Lifestyle interventions in primary health care: professional and organizational challenges

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.

Spirituality, a Neglected Dimension in Improving the Lifestyle of Coronary Artery Patients by Nurses: A Scoping Review

Background

By modifying the lifestyle of patients, the risk factors of Coronary Artery Diseases (CADs) are adjusted. This study was performed with the aim to investigate the role of nurses in the lifestyle of coronary artery patients.

Materials and Methods

This scoping review was conducted with the question of the role of nurses in improving the lifestyle of coronary artery patients. This study was conducted in databases and search engines of ScienceDirect, Springer, Scopus, PubMed, MEDLINE, and Google Scholar for English texts, and in the Magiran and Scientific Information Database (SID) databases and search engines for the texts printed in Persian. The search for articles printed from 2012 to 2022 was conducted based on the keywords used in the title and abstract of the articles. The keywords used to search domestic databases included nursing, lifestyle and healthy lifestyle, and heart diseases (based on MeSH).

Results

Nurses have made significant efforts and performed interventions to improve the lifestyle of coronary artery patients through guidance and education regarding the improvement of their diet and mobility, compliance with their treatment regimen, and reduction of the risk factors of CAD. In the psychological dimension, they had a positive effect in some fields such as stress management and mental health. However, in the spiritual dimension, effective studies and interventions have not been conducted by nurses.

Conclusions

The role of nurses in the lifestyle of coronary artery patients is effective in the physical dimension, limited in the psychological dimension, and neglected in the spiritual dimension.

Empowering patients with comorbid diabetes and hypertension through a multi-component intervention of mobile app, health coaching and shared decision-making: Protocol for an effectiveness-implementation of randomised controlled trial

INTRODUCTION

Diabetes and hypertension are prevalent and costly to the health system. We have developed a mobile app (EMPOWER app) which enables remote monitoring and education through personalised nudges. We aim to study the effectiveness of a multi-component intervention comprising the EMPOWER mobile app with health coaching and shared decision-making for diabetes and hypertension.

METHODS

We will conduct a two-arm, open-label, pragmatic randomised controlled trial (RCT). Participants with comorbid diabetes and hypertension enrolled from public primary care clinics will be randomised to either intervention or control in a 1:1 ratio. The intervention group participants will have access to health coaching with shared decision-making interventions in addition to the EMPOWER app and their usual primary care. The control group participants will continue to receive usual primary care and will neither receive the EMPOWER app nor health coaching and shared decision-making interventions. Our primary outcome is change in HbA1c level over 9 months. Secondary outcomes include change in systolic blood pressure, quality of life, patient activation, medication adherence, physical activity level, diet, and healthcare cost (direct and indirect) over 9 months.

DISCUSSION

Our trial will provide key insights into clinical- and cost-effectiveness of a multi-component intervention comprising EMPOWER mobile app, health coaching and shared decision-making in diabetes and hypertension management. This trial will also offer evidence on cost-effective and sustainable methods for promoting behavioural changes among patients with comorbid diabetes and hypertension.

TRIAL REGISTRATION

This study was registered on clintrials.gov on August 3, 2022, with the trial registration number: NCT05486390.

Precision medicine for cardiometabolic disease: a framework for clinical translation

Cardiometabolic disease is a major threat to global health. Precision medicine has great potential to help to reduce the burden of this common and complex disease cluster, and to enhance contemporary evidence-based medicine. Its key pillars are diagnostics; prediction (of the primary disease); prevention (of the primary disease); prognosis (prediction of complications of the primary disease); treatment (of the primary disease or its complications); and monitoring (of risk exposure, treatment response, and disease progression or remission). To contextualise precision medicine in both research and clinical settings, and to encourage the successful translation of discovery science into clinical practice, in this Series paper we outline a model (the EPPOS model) that builds on contemporary evidence-based approaches; includes precision medicine that improves disease-related predictions by stratifying a cohort into subgroups of similar characteristics, or using participants' characteristics to model treatment outcomes directly; includes personalised medicine with the use of a person's data to objectively gauge the efficacy, safety, and tolerability of therapeutics; and subjectively tailors medical decisions to the individual's preferences, circumstances, and capabilities. Precision medicine requires a well functioning system comprised of multiple stakeholders, including health-care recipients, health-care providers, scientists, health economists, funders, innovators of medicines and technologies, regulators, and policy makers. Powerful computing infrastructures supporting appropriate analysis of large-scale, well curated, and accessible health databases that contain high-quality, multidimensional, time-series data will be required; so too will prospective cohort studies in diverse populations designed to generate novel hypotheses, and clinical trials designed to test them. Here, we carefully consider these topics and describe a framework for the integration of precision medicine in cardiometabolic disease.

Health care professionals' experiences of supporting persons with metabolic risk factors to increase their physical activity level - a qualitative study in primary care

OBJECTIVE

To be regularly physically active is of major importance for the health of people with metabolic risk factors. Many of these persons are insufficiently active and in need of support. This study aimed to explore barriers and facilitators perceived by health care professionals' within Swedish primary care in their work to support persons with metabolic risk factors to increase their physical activity.

DESIGN

A qualitative design with focus group discussions was used. The data were analysed using qualitative content analysis with a manifest, inductive approach.

SETTING

Primary health care in five Swedish healthcare regions.

SUBJECTS

Nine physiotherapists, ten physicians and five nurses participated in six digital focus group discussions including two to six participants.

RESULTS

Barriers and facilitators to supporting persons with metabolic risk factors to increase their physical activity were found within four generic categories, where the barriers and facilitators related to each generic category: 'Patient readiness for change', 'Supporting the process of change', 'The professional role', and 'The organisation of primary care'.

CONCLUSION

The findings suggests that barriers and facilitators for supporting patients with metabolic risk factors can be found at several levels within primary care, from individual patient and the health care professionals to the organisational level. In the primary care setting, this should be highlighted when implementing support to increase physical activity in people with metabolic risk factors.KEY POINTSHealth care professionals within primary care are in a position to support people with metabolic risk factors to increase their physical activity.Barriers and facilitators to support the patients should be addressed at several levels within primary care.The study highlights factors on multiple levels such as professional responsibility, organisational prioritisation and resources, and the challenge to motivate behaviour change.

[Proposals for the community orientation of primary health care: to identify key agents for training]

OBJECTIVE

To identify the strengths available for the community orientation of primary health care (PHC) in the context of the evaluation of the piloting of a training program in Community Health for Resident Internal Specialists in Andalusia (Spain).

METHOD

We will conduct a qualitative, phenomenologically-oriented, explanatory research in which the opinion of the participants is analyzed. Sixty-seven professionals from six PHC Districts of Andalusia which were part of the training program called Project to Support the Revitalization of Primary Care Assets for Community Health (PARAC) were interviewed.

RESULTS

There is consensus in giving training a key weight in the community orientation of PHC. For this reason, those agents linked to training are identified as assets: general practice (GP) trainers, young professionals in training who bring updated perspectives and approaches to accredited PHC training centers, whose professionals must respond to the needs of their GP trainees, the multi-professional teaching units responsible for the GP trainees training and a medium and long-term health system thinking along with structures that coordinate and support the community work at the PHC centers.

CONCLUSIONS

The community orientation of PHC is an objective that requires the participation of all levels of the health system. Knowing its assets and working with them can contribute to provide proposals to advance towards a community-oriented PHC system.

Impact of Reducing Sitting Time in Women with Fibromyalgia and Obesity: A Randomized Controlled Trial

BACKGROUND

Sitting time has negative effects on health, increasing the risk of obesity, osteoporosis, diabetes, and cancer. Thus, primary health care education interventions aimed to reduce sitting time and sedentary behavior could have beneficial effects on people's health and wellbeing. The purpose of this study was to assess the effectiveness of an intervention based on reducing sitting time to decrease cardiometabolic risk on a sample of women diagnosed with fibromyalgia and moderate obesity.

METHODS

Randomized controlled trial to evaluate the effectiveness of an intervention to decrease cardiometabolic risk in 84 participants. Sedentary behavior was monitored using an accelerometer before and at 3-month follow-up.

RESULTS

Compared with the control group, body mass index decreased, and the number of steps taken increased, in the intervention group 3 months after the intervention. No significant differences were found in the rest of the variables measured.

CONCLUSION

The intervention group decreased sitting time after the intervention. Group activities and support from primary care may be useful to improve treatment adherence. RCT registration: NCT01729936.

The Doctor Will See You After Your Workout

Novel approaches to deliver lifestyle medicine that are convenient and accessible to patients are needed. Patients generally seek medical care when they are not well, reinforcing the notion of a "sick" care health system. Conversely, health clubs represent beacons of wellness amid the mire of chronic disease. Many individuals visit health clubs with the goal of becoming or remaining healthy. Expanding health care access to these health club populations creates opportunities to engage those who do not typically seek medical care, and may also attract those who are highly motivated to make lifestyle changes to prevent, treat, and reverse chronic disease. Health club clinics could be expanded with in-person or virtual offerings that go beyond traditional models. Such offerings would stand to improve health and be mutually beneficial for the provider and health club. By decreasing the barrier to access such care and meeting highly motivated patients where they are, providers may be more successful in their efforts to deliver lifestyle medicine to patients who are ready, willing, and able to make lifestyle behaviors changes.

Patients' experiences of the caring encounter in health promotion practice: a qualitative study in Swedish primary health care

BACKGROUND

Previous studies have reported that organizational structures and cultures in primary health care are obstacles to district nurses doing successful work in health promotion practice (HPP). Because organizational structures are not easily changed, Jean Watson's Attending Nurse Caring Model (ANCM) was introduced and piloted at a primary health care center in Sweden, aiming to transform HPP so as to empower district nurses and increase their work satisfaction.

AIM

To investigate patients' experiences of the caring encounter in HPP after introduction of the ANCM in Swedish primary health care, the aim being to explore the essential components of the caring encounter between patients and district nurses.

METHODS

A descriptive and qualitative research design was used. Data collection was performed using individual face-to-face interviews with twelve patients at risk for developing CVD. Data analysis consisted of both deductive content analysis, using a categorization matrix based on the ANCM and, subsequently, inductive latent content analysis.

RESULTS

The findings were abstracted into three themes: 1.'Feeling the deepest essence of being cared for': to be respected and being put at the center of the encounter; 2. 'Feeling acceptance and worth': being treated with openness and permissive attitudes, 3. 'Being in a supportive atmosphere that promotes hope': to feel trust and being trusted in the encounter, and being empowered by hope. The unifying main theme of the caring encounter was abstracted as 'Experiencing human dignity'.

CONCLUSION

The present study revealed that the essence of the caring encounter between patients and district nurses in HPP is to be unconditionally accepted in an environment that inspires hope and encouragement. The ANCM seems to be a promising model to use for strengthening the caring encounter and supporting CVD patients in making healthy lifestyle choices. However, further studies of qualitative and quantitative designs are needed to investigate what the ANCM can contribute to HPP in Swedish primary health care.

Does GP empathy influence patient enablement and success in lifestyle change among high risk patients?

Background

Chronic lifestyle-related-diseases can be prevented by healthy lifestyle. Patients at high risk of disease may benefit from targeted health checks in general practice. However, general-practice-based-studies have shown that patient outcome, enablement, and well-being may be influenced by general practitioner (GP) empathy. The aim of this study is to investigate 1) how high risk patients evaluate their GPs’ empathy during a health check consultation, 2) whether the perceived GP empathy is associated with the patient’s enablement in immediate continuation of the health check consultation and 3) the patient’s subsequent lifestyle changes.

Methods

This study is part of a population based non-randomized feasibility study testing a complex intervention that systematically identifies citizens at high risk of lifestyle-related disease and with health-risk behavior and offers targeted preventive services in the Danish primary care sector. The ultimate aim of the intervention is to improve lifestyle and thereby reduce the risk of lifestyle-related disease. In the feasibility study a random sample of patients aged 30 to 59 years were invited to participate, and to fill in a questionnaire on lifestyle-risk factors. Participants deemed to be at high risk of disease were offered a focused clinical examination and a subsequent health check consultation at the GP. Following each health check consultation GP empathy and patient enablement were assessed using The Care Measure (CARE) and Patient Enablement Instrument (PEI). Patient’s perceived healthy-lifestyle change (y/n) was assessed after three months. The study has been approved by the Danish Data Protection Agency (J.nr 2015–57-0008) and registered at ClinicalTrial. Gov on June 13, 2016.

Results

Twenty-six GP’s participated in the study. Among 93 patients receiving a health check consultation 60 rated the GPs empathy. The median CARE-score was 40. The PEI median was 5.5 and 44.9% achieved a healthier lifestyle. No association was observed between GP empathy and patient enablement or a perceived healthier lifestyle.

Conclusion

No statistical significant association between the CARE-score and patient enablement or a perceived healthier lifestyle was observed. Our results contrast previous findings and may to some extent be explained by a small sample size and the selected high-risk group.

Trial registration number

NCT02797392.

The role of registered nurses in primary care and public health collaboration: A scoping review

Aim

The purpose of this work was to examine the roles of Registered Nurses (RNs) in primary care (PC) and public health (PH) collaboration. Additionally, we aimed to explore whether the current scope of practice for RNs is adequate to support their roles in PC/PH collaboration.

Design

A scoping review of current literature relating to the RN's role in PC/PH collaboration was conducted using the PRISMA 2009 checklist.

Methods

The review used key terms: primary care, public health, collaboration, nursing and nurse role across six electronic databases; 23 articles that were included in the final review were published over a 7-year span.

Results

Four key RN roles relating to PC/PH collaboration were identified: relationship builder, outreach professional, programme facilitator and care coordinator. RNs supported transitions in chronic disease, communicable disease care and maternity care at various healthcare system levels including systemic, organizational, intrapersonal and interpersonal levels.

[Prevention of cardio-vascular disease in Swiss: general practitioners’ opinions and practices]

OBJECTIVE

The aim of this research is, on the one hand, to describe the customs and attitudes of Swiss general practitioners (GP) considering cardiovascular risk, and on the other, to put into perspective with the national recommendation Eviprev (summary representations of the primary and secondary preventions recommendations for patients aged between 18 and 70 years old).

METHODS

The study was based on an online survey sent to general practitioners belonging to the same research network and who were randomly selected. The sample was made of 200 Swiss GP. This article focuses on the frequency with which GP give advice related to consumption of tobacco and alcohol, exercising and nutrition during a regular meeting with their patient or a first visit. The results were analyzed according to age, sex, linguistic area and the extent to which they lived in a city or in the countryside.

RESULTS

Results suggest that the majority (97.6%) of GP show concern about informing patients on cardiovascular risk factors. Nonetheless most of the advice given are usually related to the patient’s case and not given in a systematic way. Tobacco addiction is the most systematically discussed theme during a first visit (33.9%), exercise comes second (25.6%), then nutrition (16.1%), and finally alcohol consumption (18.5%). Differences in numbers based on the different languages are little, except dealing with exercise.

CONCLUSIONS

Recommendations on prevention are followed by a majority of GP. Improvements could be made considering the training given and the remuneration of these counseling activities.

To initiate the conversation - Public health nurses' experiences of working with obesity in persons with mobility disability

Aim

Developing a theory explaining how public health nurses accomplish and adapt counselling in lifestyle habits to decrease obesity in people with mobility disability.

Design

Empirical research ‐ qualitative.

Method

Classic grounded theory with face‐to‐face interviews, 2017–2018, using inductive approach to understand public health nurses' intervening experiences with obesity patients.

Results

To initiate the conversation emerged as the main concern meaning having difficulties initiating conversations about obesity with patients. Public health nurses’ facilitators to communicate lifestyle changes emerged as the pattern generating the theory, which consists of the categories; person‐centeredness in the situation, experience and knowledge, strengthening conditions, access to other professionals and prioritization in everyday work.

Conclusions

Public health nurses hesitate to raise topics of obesity in patients with mobility disability. They advocate increased integration with lifestyle changes in everyday work including multi‐professional cooperation. The implication is testing the emerged theory at primary health care centres.

Impact

Obesity is more common in people with mobility disability than in those without. There is a need to understand how public health nurses adapt counselling in lifestyle habits. Public health nurses hesitate to talk about obesity with patients in fear of offending anyone. Public health nurses did not distinguish between patients with or without mobility disability. Several facilitators could be helpful initiating conversation with the patients. Public health nurses need more time and resources to facilitate conversation with patients with mobility disability to counsel lifestyle changes.

Influence of Psychosocial Factors on Energy Drink Consumption in Korean Nursing Students: Never-consumers versus Ever-consumers

Purpose

This study aimed to investigate the status of caffeine-containing energy drink consumption among Korean nursing students and to identify associated psychological factors.

Methods

In total, 187 Korean nursing students participated in this cross-sectional study. A self-administered questionnaire was used to identify participants' general characteristics and psychosocial factors (self-esteem, academic stress, depression, and college adjustment) associated with energy drink consumption. Data were analyzed with SPSS using descriptive statistics, the x² test, the t-test, and logistic regression.

Results

More than two-thirds (73.3%) of the participants had consumed energy drinks. Among the investigated psychological factors, depression appeared to most strongly influence energy drink consumption behaviors in this population.

Conclusion

The consumption of caffeine-containing energy drinks was found to be common among nursing students preparing to become health care professionals; depressed nursing students were more likely to have consumed energy drinks than non-depressed students. Nursing educators should emphasize the early detection of unhealthy beverage consumption habits and provide appropriate education to enhance healthy behaviors in future health care professionals.

Reorientation of health services: enablers and barriers faced by organisations when increasing health promotion capacity

Issue addressed Primary healthcare settings are important providers of health promotion approaches. However, organisational challenges can affect their capacity to deliver these approaches. This review identified the common enablers and barriers health organisations faced and it aimed to explore the experiences health organisations, in particular Aboriginal organisations, had when increasing their health promotion capacity. Methods A systematic search of peer-reviewed literature was conducted. Articles published between 1990-2014 that focused on a health care-settings approach and discussed factors that facilitated or hindered an organisation's ability to increase health promotion capacity were included. Results Twenty-five articles met the inclusion criteria. Qualitative (n=18) and quantitative (n=7) study designs were included. Only one article described the experiences of an Aboriginal health organisation. Enablers included: management support, skilled staff, provision of external support to the organisation, committed staffing and financial resources, leadership and the availability of external partners to work with. Barriers included: lack of management support, lack of dedicated health promotion staff, staff lacking skills or confidence, competing priorities and a lack of time and resources allocated to health promotion activities. Conclusions While the literature highlighted the importance of health promotion work, barriers can limit the delivery of health promotion approaches within primary healthcare organisations. A gap in the literature exists about how Aboriginal health organisations face these challenges. So what? Primary healthcare organisations wanting to increase their health promotion capacity can pre-empt the common barriers and strengthen identified enablers through the shared learnings outlined in this review.

Implementation of clinical practice guidelines on lifestyle interventions in Swedish primary healthcare - a two-year follow up

Background

Implementation of interventions concerning prevention and health promotion in health care has faced particular challenges resulting in a low frequency and quality of these services. In November 2011, the Swedish National Board of Health and Welfare released national clinical practice guidelines to counteract patients’ unhealthy lifestyle habits. Drawing on the results of a previous study as a point of departure, the aim of this two-year follow up was to assess the progress of work with lifestyle interventions in primary healthcare as well as the uptake and usage of the new guidelines on lifestyle interventions in clinical practice.

Methods

Longitudinal study among health professionals with survey at baseline and 2 years later. Development over time and differences between professional groups were calculated with Pearson chi-square test.

Results

Eighteen percent of the physicians reported to use the clinical practice guidelines, compared to 58% of the nurses. Nurses were also more likely to consider them as a support in their work than physicians did. Over time, health professionals usage of methods to change patients’ tobacco habits and hazardous use of alcohol had increased, and the nurses worked to a higher extent than before with all four lifestyles. Knowledge on methods for lifestyle change was generally high; however, there was room for improvement concerning methods on alcohol, unhealthy eating and counselling. Forty-one percent reported to possess thorough knowledge of counselling skills.

Conclusions

Even if the uptake and usage of the CPGs on lifestyle interventions so far is low, the participants reported more frequent counselling on patients’ lifestyle changes concerning use of tobacco and hazardous use of alcohol. However, these findings should be evaluated acknowledging the possibility of selection bias in favour of health promotion and lifestyle guidance, and the loss of one study site in the follow up. Furthermore, this study indicates important differences in physicians and nurses’ attitudes to and use of the guidelines, where the nurses reported working to a higher extent with all four lifestyles compared to the first study. These findings suggest further investigations on the implementation process in clinical practice, and the physicians’ uptake and use of the CPGs.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3023-z) contains supplementary material, which is available to authorized users.

Challenges and demands in the population-based work of public health nurses

AIMS

Government programs and the Norwegian Directorate of Health give public health nurses in Norway an explicit role in population-based health promotion and disease-prevention work. The aim of this paper is to explore Norwegian public health nurses' experiences with population-based work.

METHODS

A phenomenological hermeneutic approach was adopted, involving face-to-face interviews with a purposeful sample of 23 public health nurses from urban and rural districts in two counties in Norway.

RESULTS

Three themes were identified: the predominance of work at the individual level, a lack of resources, and adherence to administrative directives. The interviews revealed that the public health nurses were mostly occupied with individual problem-solving activities. Population-based work was hardly prioritized, mostly because of a lack of resources and a lack of recognition of the population-based role of public health nurses.

CONCLUSIONS

The study indicates contradictions between the public health nursing practice related to population-based work and the direction outlined by the government and the public health nursing curriculum, which may mean that the public health nursing role is not sufficiently clarified. The implementation of practice models and administrative directives and resources, as well as an explicit emphasis on population health in public health nursing education, can contribute to increased population-based interventions. Greater knowledge of and emphasis on population-based work in public health nursing are needed.

Validity and reliability of the Spanish version of the Organizational Readiness for Knowledge Translation (OR4KT) questionnaire

BACKGROUND

Organizational readiness to change healthcare practice is a major determinant of successful implementation of evidence-based interventions. However, we lack of comprehensive, valid, and reliable instruments to measure it. We assessed the validity and reliability of the Spanish version of the Organizational Readiness for Knowledge Translation (OR4KT) questionnaire in the context of the implementation of the Prescribe Vida Saludable III project, which seeks to strengthen health promotion and chronic disease prevention in primary healthcare organizations of the Osakidetza (Basque Health Service, Spain).

METHODS

A cross-sectional study was conducted including 127 professionals from 20 primary care centers within Osakidetza. They filled in the OR4KT questionnaire twice in a 15- to 30-day period to test repeatability. In addition, we used the Survey of Organizational Attributes for Primary Care (SOAPC) and we documented the number of healthcare professionals who formally engaged in the Prescribe Vida Saludable III project within each participating center to assess concurrent validity.

RESULTS

Cronbach's alpha for the overall OR4KT was .95, and the overall repeatability coefficient was 6.95%, both excellent results. Confirmatory factor analysis supported the underlying theoretical structure of 6 dimensions and 23 sub-dimensions. There were positive moderate-to-high internal correlations between these six dimensions, and there was evidence of good concurrent validity (correlation coefficient of .76 with SOAPC, and .80 with the proportion of professionals engaged by center). A score higher than 64 (out of 100) would be indicative of an organization with high level of readiness to implement the intervention (sensitivity = .75, specificity = 1).

CONCLUSIONS

The Spanish version of the OR4KT exhibits very strong reliability and good validity, although it needs to be validated in a larger sample and in different implementation contexts.

Cost analysis of a peer support programme for patients with type 2 diabetes: a secondary analysis of a controlled trial

Background

This study aimed to explore if group-based peer support as an additional component to a disease management programme (DMP) in type 2 diabetes can reduce the number of prescribed drugs; hospital admissions; and length of hospital stay and therefore be a cost-effective model.

Methods

Controlled study based on a secondary data analysis of a cluster randomized trial. Our study population was general practitioners and patients in the province of Salzburg. The 24-months intervention consisted of regular group meetings facilitated by trained peer supporters. The groups exercised together, discussed diabetes related topics, and received support by professionals. Data was anonymously collected on clusters through the statutory health insurance.

Results

Data were available of 118 (82.5%,17 clusters of the patients in the original randomized trial) participants in the intervention and 143 (77.3%,19 clusters) in the control groups. The length of hospital stay was shorter in the intervention groups compared with controls. The mean difference during the 24-month study period was -40.13 days (95% CI - 78.54 to - 1.71, P = 0.041) in favour of the intervention groups. No differences were seen in the number of prescribed drugs and hospital admission. Estimated yearly savings by reducing the length of hospital stay was €1660.60 per patient.

Conclusion

A group-based peer support programme as an additional component of a DMP in type 2 diabetes is a promising approach to optimize diabetes care and to enhance lifestyle interventions in primary care. Peer support seems to reduce length of hospital stay and could therefore be a cost-effective model.

Are Jordanian primary healthcare practitioners fulfilling their potential in cancer prevention and community health? Findings from a cross-sectional survey

INTRODUCTION

Primary healthcare practitioners (PHCPs) can contribute to the control of cancer by promoting healthy lifestyles to patients. Given the scarcity of data in the Middle East on this subject, we sought to determine, through a cross-sectional survey, the status of healthy lifestyle promotion by PHCPs (physicians, nurses, midwives, nurse aids) in Jordan.

METHODS

Building on published studies, an Arabic questionnaire was developed to measure knowledge, perceptions and practices of Jordanian PHCPs with regard to healthy lifestyle counselling. A purposive sample of 20 clinics covering the main regions of Jordan was selected and all PHCPs were asked to complete the questionnaire.

RESULTS

322 practitioners (32.3% physicians) responded (a 75.1% response rate). 24.4% of PHCPs were current cigarette smokers (physicians 44.2%). Roughly 58% of physicians and 50% of non-physicians reported advising the majority of patients to quit tobacco, but proportions were lower for providing other services (eg, asking about frequency of tobacco use, inquiring about diet and exercise, providing evidence-based guidance on quitting tobacco or improving diet and activity). Only 8% of the sample reported collectively asking the majority of patients about smoking status, exercise and diet; and providing evidence-based tips to improve these. Among physicians and non-physicians, 14.2% and 40.4% were able to identify the lifestyle-related risk factors associated with breast, colorectal and lung cancer. In multivariable analyses, confidence was the only significant variable associated with provision of counselling on healthy lifestyles.

CONCLUSIONS

Among Jordanian PHCPs, primary prevention services are underprovided, and data suggest ample room to improve PHCPs' skills and practices.

Are first-year nursing students' lifestyles coherent with their future career?

Nursing students are going to be professionals in the near future, and as carers, it will be essential for them to behave in a way that will allow them to have a positive influence on the health of others as well as their own health. The objective of this study was to evaluate the lifestyles of first-year nursing students of 2 universities (one in Spain and the other in Colombia). A cross-sectional descriptive study design using validated surveys was adopted. A sample of 140 nursing students enrolled in 2014 in their first year of 2 universities (Seville in Spain, n = 37, and Antioquia in Colombia, n = 93) self-reported the FANTASTICO Lifestyle checklist. Findings reveal that (1) the lifestyles are not appropriate in 1 of 3 of nursing students in both universities and (2) there are statistically significant differences for family items, positive thinkers, the use of safety belts, and alcohol consumption before driving. A high proportion of the study's participants have inappropriate lifestyles that involve risks for the deferred development of chronic diseases. It is necessary for universities to develop educational interventions in the design of nursing degrees to strengthen healthy behaviours during training.

Implementation of national guidelines for the prevention and treatment of overweight and obesity in children and adolescents: a phenomenographic analysis of public health nurses' perceptions

Objective

To explore and describe how public health nurses (PHNs) perceive the implementation of national guidelines for the prevention and treatment of overweight and obesity among children and adolescents in well-baby clinics and school health services.

Design, sample, and measurements

An explorative descriptive design was carried out through individual interviews with 18 PHNs and analysed according to the phenomenographic tradition.

Results

Four implementation strategies were described and assigned a metaphor: the structured PHN, pragmatic PHN, critical PHN, and the resigned PHN. Competence, patient receptiveness, internal consensus, interdisciplinary collaboration, resources, and organizational embedding were the determinants identified that most frequently affect implementation, and these determinants were distributed at different levels of the organization. The extent of facilitation seemed to determine which implementation strategy would be used.

Conclusions

How PHNs implemented the guidelines for overweight and obesity were affected by determinants at different organizational levels. Contextual facilitation of implementation seemed better in larger organizations, but factors such as leadership, drive, and experience compensated in smaller municipalities. The implementation of guidelines was hindered when the barriers exceeded the benefits.

[Counseling and preventive action in elderly population in hospitals and residences in Spain]

Objetivos

Conocer el perfil sociosanitario de los pacientes mayores atendidos en consultas; conocer las acciones preventivas que se llevan a cabo, de forma rutinaria, en hospitales, residencias geriátricas y otros centros asistenciales en España.

Diseño

Estudio descriptivo transversal, basado en un cuestionario a médicos que atienden a población mayor de 65 años en España (2013).

Emplazamiento

Centros de diferentes comunidades autónomas en España.

Participantes: Un total de 420 médicos de hospitales, residencias y otros centros. Se obtuvieron datos de 840 consultas a pacientes geriátricos.

Mediciones principales

Variables principales de resultados: dependencia, comorbilidad, motivo de consulta, actuación en consulta y recomendación de estilos de vida saludable. Factor asociado, tipo de institución en la que se atendió al paciente. Análisis de prevalencias y diferencias con Chi-cuadrado.

Resultados

El 66,7% presentaban dependencia, siendo mayor entre las mujeres: 68,9% vs 62,4% (p = 0,055). El 88,6% de mujeres atendidas con 85 o más años presentaban comorbilidad, mientras que en hombres de ese mismo grupo de edad eran un 79,8%. Solo un 6,6% de pacientes con comorbilidad recibieron recomendaciones saludables durante la consulta. El 79,6% de pacientes atendidos en hospitales recibieron recomendaciones de estilo de vida saludable, mientras que en las residencias geriátricas las recibieron el 59,62% de los pacientes (p < 0,001).

Conclusiones

Se detecta una escasa acción preventiva y de promoción de la salud hacia las personas mayores, con diferencias entre hospitales y residencias geriátricas. Parece necesario incentivar la actitud promotora de salud y las intervenciones preventivas en la práctica clínica gerontológica.

Towards implementing coordinated healthy lifestyle promotion in primary care: a mixed method study

Background

Primary care is increasingly being encouraged to integrate healthy lifestyle promotion in routine care. However, implementation has been suboptimal. Coordinated care could facilitate lifestyle promotion practice but more empirical knowledge is needed about the implementation process of coordinated care initiatives. This study aimed to evaluate the implementation of a coordinated healthy lifestyle promotion initiative in a primary care setting.

Methods

A mixed method, convergent, parallel design was used. Three primary care centres took part in a two-year research project. Data collection methods included individual interviews, document data and questionnaires. The General Theory of Implementation was used as a framework in the analysis to integrate the data sources.

Results

Multi-disciplinary teams were implemented in the centres although the role of the teams as a resource for coordinated lifestyle promotion was not fully embedded at the centres. Embedding of the teams was challenged by differences among the staff, patients and team members on resources, commitment, social norms and roles.

Conclusions

The study highlights the importance of identifying and engaging key stakeholders early in an implementation process. The findings showed how the development phase influenced the implementation and embedding processes, which add aspects to the General Theory of Implementation.

Implementing healthy lifestyle promotion in primary care: a quasi-experimental cross-sectional study evaluating a team initiative

Background

Non-communicable diseases are a leading cause of death and can largely be prevented by healthy lifestyles. Health care organizations are encouraged to integrate healthy lifestyle promotion in routine care. This study evaluates the impact of a team initiative on healthy lifestyle promotion in primary care.

Methods

A quasi-experimental, cross-sectional design compared three intervention centres that had implemented lifestyle teams with three control centres that used a traditional model of care. Outcomes were defined using the RE-AIM framework: reach, the proportion of patients receiving lifestyle promotion; effectiveness, self-reported attitudes and competency among staff; adoption, proportion of staff reporting regular practice of lifestyle promotion; implementation, fidelity to the original lifestyle team protocol. Data collection methods included a patient questionnaire (n = 888), a staff questionnaire (n = 120) and structured interviews with all practice managers and, where applicable, team managers (n = 8). The chi square test and problem-driven content analysis was used to analyse the questionnaire and interview data, respectively.

Results

Reach: patients at control centres (48%, n = 211) received lifestyle promotion significantly more often compared with patients at intervention centres (41%, n = 169). Effectiveness: intervention staff was significantly more positive towards the effectiveness of lifestyle promotion, shared competency and how lifestyle promotion was prioritized at their centre. Adoption: 47% of staff at intervention centres and 58% at control centres reported that they asked patients about their lifestyle on a daily basis. Implementation: all intervention centres had implemented multi-professional teams and team managers and held regular meetings but struggled to implement in-house referral structures for lifestyle promotion, which was used consistently among staff.

Conclusions

Intervention centres did not show higher rates than control centres on reach of patients or adoption among staff at this stage. All intervention centres struggled to implement working referral structures for lifestyle promotion. Intervention centres were more positive on effectiveness outcomes, attitudes and competency among staff, however. Thus, lifestyle teams may facilitate lifestyle promotion practice in terms of increased responsiveness among staff, illustrated by positive attitudes and perceptions of shared competency. More research is needed on lifestyle promotion referral structures in primary care regarding their configuration and implementation.

Long-term impact of a real-world coordinated lifestyle promotion initiative in primary care: a quasi-experimental cross-sectional study

BACKGROUND

Integration of lifestyle promotion in routine primary care has been suboptimal. Coordinated care models (e.g. screening, brief advice and referral to in-house specialized staff) could facilitate lifestyle promotion practice; they have been shown to increase the quality of services and reduce costs in other areas of care. This study evaluates the long-term impact of a coordinated lifestyle promotion intervention with a multidisciplinary team approach in a primary care setting.

METHODS

A quasi-experimental, cross-sectional design was used to compare three intervention centres using a coordinated care model and three control centres using a traditional model of lifestyle promotion care. Outcomes were inspired by using the RE-AIM framework: reach, the proportion of patients receiving lifestyle promotion; effectiveness, self-reported attitudes and competency among staff; adoption, proportion of staff reporting daily practice of lifestyle promotion and referral; and implementation, of the coordinated care model. The impact was investigated after 3 and 5 years. Data collection involved a patient questionnaire (intervention, n = 433-497; control, n = 455-497), a staff questionnaire (intervention, n = 77-76; control, n = 43-56) and structured interviews with managers (n = 8). The χ(2) test or Fisher exact test with adjustment for clustering by centre was used for the analysis. Problem-driven content analysis was used to analyse the interview data.

RESULTS

The findings were consistent over time. Intervention centres did not show higher rates for reach of patients or adoption among staff at the 3- or 5-year follow-up. Some conceptual differences between intervention and control staff remained over time in that the intervention staff were more positive on two of eight effectiveness outcomes (one attitude and one competency item) compared with control staff. The Lifestyle team protocol, which included structural opportunities for coordinated care, was implemented at all intervention centres. Lifestyle teams were perceived to have an important role at the centres in driving the lifestyle promotion work forward and being a forum for knowledge exchange. However, resources to refer patients to specialized staff were used inconsistently.

CONCLUSIONS

The Lifestyle teams may have offered opportunities for lifestyle promotion practice and contributed to enabling conditions at centre level but had limited impact on lifestyle promotion practices.

Attitudes About and Practices of Health Promotion and Prevention Among Primary Care Providers

The Patient Protection and Affordable Care Act's emphasis on health promotion and prevention activities required an examination of the current practices of primary care providers in these areas. A total of 196 primary care providers completed a survey to assess current health promotion and prevention attitudes, practices, and barriers. Results of this study showed that family physicians in Pennsylvania recognize the importance of and their role in providing health promotion and prevention and offer advice in key behavioral and disease prevention areas. Results from the study suggest that their ability to provide these services is hindered by a lack of time and the heavy workload. Although most family physicians provided advice to patients in several health promotion and prevention areas, few participants reported that they referred patients to other health professionals. Finally, when it comes to preventive services, participants ranked blood pressure screening, tobacco use screening, and tobacco use cessation interventions as the most important services. Effective implementation of the Patient Protection and Affordable Care Act will require necessary resources and support of primary care providers to help patients achieve healthier lives.

The effect of health promoting intervention on healthy lifestyle and social support in elders: a clinical trial study

Background:

Many of the problems pertaining to old age originate from unhealthy lifestyle and low social support. Overcoming these problems requires precise and proper policy-making and planning.

Objectives:

The aim of the current research is to investigate the effect of health promoting interventions on healthy lifestyle and social support in elders.

Patients and Methods:

This study was conducted as a clinical trial lasting for 12 months on 464 elders aged above 60 years who were under the aegis of health homes in Tehran, Iran. Participants were selected through double stage cluster sampling and then divided into intervention and control groups (232 individuals in each). Tools for gathering data were a demographic checklist and two standard questionnaires called Health-Promoting Lifestyle Profile version 2 and personal resource questionnaire part 2. Data were analyzed using descriptive and analytical tests including paired t test, analysis of covariance (ANCOVA) and Pearson correlation coefficient.

Results:

The average age of elders in this study was 65.9 ± 3.6 years (ranging between 60 and 73 years old). Results showed that the differences between the mean post-test scores of healthy lifestyle and its six dimensions as well as perceived social support and its five dimensions in the control and intervention groups were statistically significant (P value < 0.0001).

Conclusions:

Aging is an inevitable stage of life. However, effective health promoting interventions can procrastinate it, reduce its consequences and problems, and turn it into a pleasant and enjoyable part of life.

Dietary counselling for cardiovascular disease prevention in primary care settings: results from a German physician survey

BACKGROUND

Primary care physicians (PCPs) play an important role in the promotion of healthy dietary behaviour. However, little is known about the practice of and factors associated with the provision of dietary counselling in primary health care in Germany.

OBJECTIVES

To explore the attitudes towards and factors associated with the routine provision of dietary counselling in Germany using data from the nationwide, representative sample of the Physician Survey on Cardiovascular Disease Prevention.

METHODS

A total of 4074 randomly selected PCPs (response rate: 33.9%) provided data on dietary counselling for prevention of cardiovascular disease (CVD) based on the 5 A's (Assess, Advise, Agree, Assist, Arrange), attitudes towards dietary counselling and patients' and practice characteristics.

RESULTS

While the majority of PCPs (86%) reported having high levels of competence in providing dietary advice, only 49% felt they had been successful in counselling their patients on nutrition. PCPs routinely asked (68%) and advised patients to change their dietary habits more frequently (77%) compared to other counselling techniques based on the 5 A's. Female physicians and those with a higher percentage of privately insured patients and patients at higher risk of CVD were more likely to use the 5 A's to routinely counsel their patients on nutrition.

CONCLUSIONS

The data showed high levels of involvement by German PCPs in CVD prevention and dietary counselling. The rather low perceived success of dietary intervention and differences with respect to patients' health insurance status indicate a need to address both communication skills in medical training and appropriate reimbursement of preventive services.

Lifestyle advice and lifestyle change: to what degree does lifestyle advice of healthcare professionals reach the population, focusing on gender, age and education?

Health promotion practice in health care has a high priority in the endeavour to achieve equal opportunities for health and diversity in health among the population. The purpose of the study was to investigate whether there is any connection between the lifestyle advice given by healthcare professionals and the lifestyle change of the population, focusing on age, gender and education level. The study is based on the data from a national population survey in Sweden in which 52 595 patients who had attended health care were interviewed by phone. The participants were asked whether healthcare professionals had raised the subject of lifestyle during the visit and whether the advice they gave had contributed to a lifestyle change. The results indicated that lifestyle issues were raised with 32.2% of those who attended health care, particularly among men, younger patients and those with a high education level. When lifestyle issues were raised, the advice contributed to 39.2% of patients making a lifestyle change, to a higher extent among men, older patients and those with a low education level. The study shows that lifestyle advice given by healthcare professionals, during both emergency and outpatient healthcare visits, is an important contributor to patients' lifestyle change.