Therapeutic effects of motivational interviewing on blood pressure control: a meta-analysis of randomized controlled trials. Int J Cardiol. 2014;172:509-511. [PMID: 24485630 DOI: 10.1016/j.ijcard.2014.01.051]

Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension

Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

Transforming global approaches to chronic disease prevention and management across the lifespan: integrating genomics, behavior change, and digital health solutions

Chronic illnesses are a major threat to global population health through the lifespan into older age. Despite world-wide public health goals, there has been a steady increase in chronic and non-communicable diseases (e.g., cancer, cardiovascular and metabolic disorders) and strong growth in mental health disorders. In 2010, 67% of deaths worldwide were due to chronic diseases and this increased to 74% in 2019, with accelerated growth in the COVID-19 era and its aftermath. Aging and wellbeing across the lifespan are positively impacted by the presence of effective prevention and management of chronic illness that can enhance population health. This paper provides a short overview of the journey to this current situation followed by discussion of how we may better address what the World Health Organization has termed the "tsunami of chronic diseases." In this paper we advocate for the development, validation, and subsequent deployment of integrated: 1. Polygenic and multifactorial risk prediction tools to screen for those at future risk of chronic disease and those with undiagnosed chronic disease. 2. Advanced preventive, behavior change and chronic disease management to maximize population health and wellbeing. 3. Digital health systems to support greater efficiencies in population-scale health prevention and intervention programs. It is argued that each of these actions individually has an emerging evidence base. However, there has been limited research to date concerning the combined population-level health effects of their integration. We outline the conceptual framework within which we are planning and currently conducting studies to investigate the effects of their integration.

The effects of motivational interviewing on hypertension management: A systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to examine the effects of motivational interviewing-based interventions on hypertension management.

METHODS

Six databases were searched from inception to 25 July, 2022 for randomized controlled trials involving adults diagnosed with hypertension and including motivational interviewing in the treatment interventions.

RESULTS

In total, 11 studies with 2121 participants were included. Compared with no or minimal additional intervention, motivational interviewing-based intervention showed greater reduction in systolic blood pressure (MD: -6.56, 95 % CI: -10.51, -2.62, P = 0.001) and diastolic blood pressure (MD: -3.75, 95 % CI: -4.92, -2.58, P < 0.001). Compared with the lower intensity intervention, motivational interviewing-based intervention produced statistically significant effect on reducing systolic blood pressure (MD: -2.72, 95 % CI: -5.34, -0.10, P = 0.040); while there was no significant effect on reducing diastolic blood pressure (MD: -0.47, 95 % CI: -2.21, 1.28, P = 0.600). Four out of six studies demonstrated medication adherence significantly improved following motivational interviewing-based intervention. Two studies included self-efficacy and quality of life, and inconsistent findings were observed.

CONCLUSION

Motivational interviewing could be effective in improving blood pressure control among patients with hypertension. Future studies with more rigorous study designs should be conducted to confirm the effects of motivational interviewing on medication adherence and psychological well-being.

PRACTICE IMPLICATIONS

Motivational interviewing could be applied as a promising intervention strategy among patients with hypertension.

Motivational Interviewing in the Management of Type 2 Diabetes Mellitus and Arterial Hypertension in Primary Health Care: An RCT

INTRODUCTION

Motivational interviewing is an effective style of collaborative communication for the promotion of lifestyle changes in the management of Type 2 diabetes and arterial hypertension. This study evaluates the effectiveness of motivational interviewing in the management of these conditions in primary health care.

STUDY DESIGN

This study is a double-blind parallel-group RCT performed between June 2018 and July 2019.

SETTING/PARTICIPANTS

The RCT was conducted in Porto Alegre, Rio Grande do Sul, Brazil, and included individuals with Type 2 diabetes and arterial hypertension.

INTERVENTION

The participants were randomized to the test/motivational interviewing and usual care groups. The test/motivational interviewing group received the nursing consultation intervention on the basis of motivational interviewing conducted by professionals with 20 hours of training, and the usual-care group received conventional nursing consultation.

MAIN OUTCOME MEASURES

The main outcome measure was the mean difference in HbA1c. The secondary outcome measures were the mean differences in blood pressure and adherence levels.

RESULTS

After a mean follow-up of 6 months, 174 participants completed the study (usual-care group=80; test/motivational interviewing group=94). There were statistically significant differences between the groups, with improvement in the test/motivational interviewing group for systolic blood pressure (p<0.01), diastolic blood pressure (p<0.01), and total adherence score as measured by the Martín-Bayarre-Grade questionnaire (p=0.01) and its operational dimensions of treatment adherence and personal involvement (p=0.03, p=0.03). The test/motivational interviewing group showed significantly reduced HbA1c levels (0.4%) at the end of the study (p<0.01).

CONCLUSIONS

In the context of primary health care, the nursing consultation based on motivational interviewing was shown to be a more effective care strategy than usual care for improving blood pressure levels and adherence levels in individuals with Type 2 diabetes and arterial hypertension. Moreover, motivational interviewing was demonstrated to be useful in reducing HbA1c levels in diabetes management.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03729323.

Long-acting injectable antipsychotics: what, when, and how

Current guidelines for the treatment of patients with schizophrenia advocate that patients receive treatment with a long-acting injectable (LAI) antipsychotic medication if they prefer such treatment or if they have a history of poor or uncertain adherence. Available LAI formulations in the United States include first-generation antipsychotics (fluphenazine decanoate and haloperidol decanoate), risperidone/paliperidone containing products (risperidone microspheres, paliperidone palmitate, and risperidone subcutaneous), aripiprazole containing products (aripiprazole monohydrate and aripiprazole lauroxil), and olanzapine pamoate. LAI antipsychotics can address the guesswork about adherence status and patients may prefer them if they are offered this as a choice, including individuals early in their disease course. Additional approved indications in the United States for LAI antipsychotics include bipolar I disorder maintenance treatment for risperidone microspheres and aripiprazole monohydrate, and schizoaffective disorder for paliperidone palmitate once monthly. Differences and similarities among the different products are discussed, including guidance regarding optimal treatment selection. Tips are provided to enhance effective patient communication to maximize the likelihood of acceptance of this treatment modality.

An integrative counselling program to promote active ageing for older people in Thai nursing homes: an intervention mixed methods design

BACKGROUND

Active ageing has been a rapidly developing field of study in light of the growing population of older people. Acknowledgement of the lack of a counselling program to promote active ageing for the older people in nursing homes led to the development of this study which aims to investigate active ageing of the Thai elderly in a nursing home in addition to promoting active ageing for them through integrative counselling.

METHODS

The study was conducted in a nursing home in Samut Prakan province, Thailand. The integrative counselling program referred to appropriate literature along with implementation of the Satir Model and Motivational Interviewing techniques. An intervention mixed methods design was applied in the study, which consisted of two phases. Phase 1 involved an investigation of the concept of active ageing, based on the context of older people in nursing homes by way of in-depth interviews, involving 5 participants. Phase 2 comprised of an investigation of the effects of an integrative counselling program to promote active ageing for older people in the same nursing home. There was a total of 16 participants in phase 2 which were divided equally into experimental and control groups respectively.

RESULTS

Phase 1 of the study showcased qualitative results of the progress of active ageing development in older people that resulted in 4 sub-themes (Health development, spiritual development, active engagement and psychosocial support). Two parameters were used to analyze the results in phase 2. The quantitative results showed that the active ageing score of participants in the experimental arm increased significantly after enrollment (p < 0.05). Furthermore, the experimental group had a higher overall active ageing score in comparison to the control group. Qualitative results of phase 2 elicited factors promoting active ageing in the elderly which included activities, group facilitator and group atmosphere. Both quantitative and qualitative results of phase 2 proved to be significant, showing that the program managed to develop active ageing in participants.

CONCLUSION

Psychologists and multidisciplinary teams looking after older people in nursing homes are able to use this integrative counselling program for development of active ageing in the elderly population.

An integrated intervention for chronic care management in rural Nepal: protocol of a type 2 hybrid effectiveness-implementation study

BACKGROUND

In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs.

METHODS

A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels.

DISCUSSION

This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.

Perspectives on the Training of Chinese Primary Health Care Physicians to Reduce Chronic Illnesses and Their Burden

This paper is a commentary on the training of Chinese Primary Health Care Doctors to reduce chronic illness and its burden. First, we will consider the policy position of the Chinese government concerning the development of a competent and enlarged primary physician workforce to deliver the proposed primary health care system reforms. We then turn to a review of the drivers of the high burden of chronic illnesses especially in older people in China. We argue that the curriculum for the training of primary health care medical practitioners should match the demonstrated high prevalence chronic illnesses and their risk factors and that there needs to specific competencies in prevention and mitigation of the diseases and their risk factors.

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Medication adherence and treatment-resistant hypertension: a review

Nonadherence is a common reason for treatment failure and treatment resistance. No matter how it is defined, it is a major issue in the management of chronic illnesses. There are numerous methods to assess adherence, each with its own strengths and weaknesses; however, no single method is considered the best. Nonadherence is common in patients with hypertension, and it is present in a large proportion of patients with uncontrolled blood pressure taking three or more antihypertensive agents. Availability of procedure-based treatment options for these patients has shed further light on this important issue with development of new methods to assess adherence. There is, however, no consensus on the management of nonadherence, which reflects the complex interplay of factors responsible for it.

Sleep, health behaviors, and behavioral interventions: Reducing the risk of cardiovascular disease in adults

Numerous health behaviors, including physical activity, diet, smoking, and sleep, play a major role in preventing the development and progression of cardiovascular disease (CVD). Among these behaviors, sleep may play a pivotal role, yet it has been studied somewhat less than other behaviors and there have been few well-designed sleep intervention studies targeting CVD. Furthermore, despite the fact that these behaviors are often interrelated, interventions tend to focus on changing one health behavior rather than concurrently intervening on multiple behaviors. Psychological constructs from depression to positive affect may also have a major effect on these health behaviors and ultimately on CVD. In this review, we summarize the existing literature on the impact of sleep and other cardiac health behaviors on CVD onset and prognosis. We also describe interventions that may promote these behaviors, from established interventions such as motivational interviewing and cognitive behavioral therapy, to more novel approaches focused on mindfulness and other positive psychological constructs. Finally, we outline population-health-level care management approaches for patients with psychiatric conditions (e.g., depression) that may impact cardiac health, and discuss their potential utility in improving mental health, promoting health behaviors, and reducing CVD-related risk. Much work is still needed to better understand how sleep and other health behaviors may uniquely contribute to CVD risk, and additional high-quality studies of interventions designed to modify cardiac health behaviors are required to improve cardiovascular health in individuals and the population at large.