The initial psychometric evaluation of the scales indicated adequate internal consistency and test-retest reliability. (4) Conclusions: The Social Distance Scale (v1) is a promising new instrument which may be applied at the population or individual level. It may be used in conjunction with COVID-19 testing to measure interactions between social distancing factors and transmission. In addition, a reliable screening measure has utility for health service providers to assess patient risk and to provide educational/counseling.

Determining the Cut Off Score of the Healthy Lifestyle Screening Tool among High School Students

Background

Several lifestyle factors such as not smoking, drinking alcohol in moderation, eating healthily, regular exercise, and maintaining a normal weight have been known to play an important role in optimal health. A screening tool that has a standardized score that indicates healthy or risky lifestyle behaviors is needed for health promotion. However, such a tool that focuses on lifestyle behaviors have not incorporated scores to summarize the results. The purpose of this study is to develop the cut-off points of the Healthy Lifestyle Screening tool.

Methods

Data collection in this study was done from 198 Filipino high school students utilizing the Healthy Lifestyle Screening Tool.

Results

Receiver Operating Curve (ROC) results indicated cut-off score of 98 to separate into low and high score groups. The mean scores for all subcomponents were significantly different in between two groups. The general population fell in the high score category with a mean total score of 105.61 in which 81.31% were categorized in the high score group and 18.61% in the low score group. Subjects in general obtained low mean scores in specific subscale components such as rest (2.46) water (2.66) and exercise (2.78).

Conclusion

Increasing the total score by working on low scoring components will be beneficial in achieving a healthy lifestyle. This study reinforced the importance of holistic approach regarding health and well-being among high school students.

Comparison of psychometric properties between recall methods of interview-based physical activity questionnaires: a systematic review

BACKGROUND

This systematic review examined the methodological quality of studies and assessed the psychometric qualities of interview-administered Past-week and Usual-week Physical Activity Questionnaires (PAQs). Pubmed and Embase were used to retrieve data sources.

METHODS

The studies were selected using the following eligibility criteria: 1) psychometric properties of PAQs were assessed in adults; 2) the PAQs either consisted of recall periods of usual 7-days (Usual-week PAQs) within the past 12 months or during the past 7-days (Past-week PAQs); and 3) PAQs were interview-administered. The COSMIN taxonomy was utilised to critically appraise study quality and a previously established psychometric criteria employed to evaluate the overall psychometric qualities.

RESULTS

Following screening, 42 studies were examined to determine the psychometric properties of 20 PAQs, with the majority of studies demonstrating good to excellent ratings for methodological quality. For convergent validity (i.e., the relationship between PAQs and other measures), similar overall associations were found between Past-week PAQs and Usual-week PAQs. However, PAQs were more strongly associated with direct measures of physical activity (e.g., accelerometer) than indirect measures of physical activity (i.e., physical fitness), irrespective of recall methods. Very few psychometric properties were examined for each PAQ, with the majority exhibiting poor ratings in psychometric quality. Only a few interview-administered PAQs exhibited positive ratings for a single psychometric property, although the other properties were either rated as poor or questionable, demonstrating the limitations of current PAQs.

CONCLUSION

Accordingly, further research is necessary to explore a greater number of psychometric properties, or to develop new PAQs by addressing the psychometric limitations identified in the current review.

Child’s Challenging Behaviour Scale, Version 2 (CCBS–2): Psychometric Evaluation With Young Children

OBJECTIVE. In this article, we evaluate psychometric properties of the Child’s Challenging Behaviour Scale, Version 2 (CCBS–2) with mothers of young, typically developing children.

METHOD. A cross-sectional mail survey with Australian mothers (N = 337) included the CCBS–2, the Depression Anxiety Stress Scales, and the Parents’ Evaluation of Developmental Status scale.

RESULTS. Internal consistency was good, and no gender differences in CCBS–2 scores were significant. Significant results included differences between CCBS–2 scores: among children grouped according to age, among children grouped according to pre– and post–school entry, among mothers grouped according to extent of any symptom type, and between this sample and a previously collected age-matched sample of children with disabilities.

CONCLUSION. Of the properties tested, results support sound psychometrics. The CCBS–2 can be used to differentiate children according to age, school entry, and disability as well as to identify families for potential services in behavior management and mental health.

Metric properties of the "prescribe healthy life" screening questionnaire to detect healthy behaviors: a cross-sectional pilot study

Background

Feasible and valid assessment of healthy behaviors is the first step for integrating health promotion in routine primary care. Therefore, the aim of this study was to develop and evaluate the validity and reliability of the “prescribe healthy life” screening questionnaire, a brief tool for detecting physical activity levels, consumption of fruit and vegetables, tobacco use and patients’ compliance with minimal recommendations.

Methods

An observational cross-sectional study to determine the reliability and validity of this questionnaire by means of mixed (qualitative and quantitative) methods. Thirteen healthcare professionals designed the questionnaire. One hundred and twenty-six patients from three primary care health centers within Osakidetza (Basque Health Service, Spain) filled in the “Prescribe Healthy Life” Screening Questionnaire and completed an accelerometry record, the PREDIMED Food Frequency Questionnaire and a co-oximetry as gold standards for physical activity, dietary intake and tobacco use, respectively. Correlations, sensitivities, specificities, likelihood ratios and test-retest reliability were calculated. Additionally, the feasibility and utility of the questionnaire were evaluated.

Results

Both reliability and concurrent validity for the consumption of fruit and vegetables (r_spearman = 0.59, r_spearman = 0.50) and tobacco use (r_spearman = 0.76, r = 0.69) as their overall performance in the detection of unhealthy diet (accuracy = 76.8%, LR + = 3.1 and LR- = 0.31) and smokers (accuracy = 86.8%, LR + = 6.1 and LR- = 0.05) were good. Meanwhile, the reproducibility (0.38), the correlation between the minutes of physical activity (0.34) and LR+ (1.00) for detection of physical activity were low. On average the questionnaire was considered by patients easy to understand, easy to fill in, short (5–6 min) and useful.

Conclusion

The “Prescribe Healthy Life” Screening Questionnaire, PVS-SQ, has proved to be a simple and practical tool for use in the actual context of primary care, with guarantees of validity and reliability for the diet and tobacco scales. However, the physical activity scale show unsatisfactory results, and alternative questions ought to be tested.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3898-8) contains supplementary material, which is available to authorized users.

Building a Footbridge From Research to Practice in Cardiovascular Risk Reduction

As Rippe, Angelopoulos, and Zukley noted in their State-of-the-Art Review, empirically supported lifestyle modification strategies offer numerous advantages over other modalities for reducing cardiovascular risks. Yet, despite compelling evidence for their implementation, the translation of lifestyle interventions from research to practice has been challenging. Their review prompts discussion of several especially thorny barriers including the persistent tensions between (1) research and practice, (2) main effects and mediators, (3) single and multifactor approaches to risk management, and (4) primary care and communitybased systems of health delivery.

Nurse and Physician Involvement in Health Risk Appraisals: An Integrative Review

Unhealthy lifestyle behaviors continue to be a strong contributor to chronic illness and death in the United States. Despite the health care system's efforts to refocus on prevention, primary care visits remain acute care focused. Health risk appraisals are tools that can be used by primary care providers to enhance lifestyle behavior change and prevention efforts. The purpose of this integrative review is to examine nurse and physician use of health risk appraisals in primary care. A total of 26 national and international papers, selected through an electronic database and ancestry search, were reviewed. Identified nurse and physician interventions in addition to other programming included helping participants understand and interpret feedback, behavioral counseling, and development of plans to address unhealthy lifestyle behaviors. The most common intervention was provision of telephonic nurse advice lines. Overall outcomes were positive. The use of these tools could be key to enhancing primary care prevention.

Substance Use Patterns Through Early Adulthood: Results for Youth With and Without Chronic Conditions

INTRODUCTION

Adolescence and emergent adulthood are periods of peak prevalence for substance use that pose risks for short- and long-term health harm, particularly for youth with chronic medical conditions (YCMC) who are transitioning from adolescence to adulthood. As there have been no nationally representative studies of substance use during this period for these medically vulnerable youth, the authors sought to examine onset and intensification of these behaviors for a national sample of youth with and without chronic conditions.

METHODS

Longitudinal data are from 2,719 youth between the ages of 12 and 26 years interviewed from 2002 to 2011 for the Panel Study of Income Dynamics, Child Development and Transition to Adulthood Supplements, a nationally representative, population-based survey. Multivariate generalized linear mixed models were used to estimate patterns of alcohol, tobacco, and marijuana use during adolescence and emergent adulthood for youth with and without chronic conditions, adjusting for potential confounders.

RESULTS

Overall, 68.8%, 44.3%, and 47.8% of youth reported ever trying alcohol, tobacco, and marijuana, respectively. Among users, 42.2%, 73.4%, and 50.3% of youth reported binge drinking, regular cigarette use, and recent marijuana use, respectively. YCMC were more likely to engage in any and heavier substance use; transition years and early adulthood were periods of peak risk for YCMC compared with their healthy peers.

CONCLUSIONS

Substance use among YCMC during adolescence and emergent adulthood is a substantial concern. Increased prevention and case detection are in order to address these behaviors and promote optimal health outcomes for medically vulnerable youth.

Is Using the Strengths and Difficulties Questionnaire in a Community Sample the Optimal Way to Assess Mental Health Functioning?

An important characteristic of a screening tool is its discriminant ability or the measure's accuracy to distinguish between those with and without mental health problems. The current study examined the inter-rater agreement and screening concordance of the parent and teacher versions of SDQ at scale, subscale and item-levels, with the view of identifying the items that have the most informant discrepancies; and determining whether the concordance between parent and teacher reports on some items has the potential to influence decision making. Cross-sectional data from parent and teacher reports of the mental health functioning of a community sample of 299 students with and without disabilities from 75 different primary schools in Perth, Western Australia were analysed. The study found that: a) Intraclass correlations between parent and teacher ratings of children's mental health using the SDQ at person level was fair on individual child level; b) The SDQ only demonstrated clinical utility when there was agreement between teacher and parent reports using the possible or 90% dichotomisation system; and c) Three individual items had positive likelihood ratio scores indicating clinical utility. Of note was the finding that the negative likelihood ratio or likelihood of disregarding the absence of a condition when both parents and teachers rate the item as absent was not significant. Taken together, these findings suggest that the SDQ is not optimised for use in community samples and that further psychometric evaluation of the SDQ in this context is clearly warranted.

Should schools expect poor physical and mental health, social adjustment, and participation outcomes in students with disability?

The literature on whether students with disabilities have worse physical and mental health, social adjustment, and participation outcomes when compared to their peers without disabilities is largely inconclusive. While the majority of case control studies showed significantly worse outcomes for students with disabilities; the proportion of variance accounted for is rarely reported. The current study used a population cross-sectional approach to determine the classification ability of commonly used screening and outcome measures in determining the disability status. Furthermore, the study aimed to identify the variables, if any, that best predicted the presence of disability. Results of univariate discriminant function analyses suggest that across the board, the sensitivity of the outcome/screening tools to correctly identify students with a disability was 31.9% higher than the related Positive Predictive Value (PPV). The lower PPV and Positive Likelihood Ratio (LR+) scores suggest that the included measures had limited discriminant ability (17.6% to 40.3%) in accurately identifying students at-risk for further assessment. Results of multivariate analyses suggested that poor health and hyperactivity increased the odds of having a disability about two to three times, while poor close perceived friendship and academic competences predicted disability with roughly the same magnitude. Overall, the findings of the current study highlight the need for researchers and clinicians to familiarize themselves with the psychometric properties of measures, and be cautious in matching the function of the measures with their research and clinical needs.

Provider Advice on Exercise and Diet Among Adults With Comorbid Serious Psychological Distress and Diabetes or Diabetes Risk Factors

Purpose

To examine the lifetime prevalence and correlates of provider advice to increase exercise and reduce dietary fat intake among adults with comorbid serious psychological distress (SPD) and diabetes or diabetes risk factors.

Methods

Study sample (n = 5942) was selected from the Medical Expenditure Panel Survey Household Component (MEPS-HC) series of 2007-2011. SPD was defined as a score of ≥13 on the Kessler Psychological Distress Scale (K6). Multivariate logistic regression was used to examine correlates of lifetime provider advice.

Results

Less than half of adults with SPD had been advised to increase exercise (49.4%) or reduce dietary fat intake (45.6%). The prevalence of receiving provider advice increased in a linear fashion as the number of diabetes risk factors increased and was the highest among those with diabetes. Provision of provider advice was strongly associated with clinical factors rather than individuals’ sociodemographic characteristics and current health behaviors.

Conclusions

Health care providers are missing opportunities to provide exercise and low-fat dietary advice to patients with SPD before they manifest clinical risk factors associated with diabetes. It is important that providers counsel them as early as possible about exercise and nutritional changes that reduce the risks associated with diabetes.

Personality and Serum Lipids: Does Lifestyle Account for Their Concurrent and Long–Term Relationships

This study evaluates concurrent and over time associations of personality with measures of three serum lipids associated coronary heart disease morbidity, namely, high–density lipoprotein cholesterol (HDL–C), low–density lipoprotein cholesterol and triglyceride (TRI). Participants were individuals who underwent a health examination at two points of time, T1 (N = 3835) and T2 (N = 2283), about 2.5 years apart. Personality was assessed by the Five–Factor Model. Health, socioeconomic status and healthy lifestyle behaviours (smoking intensity, physical activity and body weight) were controlled. Regression analyses indicate that the personality factors of neuroticism, extraversion and conscientiousness are each significantly associated with HDL–C and TRI, both concurrently and over time. However, most of these associations decreased to marginal significance when adjusted for body weight or physical activity as possible mediators. Both concurrent and over time associations of the openness personality trait with HDL–C and TRI were significant and persisted after adjustment for measures of a healthy lifestyle. This study emphasizes the importance of collecting measures of a healthy lifestyle to better understand how personality might influence serum lipids. Copyright © 2013 European Association of Personality Psychology

A systematic review of randomized controlled trials on the effectiveness of computer-tailored physical activity and dietary behavior promotion programs: an update

Background

A review update is necessary to document evidence regarding the effectiveness of computer-tailored physical activity and nutrition education.

Purpose

The purpose of this study was to summarize the latest evidence on the effectiveness of computer-tailored physical activity and nutrition education, and to compare the results to the 2006 review.

Methods

Databases were searched for randomized controlled trials evaluating computer-tailored physical activity and nutrition education aimed at primary prevention in adults, published from September 2004 through June 2011.

Results

Compared to the findings in 2006, a larger proportion of studies found positive effects for computer-tailored programs compared to generic or no information, including those for physical activity promotion. Effect sizes were small and generally at short- or medium-term follow-up.

Conclusions

The results of the 2006 review were confirmed and reinforced. Future interventions should focus on establishing larger effect sizes and sustained effects and include more generic health education control groups and objective measurements of dietary behavior.

Electronic supplementary material

The online version of this article (doi:10.1007/s12160-012-9384-3) contains supplementary material, which is available to authorized users.

Low conscientiousness and risk of all-cause, cardiovascular and cancer mortality over 17 years: Whitehall II cohort study

OBJECTIVE

To examine the personality trait conscientiousness as a risk factor for mortality and to identify candidate explanatory mechanisms.

METHODS

Participants in the Whitehall II cohort study (N=6800, aged 34 to 55 at recruitment in 1985) completed two self-reported items measuring conscientiousness in 1991-1993 ('I am overly conscientious' and 'I am overly perfectionistic', Cronbach's α=.72), the baseline for this study. Age, socio-economic status (SES), social support, health behaviours, physiological variables and minor psychiatric morbidity were also recorded at baseline. The vital status of participants was then monitored for a mean of 17 years. All-cause and cause-specific mortality was ascertained through linkage to a national mortality register until January 2010.

RESULTS

Each 1 standard deviation decrease in conscientiousness was associated with a 10% increase in all-cause (hazard ratio [HR]=1.10, 95% CI 1.003, 1.20) mortality. Patterns were similar for cardiovascular (HR=1.17, 95% CI 0.98, 1.39) and cancer mortality (HR=1.10, 95% CI 0.96, 1.25), not reaching statistical significance. The association with all-cause mortality was attenuated by 5% after adjustment for SES, 13% for health behaviours, 14% for cardiovascular risk factors, 5% for minor psychiatric morbidity, 29% for all variables. Repeating analyses with each item separately and excluding participants who died within five years of personality assessment did not change the results materially.

CONCLUSION

Low conscientiousness in midlife is a risk factor for all-cause mortality. This association is only partly explained by health behaviours, SES, cardiovascular disease risk factors and minor psychiatric morbidity in midlife.

Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension

Behavioral risk factors are among the preventable causes of health disparities, yet long-term change remains elusive. Many interventions are designed to increase self-efficacy, but little is known about the effect on long-term behavior change in older, low-income African Americans, especially when facing more problematic barriers. A cohort of 185 low-income African-Americans with hypertension reported barriers they encountered while undergoing a multiple behavior change trial from 2002 to 2006. The purpose of the present study was to explore the relationships between self-efficacy, barriers, and multiple behavior change over time. Higher self-efficacy seemed to be partially helpful for smoking reduction and increasing physical activity, but not for following a low-sodium diet. Addiction was indirectly associated with less reduction in smoking through lower self-efficacy. Otherwise, different barriers were associated with behavior change than were associated with self-efficacy: being "too busy" directly interfered with physical activity and "traditions" with low-sodium diet; however, they were neither the most frequently reported barriers, nor associated with lower self-efficacy. This suggests that an emphasis on self-efficacy alone may be insufficient for overcoming the most salient barriers encountered by older African Americans. Additionally, the most common perceived barriers may not necessarily be relevant to long-term behavioral outcomes.

Who is not adhering to physical activity referrals, and why?

OBJECTIVE

To analyse patients' self-reported reasons for not adhering to physical activity referrals (PARs).

DESIGN AND SETTING

Data on 1358 patients who did not adhere to PARs were collected at 38 primary health care (PHC) centres in Sweden.

INTERVENTION

PHC providers issued formal physical activity prescriptions for home-based activities or referrals for facility-based activities.

SUBJECTS

Ordinary PHC patients whom regular staff believed would benefit from increased physical activity.

MAIN OUTCOME MEASURE

Reasons for non-adherence to PARs: "sickness", "pain", "low motivation", "no time", "economic factors", and "other".

RESULTS

Sickness and pain were the most common motives for non-adherence among older patients. The youngest patients blamed economic factors and lack of time more frequently than those in the oldest age group. Economic factors was a more common reason for non-adherence among those referred for facility-based activities compared with those prescribed home-based activities. Low motivation was a more frequent cause of non-adherence among those prescribed home-based activities compared with those referred for facility-based activities. Furthermore, lack of time was a more common reason for non-adherence among patients issued with PARs due to high blood pressure than other patients, while low motivation was a more common reason among patients issued with PARs because of a BMI of > 25.

CONCLUSION

The reasons for non-adherence differ between patients prescribed home-based activities and referred for facility-based activities, as well as between patients with different specific characteristics. The information obtained may be valuable not only for the professionals working in PHC, but also for those who work to develop PARs for use in different contexts.

Zur wahrgenommenen Förderlichkeit multipler Gesundheitsverhaltensweisen für die Gesundheitserhaltung

Zusammenfassung. Ziel dieser Online-Studie war die Einschätzung der wahrgenommenen Förderlichkeit multipler Gesundheitsverhaltensweisen für die Gesundheitserhaltung in einer heterogenen Stichprobe von Gesundheitsexperten (Mediziner, Psychologen und andere Gesundheitsberufe) und Laien (Schüler/Studierende und gesundheitsferne Berufe). Fünfhundertundacht Personen (53% Frauen) im mittleren Alter von 34.4 Jahren schätzten ein, inwieweit sich 39 Verhaltensweisen förderlich oder hinderlich auf die Gesundheitserhaltung einer Person im Allgemeinen auswirken. Diese spezifischen Konsequenzerwartungen unterschieden sich deutlich, so dass sehr wirksame und weniger wirksame Verhaltensweisen identifiziert werden konnten. Eine Hauptkomponentenanalyse mit obliquer Rotation ergab eine Lösung mit fünf unabhängigen Komponenten, die 44.3% der Varianz erklärten und als abhängige Variablen in eine altersadjustierte 5 × 2 MANCOVA (Fachlichkeit × Geschlecht) eingingen. Der signifikante multivariate Haupteffekt für Fachlichkeit war auf Vorsorgeverhalten und Sicherheitsorientiertes Verhalten zurückzuführen, wobei insbesondere Mediziner die stärksten Gesundheitskontingenzen wahrnahmen. Der signifikante multivariate Haupteffekt für Geschlecht ging auf Psychosoziales Regulationsverhalten, Substanzenbezogene Abstinenz, Vorsorgeverhalten und Selbstpflegeverhalten zurück, wobei Frauen erwartungsgemäß stärkere Kontingenzen wahrnahmen als Männer. Auf Gesundheitserhaltung bezogene Konsequenzerwartungen sind das Ergebnis einer Berufs- und Geschlechtersozialisation und damit prinzipiell veränderbar. Als Voraussetzung für die Entwicklung von Kompetenzerwartungen sollten Konsequenzerwartungen im Rahmen von Interventionsmaßnahmen mehr Beachtung finden.

Factors associated with patients self-reported adherence to prescribed physical activity in routine primary health care

Background

Written prescriptions of physical activity have increased in popularity. Such schemes have mostly been evaluated in terms of efficacy in clinical trials. This study reports on a physical activity prescription referral scheme implemented in routine primary health care (PHC) in Sweden. The aim of this study was to evaluate patients' self-reported adherence to physical activity prescriptions at 3 and 12 months and to analyse different characteristics associated with adherence to these prescriptions.

Methods

Prospective prescription data were obtained for the general population in 37 of 42 PHC centres in Östergötland County, during 2004. The study population consisted of 3300.

Results

The average adherence rate to the prescribed activity was 56% at 3 months and 50% at 12 months. In the multiple logistic regression models, higher adherence was associated with higher activity level at baseline and with prescriptions including home-based activities.

Conclusions

Prescription from ordinary PHC staff yielded adherence in half of the patients in this PAR scheme follow-up.

Multiple health behavior clusters among female college students

OBJECTIVE

To examine prevalence of multiple unhealthful behaviors and detect clusters of unhealthful behaviors among college women.

METHODS

Women ages 18-22 enrolled full-time at an urban university located in the Northeastern United States were invited to complete an online survey, which assessed maintenance behaviors: fruits/vegetables, physical activity, cervical screening and at-risk behaviors: frequent drinking, smoking, and non-use of protective measures during sexual intercourse. Of 4774 invited, complete data is available for 1463 participants (1463/4774=30.6%).

RESULTS

Nearly 65% had two or more unhealthful behaviors. Three distinct clusters were defined: cluster one included women who were lower in health maintenance and higher in at-risk behaviors; cluster two included women who were lower in health maintenance and lower in at-risk behaviors; and cluster three included women who were higher in health maintenance and intermediate in at-risk behaviors.

CONCLUSION

These clustering patterns suggest health programs directed at college students address multiple behaviors simultaneously.

PRACTICE IMPLICATIONS

Programs targeting multiple behaviors should consider activities for those seen within and outside of the context of health services.

Acceptance, Communication Mode and Use of Audio Computer-Assisted Self Interview Using Touchscreen to Identify Risk Factors among Pregnant Minority Women

This paper evaluates the acceptability, communication mode and use of audio computer-assisted self-interview (A-CASI) among minority pregnant women receiving prenatal care in six Washington, DC sites. A total of 2,913 women were screened for demographic eligibility (18+ years old, <29 weeks gestation, Black/African-American or Hispanic) and risk (smoking, environmental tobacco smoke exposure, depression, intimate partner violence). Questions were displayed on touch screen laptop monitors and heard through earphones. The mean length of time to complete the screener was almost 6 minutes.A-CASI experience, which included difficulty in using the computer, acceptability (enjoyment), and preferred communication mode, was compared across sites, the eligibility and risk groups and a subset of 878 enrolled women for whom educational attainment and receipt of WIC (a proxy for income) were available. Respondents thought A-CASI was not difficult to use and liked using the computer. Black/African-American or Hispanic respondents enjoyed it significantly more than did respondents of other race/ethnicities. Respondents who were demographically eligible, Black/African-American or Hispanic, or with lower education levels listened to questions significantly more than did their counterparts. Mainly listening or listening and reading does not impact burden in terms of the length of time it took to complete the screener.The acceptance of A-CASI as a screening tool opens the door for more uses of this technology in health-related fields. The laptop computer and headphones provide privacy and mobility so the technology can be used to ask sensitive questions in almost any locale, including busy clinic settings.

Preventing and managing cardiometabolic risk: the logic for intervention

Cardiometabolic risk (CMR), also known as metabolic syndrome or insulin resistance syndrome, comprises obesity (particularly central or abdominal obesity), high triglycerides, low HDL, elevated blood pressure, and elevated plasma glucose. Leading to death from diabetes, heart disease, and stroke, the root cause of CMR is inadequate physical activity, a Western diet identified primarily by low intake of fruits, vegetables, and whole grains, and high in saturated fat, as well as a number of yet-to-be-identified genetic factors. While the pathophysiological pathways related to CMR are complex, the universal need for adequate physical activity and a diet that emphasizes fruits and vegetables and whole grains, while minimizing food high in added sugars and saturated fat suggests that these behaviors are the appropriate focus of intervention.

The socio-demographic patterning of sexual risk behaviour: a survey of young men in Finland and Estonia

BACKGROUND

Sexually transmitted infections (STIs) among the youth are an increasing challenge for public health in Europe. This study provided estimates of men's (18-25 years) sexual risk behaviour and self-reported STIs and their socio-demographic patterning in Finland and Estonia; two countries that are geographically close, but have very different STI epidemics.

METHOD

Nationally representative cross-sectional population surveys with comparable survey questions were used. Data from self-administered questionnaires for 1765 men aged 18-25 years in Finland (85% of the age cohort was included in the sampling frame, 95% of the sample responded) and 748 in Estonia, with a response rate of 43% respectively, were analysed. Socio-demographic patterning of multiple partners, condom use and self-reported STIs are presented was studied using multiple logistic regression analysis.

RESULTS

The main findings focus on associations found within each country. In Finland, higher age, low education and to a lesser extent relationship with a non-steady partner increased the likelihood of reporting multiple lifetime-partners, while in Estonia only higher age and low education revealed this effect. In relation to unprotected intercourse, in Finland, higher age, low education and relationship status with a steady partner increased the likelihood of reporting unprotected intercourse. In Estonia, the same was observed only for relationship status. In Finland the likelihood of self-reported STIs increased by older age and lower education and decreased by being with a non-steady partner, while in Estonia, a non-significant increase in self-reported STIs was observed only in the older age group.

CONCLUSION

A clear socio-demographic patterning for sexual behaviour and self-reported STIs was revealed in Finland, but a less consistent trend was seen in Estonia. The findings of this study suggest that prevention strategies should focus in Finland on less educated singles and in Estonia on young men generally.

Common measures, better outcomes (COMBO): a field test of brief health behavior measures in primary care

BACKGROUND

Primary care offices have been characterized as underutilized settings for routinely addressing health behaviors that contribute to premature death and unnecessary suffering. Practical tools are needed to routinely assess multiple health risk behaviors among diverse primary care patients. The performance of a brief set of behavioral measures used in primary care practice is reported here.

METHODS

Between August 2005 and January 2007, 75 primary care practices assessed four health behaviors, using a 21-item patient self-report questionnaire for adults or a 16-item questionnaire for adolescents. Data were collected via telephone, paper, or electronic means, either with or without assistance. The performance of these measures was evaluated by describing risk-behavior prevalences, combinations of risk behaviors, and missing data.

RESULTS

Of 227 adolescents and 5358 adults, most patients completed all of the survey questions. Two or more unhealthy behaviors were reported by 47.1% of adolescents and 69.2% of adults. Percentages of adults who completed all the survey items varied by health behavior: tobacco use, 98.5%; diet, 98.2%; physical activity, 96.2%; alcohol use, 85.1%. Missing data rates were higher for unassisted patient self-reporting.

CONCLUSIONS

A relatively brief set of health behavior measures was usable in a variety of primary care settings with adults and adolescents. The performance of these measures was uneven across behaviors and administration modes, but yielded estimates of unhealthy behaviors consistent overall with what would be expected based on published population estimates. Further work is needed on measures for alcohol use and physical activity to bring practical assessment tools for key health behaviors to routine primary care practice.

Practice-level approaches for behavioral counseling and patient health behaviors

BACKGROUND

There is little empirical evidence to show that a practice-level approach that includes identifying patients in need of health behavior advice and linking them to counseling resources either in the practice or in the community results in improvements in patients' behaviors. This study examined whether patients in primary care practices that had practice-level approaches for physical activity and healthy-diet counseling were more likely to have healthier behaviors than patients in practices without practice-level approaches.

METHODS

A cross-sectional study of 54 primary care practices was conducted from July 2005 to January 2007. Practices were categorized into four groups depending on whether they had both identification tools (health risk assessment, registry) and linking strategies (within practice or to community resources); identification tools but no linking strategies; linking strategies but no identification tools; or neither identification tools nor linking strategies.

RESULTS

Controlling for patient and practice characteristics, practices that had both identification tools and linking strategies for physical activity counseling were 80% more likely (95% CI=1.25, 2.59) to have patients who reported exercising regularly compared to practices that lacked both. Also, practices that had either identification tools or linking strategies but not both were approximately 50% more likely to have patients who reported exercising regularly. The use of a greater number of practice-level approaches for physical activity counseling was associated with higher odds of patients' reporting exercising regularly (p for trend=0.0002). Use of identification tools and linking strategies for healthy-eating counseling was not associated with patients' reports of healthy diets.

CONCLUSIONS

This study suggests that practice-level approaches may enable primary care practices to help patients improve physical activity. However, these approaches may have different effects on different behaviors, and merit further research to determine if causal pathways exist and, if so, how they should be applied.

Does a physical activity referral scheme improve the physical activity among routine primary health care patients?

Physical activity referral (PAR) schemes or concepts occur in varying forms. Because few physical activity intervention studies have been carried out in routine health care settings, it is difficult to translate research findings into daily practice. The aim of this study was to analyze the effectiveness of a PAR scheme implemented in routine primary health care. The study did not include a control group and was based on the ordinary staff's work efforts and follow-up measures. During a 2-year period, 6300 PARs were issued. Effectiveness was measured by an increase in self-reported physical activity. Half of the patients reached reported increased physical activity both at 3 months (49%) and at 12 months (52%). The proportion of inactive patients decreased from 33% at baseline to 17% at 3 months and 20% at 12 months. The proportion of patients who were physically active on a regular basis increased from 22% at baseline to 33% at 3 months and 32% at 12 months. Neither the patient's age nor the profession of the prescriber was associated with differences in effectiveness. The patient's activity level at baseline, the type of physical activity as well as the reason for the prescription were associated with increased physical activity.

A quality improvement tool to assess self-management support in primary care

BACKGROUND

Self management is an essential, central component of effective care for diabetes and other chronic illnesses, yet very few instruments exist to assess delivery or consistency of self-management support. The Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management (PCRS) tool assesses both organizational infrastructure and delivery of self-management support services.

METHODS

The PCRS was developed by the Robert Wood Johnson Foundation Diabetes Initiative and underwent several stages of development, including three pilot tests, review by experts, and implementation by a national quality improvement (QI) program.

RESULTS

The development and testing of the instrument resulted in the current 16-item measure. Use of the PCRS in a QI collaborative with 20 diverse health care teams across the United States demonstrated that the instrument is helpful in assessing areas for improvement.

DISCUSSION

Initial experience suggests that the PCRS is a user-friendly self-assessment tool that primary care teams can use to assess their current capacity to support and implement consistent patient-centered self management. The initial evaluation indicates that the PCRS has acceptable psychometric properties and is applicable across different types of primary care teams and chronic illness conditions.

Men's tobacco and alcohol use during and after pregnancy

Men's health risk behaviors are rarely considered as a component of their partners' prenatal care. Men living with a pregnant partner completed telephone surveys at two time points, during pregnancy and postpartum, answering questions about tobacco and alcohol use behaviors and other sociodemographic variables. Men's smoking did not change significantly from pregnancy (46.9%) to postpartum (45.8%). Hazardous drinking (five or more drinks/day in a month) changed from 27.1% to 22.9%. Nonsmoking status of men was significantly related to a pregnant partner's quitting smoking during pregnancy and remaining quit at postpartum (p = .019). Household prohibitions from indoor smoking increased from 62.5% at pregnancy to 76% postpartum (p = .009). Pregnancy alone does not appear sufficient for men to quit smoking or change hazardous drinking. Continued exclusion of young men during prenatal care is a missed opportunity to address health risk behaviors and improve paternal, maternal, and family health.

Multiple behavioral risk factors for colorectal cancer and colorectal cancer screening status

BACKGROUND

Individuals who are not adherent to colorectal cancer screening have a greater prevalence of several other behavioral risk factors for colorectal cancer than adherent individuals. However, previous relevant studies have typically not considered the co-occurrence of such behavioral risk factors at the individual level. In the current study, we examined the prevalence, patterns, and predictors of multiple behavioral risk factors for colorectal cancer according to colorectal cancer screening status (adherent versus not adherent).

METHODS

The study sample consisted of 11,090 individuals ages 50 years and older who participated in the 2000 National Health Interview Survey. Based on responses to survey questions, individuals were categorized as being adherent or not adherent to colorectal cancer screening guidelines and were also denoted as having or not having each of seven behavioral risk factors for colorectal cancer (smoking, low physical activity, low fruit and vegetable intake, high caloric intake from fat, obesity, high alcohol intake, and low intake of multivitamins).

RESULTS

Individuals who were not adherent to screening reported having a greater number of risk factors than adherent individuals. For each screening group, there was a high prevalence of having low physical activity, low fruit and vegetable intake, and low intake of multivitamins. Demographic and health-related correlates of behavioral risk factor prevalence were identified in both screening groups.

CONCLUSIONS

In combination with efforts to promote colorectal cancer screening uptake and adherence, there is a need to develop interventions to modify the colorectal cancer behavioral risk factors that are common among screening-adherent and nonadherent individuals.

Health Risk Behavior of Rural Low-Income Expectant Fathers

OBJECTIVE

To assess expectant fathers' health risk behaviors and attitudes about pregnancy-related health issues. Pregnancy may be viewed as a teachable moment: a time when women are receptive to health advice and take action to improve their health and the health of their babies. Pregnancy may also be a teachable moment for expectant fathers, although men's behaviors are rarely considered as part of prenatal care or in associated research.

DESIGN

Cross-sectional prevalence study.

SAMPLE

Rural low-income expectant fathers (N=138) whose pregnant partners had enrolled in a Medicaid managed care health plan.

MEASUREMENT

A telephone survey measuring five health risk behaviors, sociodemographic variables, and pregnancy- and behavior change-related attitudes.

RESULTS

Analyses found the following: 49.3% smoked cigarettes; 30.4% engaged in hazardous drinking in the past month; 27.5% had very low physical activity levels; 94.9% had at-risk fruit/vegetable intake; and 42% had weight-related health risk (25.4% met body mass index [BMI] criteria for obesity). Further, 47.9% of the men engaged in three or more of five assessed health risk behaviors.

CONCLUSIONS

This sample of expectant fathers engages in high rates of health risk behaviors. Failure to address the health risk behavior of men during prenatal care represents a missed opportunity to improve paternal, maternal, and family health.

Practical and relevant self-report measures of patient health behaviors for primary care research

PURPOSE

With increasing evidence for the value of behavior change counseling, there is a need for health behavior measurements that can be implemented in primary care research. This article discusses criteria for and reviews self-report measures to briefly assess cigarette smoking, eating patterns, physical activity, and risky drinking across the life course. It then proposes pragmatic measures for use in practice-based research.

METHODS

Drawing from literature reviews, previous multisite studies, personal communications with experts in the field, and guidance from an expert panel, we identified self-report behavior change measures and gave priority to items that addressed Healthy People 2010 goals, as well as those that were practical (ie, shorter, and easier to score and use for intervention), were sensitive to change, and produced results that could directly inform primary care intervention.

RESULTS

Separate recommendations are described for measures for adults and for children/adolescents. We recommend a set of 22 items for adults and 16 items for adolescents to track succinctly their status on the 4 health behaviors above. Perfected measures remain elusive: newly developed measures of physical activity and eating patterns are recommended, and in general, the brief measures for adults are currently better validated than are the child measures.

CONCLUSIONS

A set of totally satisfactory practical instruments for measuring behavior change in primary care settings does not yet exist. There is sufficient progress to encourage use of and further research on the proposed items. Use of a common set of items across different interventions and projects will help to advance clinical and behavioral research in primary care settings.

Multiple behavioral risk factor interventions in primary care. Summary of research evidence

BACKGROUND

An important barrier to the delivery of health behavior change interventions in primary care settings is the lack of an integrated screening and intervention approach that can cut across multiple risk factors and help clinicians and patients to address these risks in an efficient and productive manner.

METHODS

We review the evidence for interventions that separately address lack of physical activity, an unhealthy diet, obesity, cigarette smoking, and risky/harmful alcohol use, and evidence for interventions that address multiple behavioral risks drawn primarily from the cardiovascular and diabetes literature.

RESULTS

There is evidence for the efficacy of interventions to reduce smoking and risky/harmful alcohol use in unselected patients, and evidence for the efficacy of medium- to high-intensity dietary counseling by specially trained clinicians in high-risk patients. There is fair to good evidence for moderate, sustained weight loss in obese patients receiving high-intensity counseling, but insufficient evidence regarding weight loss interventions in nonobese adults. Evidence for the efficacy of physical activity interventions is limited. Large gaps remain in our knowledge about the efficacy of interventions to address multiple behavioral risk factors in primary care.

CONCLUSIONS

We derive several principles and strategies for delivering behavioral risk factor interventions in primary care from the research literature. These principles can be linked to the "5A's" construct (assess, advise, agree, assist, and arrange-follow up) to provide a unifying conceptual framework for describing, delivering, and evaluating health behavioral counseling interventions in primary healthcare settings. We also provide recommendations for future research.

Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care

BACKGROUND

The evidence base regarding what works in practice for helping patients change multiple risk behaviors is less developed than is the more basic literature on behavior change. Still, there is enough consistency of findings to present testable hypotheses for clinicians and administrators to evaluate and guide practice until more definitive evidence is available.

METHODS

The behavior change principles known as the 5A's outline a sequence of support activities (assess, advise, agree, assist, arrange) that are effective for helping patients to change various health behaviors. These same principles also apply at the clinic level for designing activities to support behavior change.

RESULTS

Successful practices promoting sustainable changes in multiple behaviors are patient centered, tailored, proactive, population based, culturally proficient, multilevel, and ongoing. Often a stepped-care model can be used to provide increasingly intensive (and costly) interventions for patients who are not successful at earlier intervention levels.

CONCLUSIONS

Contextual factors are influential in determining success at both the patient and the office practice level. Therefore, greater attention should be paid to creating supportive family, healthcare system, and community resources and policies. We enumerate 15 hypotheses to be tested for improving patient-clinician interactions and for medical office change.

Addressing multiple behavioral risk factors in primary care. A synthesis of current knowledge and stakeholder dialogue sessions

BACKGROUND

Addressing behavioral risk factors in primary care has become a pressing concern due to the increasing burden of behavioral risk factors on disease, healthcare costs, and public health. Risk factors considered include smoking, risky drinking, sedentary lifestyle, and unhealthy diet-singly or in combination. The already burdened primary care system needs a practical approach to efficiently and effectively address any combination of multiple risk factors. Multiple perspectives and broad insight are urgently needed to gain a deeper understanding of the interacting scientific, systems, and policy issues associated with multiple risk factor interventions (MRFIs).

PURPOSE

This paper synthesizes findings from literature reviews, epidemiologic analyses, and structured interactive dialogue sessions, and includes a set of recommendations designed to stimulate further action.

METHODS

Several papers were produced to document current knowledge, research evidence, and salient issues related to multiple risk factor assessment and intervention. Structured interactive dialogue sessions were then conducted with clinician, health system, and health policy leaders regarding what advantage or energy would be liberated by a multiple risk factor approach (rather than separate single risk factor approaches), and how to build a policy framework or constituency for MRFIs. This information is synthesized in this paper.

RESULTS

There is a clear need to address MRFIs among multiple stakeholders, including patients, purchasers, payers, clinicians, health system leaders, and policy-level stakeholders. MRFIs need to bring with them a compelling value proposition for all stakeholders, and a vision of practical and systematic ways to make it a reality in already-pressed primary care practices. Involving stakeholders in dialogue aimed at helping them see the world through each other's eyes helps overcome discouragement and generates energy for jointly designing new approaches. Recommendations for further action include the creation of multistakeholder dialogue, creation of a policy agenda, development of a translation or integration agenda that connects researchers and practitioners in a two-way exchange, initiation of a series of demonstration projects around MRFIs, and support for research on multiple (rather than only single) risk factor interventions.

CONCLUSIONS

The need to address multiple behavioral risk factors in primary care is increasingly urgent. Whereas stakeholders by themselves may be willing to address multiple risk factors, they agree that it can only be done successfully with a collaborative approach. Findings based on evidence reviews, hypotheses generation, and stakeholder dialogue provide guidance for appropriate further action that, based on what is known already, can be initiated right away.

Interactive behavior change technology. A partial solution to the competing demands of primary care

BACKGROUND

Primary care practices are faced with the challenge of having too much to do in too little time. As a result, behavioral counseling is often overlooked, especially for patients with multiple health behaviors in need of change.

METHODS

This paper describes recent examples of the application of interactive behavior change technologies (IBCTs) to deliver health behavior change counseling before, during, and after the office visit to inform and enhance patient-clinician interactions around these issues. The 5A's framework (assess, advise, agree, assist, arrange follow-up) is used to consider how interactive technology can be used to implement behavior change counseling more consistently.

RESULTS

A variety of IBCTs, including the Internet, clinic-based CD-ROMs, and interactive voice-response telephone calls have been shown to be feasible and potentially valuable adjuncts to clinic-based behavioral counseling. These technologies can both increase the effectiveness of behavioral counseling and extend the reach of these services to patients with barriers to face-to-face interactions.

CONCLUSIONS

If appropriately developed with the context of primary care in mind and integrated as part of a systems approach to intervention, IBCT can be a feasible and appropriate aid for primary care. Recommendations are made for the types of IBCT aids and research that are needed to realize this potential.