MOTIVATING CHANGE IN HEALTH BEHAVIOR

Prevalence, treatment patterns, and risk factors of hypertension and pre-hypertension among Bangladeshi adults

In Bangladesh, morbidity and mortality due to non-communicable diseases (NCDs) has increased over the last few decades. Hypertension is an important risk factor for NCDs, specifically cardiovascular disease. The objective of this study was to assess prevalence and risk factors for hypertension and prehypertension among adults in Bangladesh. Data for this analysis were collected during the national NCD Risk Factor Survey of Bangladesh conducted in 2010 from a representative sample of men and women, aged 25 years or above. The survey adopted a multistage, geographically clustered, probability-based sampling approach. WHO STEPS questionnaire was used to collect data on demographics, behavioral risk factors, and physical measurements. Overall, 20% of the study population were hypertensive at study measurement. The prevalence of hypertension increased with age and body mass index(BMI). Twelve percent of the population were previously diagnosed with hypertension. Among these individuals, nearly half were not taking any medications to control their hypertension. Additionally, the prevalence of pre-hypertension was 43%, with higher levels among males, older age groups, and those with higher education, higher wealth index and high BMI. Predictors of hypertension, included older age, high BMI and diabetes comorbidity. Based on this study, we estimate that 1 out of 5 Bangladeshi adults have hypertension. The risk of hypertension increases with older age and high BMI. Additionally, prevalence of pre-hypertension is high in Bangladesh in both rural and urban areas. Findings from this study can be used to inform public health programming to control the spread of NCDs in Bangladesh.

Using Innovative Video Doctor Technology in Primary Care to Deliver Brief Smoking and Alcohol Intervention

Given physicians' increased responsibilities and time constraints, it is increasingly difficult for primary care physicians to assume a major role in delivering smoking and alcohol assessment and intervention. The authors developed an innovative use of computer technology in the form of a “video doctor” to support physicians with this. In this article, two brief interventions, delivered by an interactive, multimedia video doctor, that reduce primary care patients' smoking and alcohol use are detailed: (a) a patient-centered advice message and (b) a brief motivational intervention. The authors are testing the use of the video doctor to deliver these interventions in a randomized, controlled study, Project Choice. A pilot study testing the feasibility and acceptability of the video doctor suggests it was well received and accepted by patients (n = 52) and potentially provides an innovative, cost-effective, and practical way to support providers' efforts to reduce smoking and alcohol use in primary care populations.

Motivational interviewing within the different stages of change: an analysis of practice nurse-patient consultations aimed at promoting a healthier lifestyle

Combining the Stages of Change (SOC) model with Motivational Interviewing (MI) is seen as a helpful strategy for health care providers to guide patients in changing unhealthy lifestyle behaviour. SOC suggests that people are at different stages of motivational readiness for engaging in health behaviours and that intervention methods are most useful when tailored to a person's stage of change. However, it is unknown whether practice nurses (PNs) actually adapt their MI and more generic communication skills to a particular stage during real-life face-to-face consultations with their patients. The aim of this study was to explore whether and how PNs apply MI and general communication skills to the different SOC of patients, targeting behaviour change about smoking, alcohol use, dietary habits and/or physical activity. Real-life consultations between nineteen Dutch PNs and 103 patients were recorded on video between June 2010 and March 2011. All consultations focused on a discussion of patients' lifestyle behaviour. The Behaviour Change Counselling Index (BECCI) was used to code PNs' MI skills. Generic communication skills were rated with the MAAS-global. Patients' SOC was assessed for each consultation by observing the communication between patient and PN regarding the patient's current lifestyle behaviour. Multilevel analyses revealed that PNs adapt their MI skills to a patient's SOC to some extent. On average PNs apply MI skills more to patients in the preparation stage (P < 0.05) than during the other stages of change. PNs adjusted three MI skills and one generic communication skill to patients' SOC. This explorative study suggests that, at least to some extent, PNs intuitively assess the stage of patients' readiness to change and tailor their communication accordingly. However, differences between the stages were small. By teaching PNs to explicitly identify patients' SOC they could further enhance and adapt their MI and general communication skills to the individual.

The "10 keys" to healthy aging: 24-month follow-up results from an innovative community-based prevention program

The purpose of this report was to evaluate a prevention program to reduce risk factors for common diseases among older individuals in a lower income community. This randomized community-based study enrolled older adults into a Brief Education and Counseling Intervention or a Brief Education and Counseling Intervention plus a physical activity and (for those with hypertension) a dietary sodium intervention. Outcomes were collected on 389 adults with a mean age of 73.9 years over 24 months. Adherence to the "10 Keys" improved significantly in the proportion meeting goals for low-density lipoprotein cholesterol (+14%), bone mineral density testing (+11%), pneumonia vaccination (+11%), colonoscopy (+14%), and adherence to antihypertensive medication (+9%). This program resulted in significant reductions in key risk factors, increases in immunizations, and adherence to established prevention guidelines over 2 years. Further research is needed to refine the use of community health counselors for translating prevention knowledge into community settings. A major limitation of these studies is the low participation percentage.

The 10 keys to healthy aging: findings from an innovative prevention program in the community

OBJECTIVE

To develop and evaluate a novel, comprehensive prevention program for older adults designed to assess and improve adherence to preventive health care goals.

METHOD

In McKeesport, Pennsylvania, 389 men and women aged 65 and older were enrolled. We assessed adherence to 10 preventive health goals, provided education and counseling, and reevaluated after 12 months.

RESULTS

At baseline, adherence varied. After 12 months, proportions of participants meeting goals were improved for several areas. Overall, improvements were seen for the proportion of participants meeting goals for low-density lipoprotein (LDL) cholesterol (+43%), blood pressure control in hypertensives (+17%), blood glucose control in diabetics (+50%), and colon cancer screening (+13%). Among those without prior vaccination, influenza vaccine increased by 25% and pneumonia vaccine by 20%.

DISCUSSION

This comprehensive prevention program had short-term benefits for improving adherence to established prevention guidelines in older adults. This low-cost effective program could be disseminated nationwide.

The key to life nutrition program: results from a community-based dietary sodium reduction trial

OBJECTIVE

Evaluation of a dietary Na reduction trial in a community setting.

DESIGN

Community-based randomized trial. Ten-week nutrition intervention activities focused on lifestyle modification to decrease dietary Na intake, under the supervision of a registered dietitian. Twenty-four hour urine specimens were collected at baseline and follow-up visits to determine 24 h urinary Na excretion.

SETTING

The University of Pittsburgh Center for Healthy Aging, Key to Life Nutrition Program.

SUBJECTS

Hypertensive adults at least 65 years of age.

RESULTS

Mean age of participants was 75 years. Twenty-four hour mean urinary Na excretion at baseline was 3174 mg/d. This reduced to 2944 mg/d (P = 0.30) and 2875 mg/d (P <or= 0.03) at 6- and 12-month follow-ups, respectively. In a sub-sample (urine volume of >or=1000 ml, baseline to 12 months), mean urinary Na excretion decreased from 3220 mg/d to 2875 mg/d (P <or= 0.02).

CONCLUSIONS

Significant reductions in mean 24 h urinary Na were reported, but results fell short of the recommended guidelines of 1500 mg/d for at-risk individuals. Our results reiterate the difficulty in implementing these guidelines in community-based programmes. More aggressive public health efforts, food industry support and health policy changes are needed to decrease Na levels in older adults to the recommended guidelines.

Moving Evidence-Based Interventions to Populations: A Case Study Using Social Workers in Primary Care

This article describes a study to expand a proven evidence- based practice for depression to a population-based intervention for frail older adults. Problem-Solving Therapy (PST) has been proven effective in reducing depression and other mental health conditions in cognitively intact adults in many studies. The current study employs a randomized controlled trial to test the effectiveness of a social work intervention for frail older adults that uses PST to address depression and other psychosocial issues. The intervention employs Master's trained social workers integrated into a large primary care practice. The study population is comprised of home-dwelling older adults with multiple chronic conditions, a recent history of unnecessary hospitalizations, and no more than mild cognitive impairment.

Feasibility and acceptability of a telephone psychotherapy program for depressed adults treated in primary care

OBJECTIVE

Telephone psychotherapy is an emerging model of care that appears feasible for extending the reach of evidence-based psychotherapy treatment without accruing the full costs of traditional office-based, mental health care. This manuscript describes the development, implementation and acceptance of a 12-month telephone psychotherapy program (TPP) for depressed adults not fully responding to standard antidepressant treatment in primary care.

METHOD

The TPP combined a population-based medication monitoring and information system with a structured cognitive-behavioral treatment (CBT) program. The TPP included 8-12 telephone sessions (eight core CBT sessions and three to four clinical booster sessions) delivered by a master-level therapist working in tandem with each patient's primary care physician (PCP).

RESULTS

The TPP was well accepted (i.e., 80% completed the core program) by a population-based sample of adult primary care patients initiating antidepressant treatment. The mean duration of core telephone psychotherapy sessions was approximately 31 min during acute-phase treatment (0-6 months). Eighty-two percent of TPP patients maintained contact with their therapist during maintenance-phase treatment (6-12 months).

CONCLUSIONS

The practical and efficient nature of this TPP appears to sidestep many of the treatment barriers encountered in traditional office-based care. Implementation of this TPP program in other primary care settings may be valuable for enhancing standard pharmacotherapy treatment of adult depression, especially among populations facing greater barriers of care.

Motivating health: strategies for the nurse practitioner

PURPOSE

To provide the nurse practitioner (NP) with a practical prescription for acquiring expertise in health behavior change using integrated principles from the transtheoretical model of change and motivational interviewing.

DATA SOURCES

Extensive literature review of current theory and research on health behavior change.

CONCLUSION

Expertise in motivating health behavior change is essential to effective health promotion and to the NP role.

IMPLICATIONS FOR PRACTICE

Lifestyle choices are principal contributors to the leading causes of death and most chronic diseases in the United States. Traditional health behavior interventions are often ineffective in motivating and sustaining lifestyle change.

Maintenance of health behavior change in preventive cardiology. Internalization and self-regulation of new behaviors

Long-term health behavior maintenance remains a challenge for patients and health behavior interventionists. Resource-intensive systems of external reinforcement and behavioral cues can support behavior maintenance; an alternative approach is to promote patient internalization and self-regulation of health behaviors. Based in part on organismic internalization theory, self-determination theory, and the experience of patients successful at maintaining health behaviors, the health behavior internalization model (HBIM) is proposed to describe motivational factors associated with internalization processes and hypothesizes that integrated internalization may be associated with long-term health behavior maintenance. The HBIM identifies four self-needs (ownership, self-determination, security, and support) and four behavior-related needs (preference, context, competence, and coping) as motivating health behavior internalization. Behavior change strategies promoting integrated internalization are identified from self-determination theory, motivational interviewing, and transtheoretical model interventions. Other health behavior change constructs are reviewed in relation to internalization processes, and potential limits to the model are discussed.

The design, implementation, and acceptance of a primary care-based intervention to prevent depression relapse

OBJECTIVE

This article describes the conceptual underpinnings, implementation, and participation rates of a twelve-month low-intensity primary care-based intervention to prevent depression relapse. The intervention was designed to address the inherent problems in delivery of effective maintenance treatment in a population based sample of primary care patients.

METHODS

Patients at high risk of relapse based on psychiatric history who recovered from depression six to eight weeks after initiation of pharmacotherapy by their primary care physician were eligible; 194 were randomized to receive the intervention. The intervention combined education about depression, motivation-enhancing shared decision-making regarding the use of maintenance pharmacotherapy, and cognitive-behavioral strategies. The program included two visits with a Depression Prevention Specialist working in tandem with the primary care physician at the primary care clinic, with supervision and back up from a consulting psychiatrist, proactive follow-up telephone calls and mailed personalized feedback.

RESULTS

Ninety-three percent of patients attended both in-person visits; 97 percent attended one visit. Eighty percent of patients completed all three follow-up telephone calls, and 85 percent returned at least one mailed feedback form; 48 percent returned all four forms. Offered a menu of options for self-management, most patients chose medication as well as a variety of behavioral strategies. At six months, 72 percent ofpatients and at twelve months 62 percent of patients remained on antidepressant medication.

CONCLUSIONS

We conclude that it is feasible to integrate a low intensity, twelve-month relapse prevention intervention for depression into a primary care clinic.

The pediatrician's role in reducing tobacco exposure in children

OBJECTIVE

Pediatricians have a unique and important role to play in the prevention and treatment of childhood and adolescent tobacco use, the protection of patients from the harmful effects of environmental tobacco smoke, and the encouragement of smoking cessation among parents. However, because recent research indicates that physician training in tobacco dependence is woefully weak and lacks a model for training, this article constructs a useful approach to this problem.

METHODOLOGY

A comprehensive review of the literature served as the basis for the development of a new model for pediatrician training in tobacco dependence.

RESULTS

A comprehensive model is presented for training pediatricians in the areas of reducing infant and child exposure to environmental tobacco smoke, preventing youth smoking initiation, and providing smoking cessation assistance for adolescents and parents.

CONCLUSIONS

Pediatricians have been called on to play an active role in the antitobacco arena. Because of their unique opportunity to interact with children, adolescents, and parents, pediatricians can and should be antitobacco interventionists. For this to occur, however, additional guidance should be provided to pediatricians during their training to better prepare them to carry out effective assessment and intervention practices. smoking initiation, smoking prevention, smoking cessation, environmental tobacco smoke, pediatricians.

Patients with alcohol problems in primary care: understanding their resistance and motivating change

How can physicians motivate patients with alcohol problems when they resist advice to change? A framework for understanding patient resistance is described to help physicians use this motivational approach more effectively with patients.

Why is prevention so difficult and slow?

The abundance of perceived 'possibilities' for prevention contrasts sharply with the difficulties that face preventive programmes. We argue that this situation has emerged from an incomplete understanding of the process of prevention, involving a mixture of biological factors, human decision making and time perspectives. Based on examples, an analysis of the factors in the prevention process is presented.