Recomendaciones sobre el estilo de vida. Actualizacón PAPPS 2018

Effectiveness of a Motivational Interviewing-Based Intervention in Decreasing Risky Alcohol Use in Primary Care Patients in Spain: A Controlled Clinical Trial

OBJECTIVE

Our study aimed to evaluate the effectiveness of an intervention based on Motivational Interviewing (MI) performed by healthcare professionals in Primary Care (PC) patients with risky alcohol use through a multicenter, two-arm parallel, cluster-randomized, open-label controlled clinical trial.

METHODS

PC professionals were randomized into two groups: an Experimental Group (EG) and a Control Group (CG). The study was carried out in PC centers of the Andalusian Health Service, located in Cordoba, Spain. An MI-based approach was implemented with patients recruited in the EG, while health advice was provided to those included in the CG. The follow-up period was 12 months, with five visits scheduled. The consumption of standard drinking units per week was quantified, and risky alcohol use was estimated using the Alcohol Use Disorders Identification Test (AUDIT). An intention-to-treat statistical analysis was performed. Relative risk (RR), absolute risk reduction (ARR) and the number of subjects needed to treat (NNT) were used to estimate the intervention effect size.

RESULTS

A total of 268 patients were included, 148 in the EG and 120 in the CG. Considering the quantification of risky alcohol use, the ARR at 12 months after baseline visit was 16.46% (95% CI: 5.37-27.99), with an NNT of 6 (95% CI: 4-19). According to the AUDIT, the ARR at 12 months was 13.15% (95% CI: 2.73-24.24%), and the NNT was 8 (95% CI: 4-37).

CONCLUSIONS

We concluded that MI is more effective than the usual health advice in decreasing risky alcohol use in patients treated in PC.

Socioeconomic determinants and self-rated health among hotel housekeepers in the Balearic Islands (Spain)

Background

Hotel housekeepers constitute an important occupational group in the Balearic Islands (Spain). Housekeeping is considered low-skilled and precarious and typically involves high physical demands and time pressure. The aim of this study is to analyze the association between the socioeconomic determinants of health and hotel housekeepers' self-rated health.

Methods

This is a cross-sectional study conducted in Primary Health Care in the Balearic Islands (November 2018-February 2019). Hotel housekeepers over 18 years of age with free access to the Balearic Public Health System who had been employed during 2018 were eligible.

Results

We enrolled 1,043 hotel housekeepers; the mean score of health perceived status was 72.4/100 (SD 19.0). Those with a lower self-perceived health were statistically significant older, had Spanish nationality, lower level of studies, permanent or recurring seasonal contract, financial difficulties, a higher level of occupational stress, an external locus of control, reported work-life balance difficulties, were former smokers, insufficiently physical active and obese. We found lower scores in self-perceived health status score of -7.159 (CI95% -10.20- -4.12) among hotel housekeepers with osteoarthritis; -6.858 (CI95% -11.89- -1.82) among those with chronic depression; -3.697 (CI95% -6.08- -1.31) among those who reported difficulties in work-life balance; -2.414 (CI95% -4.69- -0.13) among participants who performed insufficient physical activity; -2.107 (CI% -4.44- -0.23) among those who reported financial strain. Lower self-rated health was also associated to a higher perceived stress, -1.440 (CI95% -2.09- -0.79); BMI (kg/m2), -0.299 (CI95% -0.53- -0.07); and longer time working as HH -0.177 (CI95% -0.33- -0.03).

Conclusion

Our results underscore the importance of psychosocial (such as difficulties in work-life balance and occupational stress) and material factors (such as financial difficulties) when explaining differences in self-perceived health. Public health interventions aimed at improving health status must consider inequalities in material and working conditions.

Development and external validation of a 1- and 5-year fracture prediction tool based on electronic medical records data: The EPIC risk algorithm

OBJECTIVES

We aimed to develop and validate a fracture risk algorithm for the automatic identification of subjects at high risk of imminent and long-term fracture risk.

RESEARCH, DESIGN, AND METHODS

A cohort of subjects aged 50-85, between 2007 and 2017, was extracted from the Catalan information system for the development of research in primary care database (SIDIAP). Participants were followed until the earliest of death, transfer out, fracture, or 12/31/2017. Potential risk factors were obtained based on the existing literature. Cox regression was used to model 1 and 5-year risk of hip and major fracture. The original cohort was randomly split in 80:20 for development and internal validation purposes respectively. External validation was explored in a cohort extracted from the Spanish database for pharmaco-epidemiological research in primary care.

RESULTS

A total of 1.76 million people were included from SIDIAP (50.7 % women with mean age of 65.4 years). Hip and major fracture incidence rates were 3.57 [95%CI 3.53 to 3.60] and 11.61 [95%CI 11.54 to 11.68] per 1000 person-years, respectively. The derived model included 19 risk factors. Internal validity showed good results on calibration and discrimination. The 1-year C-statistic for hip and major fracture were 0.851 (95%CI 0.853 to 0.864), and 0.717 (95%CI 0.742 to 0.749) respectively. The 5-year C-statistic for hip and major fracture were 0.849 (95%CI 0.847 to 0.852) and 0.724 (95%CI 0.721 to 0.727) respectively. External validation showed good performance for hip and major fracture risk prediction.

CONCLUSIONS

We have developed and validated a clinical prediction tool for 1- and 5-year hip and major osteoporotic fracture risks using electronic primary care data. The proposed algorithm can be automatically estimated at the population level using the available primary care records. Future work is needed on the cost-effectiveness of its use for population-based screening and targeted prevention of osteoporotic fractures.

Educational Intervention in the Postural Hygiene of School-Age Children

Introduction: Healthy lifestyle habits formed in childhood provide the foundation for a healthy adult life; therefore, it is important to encourage healthy habits and to correct poor habits from an early age. Aim: In this study, we aim to evaluate the influence of educational intervention in order to modify postural hygiene habits in school-age children. Materials and methods: We randomly selected three public primary education schools in the Galician provinces of Orense and Pontevedra based on stratified multistage sampling. A sample of 479 students was obtained, representing 2% of all 6- to 12-year-old children registered during the 2015/2016 academic year in those provinces. Results: Following the intervention, the students’ postural hygiene improved. We found statistically significant differences regarding a reduction in the number of hours spent watching television (0.531 h/day); the way school books and supplies were carried, with an increase in the use of backpacks with wheels (from 58.5% to 64.1%); and an improvement in postural hygiene when watching television, with an increase from 63.7% to 80.8% of those surveyed opting to watch television whilst seated on a chair instead of lying down. Conclusions: Educational intervention by inculcating healthy postural hygiene habits in children at an early age can improve and correct unhealthy behaviours.

Development and validation of the MARA scale in Spanish to assess knowledge and perceived risks and barriers relating to breast cancer prevention

Objective

The aim of this study was to develop a measurement instrument for assessing knowledge of breast cancer and perceived risk of developing the disease (MARA).

Methods

641 women with a mean age of 36.19 years (SD = 7.49) participated in the study. Data collection took place during 2019 and included sociodemographic data, data on history of cancer and breast cancer, perceived risk, and feelings of concern about developing breast cancer. Internal consistency, test–retest reliability, convergent validity, and structural validity were tested.

Results

The questionnaire items comprise 4 subscales: risk factors (9 items), signs and symptoms (9 items), perceived risk (6 items), barriers (7 items). A factor analysis revealed that the first two subscales had two dimensions each, whereas the other two subscales had one dimension each. Each subscale was shown to have adequate reliability (α = 0.74–0.92) and temporal stability (r = 0.201–0.906), as well as strong evidence of validity in relation to a questionnaire on breast cancer knowledge (r = 0.131–0.434). In addition, the subscales were shown to have high discriminatory power in terms of the presence or absence of a history of cancer or breast cancer, perceived risk, and feelings of concern.

Conclusion

The MARA questionnaire represents a valid, reliable tool for assessing Spanish women’s knowledge, risks, perceptions, and barriers regarding breast cancer.

Cost-effectiveness analysis of a multiple health behaviour change intervention in people aged between 45 and 75 years: a cluster randomized controlled trial in primary care (EIRA study)

BACKGROUND

Multiple health behaviour change (MHBC) interventions that promote healthy lifestyles may be an efficient approach in the prevention or treatment of chronic diseases in primary care. This study aims to evaluate the cost-utility and cost-effectiveness of the health promotion EIRA intervention in terms of MHBC and cardiovascular reduction.

METHODS

An economic evaluation alongside a 12-month cluster-randomised (1:1) controlled trial conducted between 2017 and 2018 in 25 primary healthcare centres from seven Spanish regions. The study took societal and healthcare provider perspectives. Patients included were between 45 and 75 years old and had any two of these three behaviours: smoking, insufficient physical activity or low adherence to Mediterranean dietary pattern. Intervention duration was 12 months and combined three action levels (individual, group and community). MHBC, defined as a change in at least two health risk behaviours, and cardiovascular risk (expressed in % points) were the outcomes used to calculate incremental cost-effectiveness ratios (ICER). Quality-adjusted life-years (QALYs) were estimated and used to calculate incremental cost-utility ratios (ICUR). Missing data was imputed and bootstrapping with 1000 replications was used to handle uncertainty in the modelling results.

RESULTS

The study included 3062 participants. Intervention costs were €295 higher than usual care costs. Five per-cent additional patients in the intervention group did a MHBC compared to usual care patients. Differences in QALYS or cardiovascular risk between-group were close to 0 (- 0.01 and 0.04 respectively). The ICER was €5598 per extra health behaviour change in one patient and €6926 per one-point reduction in cardiovascular risk from a societal perspective. The cost-utility analysis showed that the intervention increased costs and has no effect, in terms of QALYs, compared to usual care from a societal perspective. Cost-utility planes showed high uncertainty surrounding the ICUR. Sensitivity analysis showed results in line with the main analysis.

CONCLUSION

The efficiency of EIRA intervention cannot be fully established and its recommendation should be conditioned by results on medium-long term effects.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03136211 . Registered 02 May 2017 - Retrospectively registered.

Influence of Pain and Discomfort in Stroke Patients on Coping Strategies and Changes in Behavior and Lifestyle

The implementation of prevention strategies can reduce the risk of having a stroke. This prospective, longitudinal, multicenter observational study of 82 patients describes health habits, quality of life, coping strategies, and physical and neurological status at 3 months and 1 year after stroke. The EuroQoL-5D quality of life scale (EQ-5D) and the coping strategy measurement scale (COPE-28) were used to assess pain and discomfort, and behavioral and lifestyle changes. Significant differences were observed in the pain or discomfort levels of those patients with behavioral and lifestyle changes. Correlation was also found between pain or discomfort and the coping strategies associated with active emotional support at 1 year after stroke. The results of the pain or discomfort dimension were not, however, associated with better adherence to treatment. Pain and discomfort could have a predictive value in changes in lifestyles and behaviors but not for treatment adherence in patients who have had a stroke, which is significant at 1 year. In addition to important active coping strategies such as social support, these changes in behavior and lifestyle following a stroke are long-term and should therefore be assessed during the initial examination.

Effectiveness of a Multicomponent Intervention in Primary Care That Addresses Patients with Diabetes Mellitus with Two or More Unhealthy Habits, Such as Diet, Physical Activity or Smoking: Multicenter Randomized Cluster Trial (EIRA Study)

Introduction: We evaluated the effectiveness of an individual, group and community intervention to improve the glycemic control of patients with diabetes mellitus aged 45-75 years with two or three unhealthy life habits. As secondary endpoints, we evaluated the inverventions' effectiveness on adhering to Mediterranean diet, physical activity, sedentary lifestyle, smoking and quality of life. Method: A randomized clinical cluster (health centers) trial with two parallel groups in Spain from January 2016 to December 2019 was used. Patients with diabetes mellitus aged 45-75 years with two unhealthy life habits or more (smoking, not adhering to Mediterranean diet or little physical activity) participated. Centers were randomly assigned. The sample size was estimated to be 420 people for the main outcome variable. Educational intervention was done to improve adherence to Mediterranean diet, physical activity and smoking cessation by individual, group and community interventions for 12 months. Controls received the usual health care. The outcome variables were: HbA1c (main), the Mediterranean diet adherence score (MEDAS), the international diet quality index (DQI-I), the international physical activity questionnaire (IPAQ), sedentary lifestyle, smoking ≥1 cigarette/day and the EuroQuol questionnaire (EVA-EuroQol5D5L). Results: In total, 13 control centers (n = 356) and 12 intervention centers (n = 338) were included with similar baseline conditions. An analysis for intention-to-treat was done by applying multilevel mixed models fitted by basal values and the health center: the HbA1c adjusted mean difference = -0.09 (95% CI: -0.29-0.10), the DQI-I adjusted mean difference = 0.25 (95% CI: -0.32-0.82), the MEDAS adjusted mean difference = 0.45 (95% CI: 0.01-0.89), moderate/high physical activity OR = 1.09 (95% CI: 0.64-1.86), not living a sedentary lifestyle OR = 0.97 (95% CI: 0.55-1.73), no smoking OR = 0.61 (95% CI: 0.54-1.06), EVA adjusted mean difference = -1.26 (95% CI: -4.98-2.45). Conclusions: No statistically significant changes were found for either glycemic control or physical activity, sedentary lifestyle, smoking and quality of life. The multicomponent individual, group and community interventions only showed a statistically significant improvement in adhering to Mediterranean diet. Such innovative interventions need further research to demonstrate their effectiveness in patients with poor glycemic control.

Projected impact of diabetes on the Costa Rican healthcare system

INTRODUCTION

Costa Rica, similar to many other Latin American countries is undergoing population aging at a fast pace. As a result of the epidemiological transition, the prevalence of diabetes has increased. This condition impacts not only individual lives, but also the healthcare system. The goal of this study is to examine the expected impact of diabetes, in terms of economic costs on the healthcare system and lives lost. We will also project how long it will take for the number of elderly individuals who are diabetic to double in Costa Rica.

METHODS

CRELES (Costa Rican Longevity and Healthy Aging Study), a three-wave nationally representative longitudinal study, is the main source of data for this research (n = 2827). The projected impact of diabetes was estimated in three ways: length of time for the number of elderly individuals with diabetes to double; projected economic costs of diabetes-related hospitalizations and outpatient care; and years of life lost to diabetes at age 60. Data analyses and estimations used multiple regression models, longitudinal regression models, and Lee-Carter stochastic population projections.

RESULTS

Doubling time of the diabetic elderly population is projected to occur in 13 calendar years. This will cause increases in hospitalization and outpatient consultation costs. The impact of diabetes on life expectancy at age 60 around the year 2035 is estimated to lead to a loss of about 7 months of life. The rapid pace at which the absolute number of elderly people with diabetes will double is projected to result in a negative economic impact on the healthcare system. Lives will also be lost due to diabetes.

CONCLUSION

Population aging will inevitably lead to an increasing number of elderly individuals, who are at greater risk for diabetes due to their lifelong exposure to risk factors. Actions to increase the quality of life of diabetic elderly are warranted. Decreasing the burden of diabetes on elderly populations and the Costa Rican healthcare system are necessary to impact the quantity and quality of life of incoming cohorts. Health promotion and prevention strategies that reduce diabetes risk factors are needed to improve the health of elderly populations.

Knowledge on Signs and Risk Factors in Stroke Patients

Background: There is a pressing need to contribute evidence to the improvement in the early identification of signs and symptoms associated with strokes, and address the treatment-seeking delays. The objective of this study is to describe the knowledge regarding the warning signs and risk factors (RFs) among stroke patients, as well as of their attitudes toward a suspected event, and the analysis of its possible relationship with the socio-demographic and clinical characteristics of these patients. Method: A cross-sectional study was designed, in which all stroke patients admitted consecutively to the Burgos University Hospital (Spain) were included. The principal outcomes were the patient’s ability to identify two RFs and two warning signs and the patient’s hypothetical response to a possible stroke event. The possible factors associated with the knowledge of warning signs, RFs, and the correct response to a new event were studied using univariate and multivariate regression analysis. Results: A total of 529 patients were included. Having a higher education level or a history of prior stroke were associated with a greater degree of knowledge of warning signs (odds ratio (OR) 3.19, 95% confidence interval (CI) 1.70–5.74, p = 0.003; OR 3.54, 95%CI 2.09–5.99, p ≤ 0.001, respectively), RFs (OR 3.15, 95%CI 1.75–5.67, p = 0.008; OR 4.08, 95%CI 2.41–6.91, p = 0.002, respectively), and the correct response to a possible stroke (OR 1.82, 95%CI 1.16–2.86; p = 0.030; OR 2.11, 95%CI 1.29–3.46, p = 0.022, respectively). Conclusion: Knowledge of warning signs or stroke RFs is low in the hospitalized patients. A previous stroke or secondary/higher education levels are the predictor factors that increase the probability of knowledge of warning signs, RFs, or reaction to possible event.

Age-Related Risk Factors at the First Stroke Event

(1) Background: Stroke is a multifactorial disease, which can affect individuals at any age. Risk factors (RFs) associated with the first stroke event have been well identified; however, the influence of these RFs on the patient’s age needs to be studied. (2) Objective: This study aimed to examine the effect of modifiable RFs on the age at which a stroke occurs. (3) Methods: A cross-sectional study was conducted on patients admitted consecutively with a first-ever acute stroke at the Burgos University Hospital (Spain). Data on sociodemographic and clinical parameters were collected (high blood pressure (HBP), smoking habit, diabetes mellitus (DM), dyslipemia, abdominal obesity, sedentary lifestyle, alcohol consumption, and cardiovascular diseases). The possible associations between RFs and age were studied using univariate and multivariate regression analyses and a decision tree. (4) Results: A total of 436 patients with a mean age of 75.39 years (standard deviation (SD) ± 12.67) were included. HBP and overweight/obesity were the most prevalent stroke RFs. Being an active smoker (OR 21.48; 95% confidence interval (CI) 8.80–52.41), having a sedentary lifestyle (OR 3.24; 95% CI 1.97–5.31), being an excessive alcohol drinker (OR 2.36; 95% CI 1.45–3.84), or being overweight or obese (OR 1.95; 95% CI 1.14–3.34) increased the risk of having an acute cerebrovascular event in individuals aged 75 years or below. However, a personal history of HBP (OR 0.40; 95% CI 0.24–0.67) was significantly associated with a greater likelihood of having an acute stroke in individuals aged more than 75 years. (5) Conclusions: This study showed that the modifiable RFs strongly influence the first stroke event in patients aged below 75 years, which will be useful in guiding different prevention strategies.

Are partner's features important to understand health at older ages? The Spanish case

OBJECTIVE

To analyse health differences among partnered individuals in Spain aged 65-81 considering their combined (education of both partners and age gap) and household (economic capacity of the household) characteristics.

METHOD

A cross-sectional study of the 2015 Spanish sample of the European Union Statistics on Income and Living Conditions survey (EU-SILC) on partnered individuals aged 65-81 years (N=1787). Using logistic regression models separately for women and men we obtained odds and predicted probabilities of having less than good health (95% confidence intervals) according to combined information from both partners on education and age, the household's economic capacity and partner's health status.

RESULTS

Probabilities of not having good health are significantly less among lower educated women whose partners are more highly educated (compared to both partners being lower educated) and among women whose partner is younger or has good health status. The latter also applies to men. Living in a household without economic difficulties also favours health (both sexes).

CONCLUSIONS

For both sexes a partner's health status is the variable that shows the largest effect on elderly partnered Spanish people's health but women's health appears to be more sensitive to their partner's educational attainment and the household's economic situation.

Prevalence of hazardous alcohol use among Spanish primary care providers

BACKGROUND

Alcohol use by health care professionals is one of the potential factors that may affect the prevention of hazardous drinking in Primary Care (PC). The objective of the study was to estimate the prevalence of hazardous alcohol use by PC professionals and assess the existing relationship between socio-demographic and occupational variables of PC professionals and their alcohol use.

METHODS

A descriptive, cross-sectional, observational, multicenter study was performed.

LOCATION

PC sites of the Spanish National Health Care System (NHS).

PARTICIPANTS

Physicians and nurses, who completed an online questionnaire intended to identify the pattern of hazardous alcohol use through the AUDIT-C test. The study population was recruited through random sampling stratified by regions of the PC sites in the NHS. The primary measurements: Frequency of alcohol use, number of drinks containing alcohol on a typical day, frequency of six or more drinks on one occasion.

RESULTS

One thousand seven hundred sixty professionals completed the questionnaire. Hazardous alcohol use was detected in 27.80% (95% CI: 25.5-29.7) of PC providers. The prevalence of hazardous alcohol use was higher in males (34.2%) [95% CI: 30.4-37.6] and professionals aged 56 years or over (34.2%) [95% CI: 28.2-40.2]. The multiple logistic regression analysis revealed a higher hazardous use in males (OR = 1.52; 95% CI: 1.22-1.90), PC physicians (OR = 1.42; 95% CI: 1.01-2.02) and professionals with more time worked (OR = 1.03; 95% CI: 1.01-1.05).

CONCLUSION

Our study shows the current prevalence of hazardous alcohol use among Spanish PC providers, revealing a higher percentage of hazardous alcohol use in healthcare professionals compared to the Spanish general population. Further interventions are required to increase the awareness of negative consequences derived from alcohol use among PC professionals and its impact on the clinical setting.

[SEA/SEMERGEN consensus document 2019: Dietary recommendations in the prevention of cardiovascular disease]

The current paradigm in the nutrition sciences states that the basic nutritional unit is not the nutrients, but the foods that contain them (oils, nuts, dairy products, eggs, red or processed meats, etc.). These act as a food matrix in which the different nutrients synergistically or antagonistically modulate their effects on the various metabolic pathways determining health and disease. Food is not based on nutrients or isolated foods but on complex mixtures of one and the other that are part of a specific food pattern, a concept that has been targeted as the most pertinent to evaluate the associations between nutrition and health or disease. This document presents a summary of the available evidence on the relationship between different foods and cardiovascular health, and offers simple recommendations to be implemented in the dietary advice offered by the health professional.

SEA/SEMERGEN consensus document 2019: Dietary recommendations in the prevention of cardiovascular disease

The current paradigm in the nutrition sciences states that the basic nutritional unit is not the nutrients, but the foods that contain them (oils, nuts, dairy products, eggs, red or processed meats, etc.). These act as a food matrix in which the different nutrients synergistically or antagonistically modulate their effects on the various metabolic pathways determining health and disease. Food is not based on nutrients or isolated foods but on complex mixtures of one and the other that are part of a specific food pattern, a concept that has been targeted as the most pertinent to evaluate the associations between nutrition and health or disease. This document presents a summary of the available evidence on the relationship between different foods and cardiovascular health, and offers simple recommendations to be implemented in the dietary advice offered by the health professional.