Effects of health counseling on behavioural risk factors in a high-risk cardiology outpatient population: a randomized clinical trial

The effect of behaviour change interventions on changes in physical activity and anthropometrics in ambulatory hospital settings: a systematic review and meta-analysis

Background

The aim of this systematic review and meta-analysis was to investigate whether behaviour change interventions promote changes in physical activity and anthropometrics (body mass, body mass index and waist circumference) in ambulatory hospital populations.

Methods

Randomised controlled trials were collected from five bibliographic databases (MEDLINE, Embase, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO). Meta-analyses were conducted using change scores from baseline to determine mean differences (MD), standardised mean differences (SMD) and 95% confidence intervals (95% CI). The Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of the evidence.

Results

A total of 29 studies met the eligibility criteria and 21 were included in meta-analyses. Behaviour change interventions significantly increased physical activity (SMD: 1.30; 95% CI: 0.53 to 2.07, p < 0.01), and resulted in significant reductions in body mass (MD: -2.74; 95% CI: − 4.42 to − 1.07, p < 0.01), body mass index (MD: -0.99; 95% CI: − 1.48 to − 0.50, p < 0.01) and waist circumference (MD: -2.21; 95% CI: − 4.01 to − 0.42, p = 0.02). The GRADE assessment indicated that the evidence is very uncertain about the effect of behaviour change interventions on changes in physical activity and anthropometrics in ambulatory hospital patients.

Conclusions

Behaviour change interventions initiated in the ambulatory hospital setting significantly increased physical activity and significantly reduced body mass, body mass index and waist circumference. Increased clarity in interventions definitions and assessments of treatment fidelity are factors that need attention in future research.

PROSPERO registration number: CRD42020172140.

Patients' knowledge on cardiovascular risk factors and associated lifestyle behaviour in Ethiopia in 2018: A cross-sectional study

BACKGROUND

Cardiovascular disease (CVD) is posing a major public health challenge globally. Evidence reports significant gaps in knowledge of cardiovascular risk factors among patients with CVD. Despite the growing burden of cardiovascular disease in developing countries, there is limited data available to improve the awareness of this area, which is crucial for the implementation of prevention programs.

METHODS

A cross-sectional survey was conducted in two referral hospitals in Eastern Ethiopia from June-September 2018. Outpatients with a confirmed diagnosis cardiovascular conditions were eligible for participation in the study. A convenience sampling technique was used. The primary outcome of the study was knowledge of cardiovascular risk factors among patients with cardiovascular disease. The knowledge of cardiovascular disease risk factors was measured using a validated instrument (heart disease fact questionnaire). A score less than 70% was defined as suboptimal knowledge. Multivariable linear regression was used to examine the relationship between knowledge of cardiovascular risk factors and explanatory variables.

RESULTS

A total of 287 patients were enrolled in the study. Mean age was 47±11yrs and 56.4% of patients were females. More than half of patients (54%) had good knowledge on cardiovascular risk factors (scored>70%), whilst 46% demonstrated suboptimal knowledge levels in this area. Urban residency was associated with higher cardiovascular risk factors knowledge scores, whereas, never married and no formal education or lower education were identified as predictors of lower knowledge scores. There was no statistically significant association between knowledge of cardiovascular risk factors and actual cumulative risk behaviour.

CONCLUSION

Almost half of CVD patients in Ethiopia have suboptimal knowledge regarding cardiovascular risk factors. Residence, education level and marital status were associated with knowledge of cardiovascular risk factors. Implementation of innovative interventions and structured, nurse-led lifestyle counselling would be required to effectively guide patients in developing lifestyle modification and achieve sustainable behaviour change.

Cardiovascular risk behaviour is an emerging health issue in developing countries: a cross-sectional study

BACKGROUND

Low and middle-income countries are facing a high burden of cardiovascular disease while there is limited availability of resources and evidence to educate and modify lifestyle behaviours in the population as well as to guide policy making.

AIM

The goal of the present study was to quantify the prevalence of different cardiovascular risk behaviours among patients with known cardiovascular conditions in a developing country.

METHODS

A hospital-based cross-sectional survey was conducted in two referral hospitals in eastern Ethiopia. Outpatients who had a confirmed diagnosis of cardiovascular disease were recruited for the study. Data were collected through face-to-face interviews with patients using validated tools.

RESULTS

A total of 287 cardiovascular disease patients was recruited, of which 56.4% were women and 90.2% were urban residents. Most patients had inadequate consumption of fruit and vegetables, 51.6% were physically inactive, 20% were current khat chewers, 19% were current alcohol drinkers and only 1% were current smokers. Approximately one-third (30%) of the patients had one of these risk behaviours, more than half (51.9%) had two, 15% had three and 3.1% had four risk behaviours. The majority (70%) of the patients had multiple (more than two) risk behaviours. The prevalence of multiple risk behaviours did not significantly vary with sex, residence and educational level differences (P>0.05).

CONCLUSION

Cardiovascular disease patients continue to follow unhealthy lifestyles although they attend follow-up care with a specific focus on risk management. The findings of this study provide evidence for policy makers that health services reform is required to promote healthy lifestyle behaviours for the patients.

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

Changes in diet, exercise and stress behaviours using the stages of change model in cardiac rehabilitation patients

The behavioural changes initiated during Phase III cardiac rehabilitation programmes were recorded using Prochaska and Diclemente's “stages of change” model. This study aimed to ascertain if changes were initiated, maintained or further developed during Phase III programmes and 6 months after the programmes with a view to ascertaining the usefulness of this tool in providing stage matched individualised care. The risk factors examined were: exercise, diet and stress. The stages were recorded quantitatively and were numerically designated a value of 1–5. The results were analysed using SPSS. The sample number was one hundred and eighty seven patients.

Significant improvements were made by the end of the programme (6 or 8 weeks) indicating that most patients had modified their behaviour during the programme. There was no significant additional improvement in the risk factors 6 months later. These results are a further indication of the need for support post Phase III programmes. Patients entered Phase III rehabilitation at different stages in their risk behaviours and with regard to exercise this stage at commencement influences the final stage achieved. “Stages of change” is a useful simple method of recording behavioural change and this type of routine monitoring of a patient could be used effectively as part of the individual care plan during the programme.

Efficacy of multifactorial lifestyle interventions in patients with established cardiovascular diseases and high risk groups

BACKGROUND

Lifestyle modification is recommended for patients with established cardiovascular diseases (CVD) or at high risk of CVD. In recent years, risk factor interventions in which multiple risk factors are addressed simultaneously are increasingly conducted.

AIM

To determine, and if possible quantify, the efficacy of multifactorial lifestyle interventions (without drug therapy) in patients with established CVD or in high risk groups.

METHODS

A literature search was conducted using 'Pubmed', to identify articles of randomized controlled trials (RCTs) or reviews of RCTs, published between 1990 and 2007.

RESULTS

In patients with established CVD, multifactorial lifestyle interventions can reduce the occurrence of cardiovascular diseases and/or mortality, even many years after the end of the intervention. Further, in both patients and high risk groups, multifactorial lifestyle interventions have favorable effects on biological risk factors and lifestyle and are able to reduce the incidence of diabetes. In the long-term, in particular lifestyle changes seem to persist, such as improved dietary habits and increased physical activity, while the favorable effects on biological risk factors, such as body weight and blood pressure, are no longer different from the control group. Regular contact with the participants seems to be part of the "success factor".

CONCLUSION

It can be recommended to offer patients with established CVD as well as individuals at high risk of CVD a comprehensive lifestyle advice, as part of their medical treatment, combined with intensive counseling.

Risk groups and predictors of short-term abstinence from smoking in patients with coronary heart disease

OBJECTIVES

We sought to identify risk groups among smoking cardiac patients from their social cognitive profiles, and to assess predictors of smoking abstinence shortly after discharge.

METHODS

Smoking cardiac patients (n = 133) completed questionnaires at hospital admission and 1 month after discharge. Hierarchical cluster analysis was used to detect risk groups of smokers, based on baseline scores for smoking-related social cognitions. Regression analyses were used to identify predictors of the intention to abstain from smoking and smoking abstinence 1 month after discharge.

RESULTS

Three groups of smokers were distinguished that differed significantly on the pros of nonsmoking, self-efficacy expectancies toward nonsmoking, social support, social modeling, and smoking behavior. Abstinence from smoking 1 month after discharge was predicted by group membership and a stronger intention to quit. A previous hospital admission because of a cardiac event significantly decreased the likelihood of abstinence.

CONCLUSIONS

One third of cardiac patients are at high risk of continuing smoking after hospital discharge because of an unfavorable smoking and disease history and a poor social cognitive profile. Interventions for cardiac patients should address risk profiles to achieve long-term abstinence. The implications of nursing practices in smoking cessation treatments are discussed.

A randomized controlled trial of stage-matched intervention for smoking cessation in cardiac out-patients

AIM

To examine the effectiveness of a stage-matched smoking cessation counselling intervention for smokers who had cardiac diseases.

METHODS

A total of 1860 Chinese cardiac patients who smoked at least one cigarette in the past 7 days and aged 18 years or above recruited from cardiac out-patient clinics in Hong Kong hospitals were allocated randomly to an intervention group or control group. The intervention group (n = 938) received counselling matched with their stage of readiness to quit by trained counsellors at baseline, 1 week and 1 month. The control group (n = 922) received brief counselling on healthy diet at baseline. The primary outcomes were self-reported 7-day and 30-day point prevalence (PP) of tobacco abstinence at 12 months after baseline. The secondary outcome measures included biochemically validated abstinence at 12-month follow-up, self-reported 7-day and 30-day PP abstinence and reduction of cigarette consumption by 50% at 3 and 6 months.

RESULTS

By intention-to-treat analysis, the intervention and control groups showed no significant difference in self-reported 7-day PP abstinence (intervention: 26.5% versus control: 25.5%; P = 0.60) and 30-day PP (intervention: 25.4% versus control: 24.2%; P = 0.55), biochemically validated abstinence (intervention: 6.6% versus control: 4.9%; P = 0.14) and overall quit attempts of least 24 hours (intervention: 40.3% versus control: 34.3%; P = 0.007) at the 12-month follow-up, adjusted for the baseline stage of readiness to quit smoking.

CONCLUSIONS

An intervention, based on the Stages of Change model, to promote smoking cessation in cardiac patients in China failed to find any long-term benefit.

Psychological interventions for coronary heart disease

BACKGROUND

Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures.

OBJECTIVES

Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac-related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study-level predictors of the impact of these interventions.

SEARCH STRATEGY

The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review.

SELECTION CRITERIA

Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow-up of six months. Adults with specific diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information.

MAIN RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non-fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): -0.21 (95% CI -0.35, -0.08) and anxiety, SMD: -0.25 (95% CI -0.48 to -0.03). Results for mortality indicated some evidence of small-study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type-A behaviours (ß = -0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (ß = 0.23, p = 0.03), (3) included client-led discussion and emotional support as core therapeutic components (ß = 0.31, p < 0.01), or (4) included family members in the treatment process (ß = 0.26, p < 0.01) were significantly less effective.

AUTHORS' CONCLUSIONS

Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Knowledge and management of smoking-cessation strategies among cardiologists in France: a nationwide survey

BACKGROUND

While cardiologists are very active in the prevention of cardiovascular disease, their attitudes towards patients' smoking habits are poorly studied.

AIMS

In a nationwide French survey, we assessed cardiologists' levels of knowledge and management of smoking cessation.

METHODS

We sent out a questionnaire to a random sample of 1000 cardiologists.

RESULTS

A total of 371cardiologists agreed to participate in the survey; 8.1% were current smokers and 32.4% were past smokers. Most classified smoking cessation as the top priority for patients with coronary artery disease (56.5%) and peripheral arterial disease (88.5%). Cardiologists routinely assessed active and passive smoking in 96.2% and 43% of their patients, respectively. Only 29.2% considered themselves well informed about smoking-cessation management. While 39.9% declared they knew about the minimal counselling 7.3% described it correctly. Only 17.5% used the Fagerström questionnaire. Smoking cessation was advised systematically by 85% but only 5.4% of cardiologists followed up their patients specifically on this issue. They referred smokers to either their general practitioner or to smoking-cessation centres and/or quitlines in 16.0% and 67.0% of cases, respectively; 31.8% never referred their patients to a smoking-cessation centre, and 25% declared being unaware of any such centre in their area. Cardiologists who smoked were less likely to ask about patients' smoking status than non-smokers (90% vs 98.2%, p=0.039). Similarly, they were more passive in offering smoking-cessation counselling (23% vs 7%, p=0.011), and referred less frequently their patients to a smoking-cessation centre (37% vs 64%, p=0.028).

CONCLUSION

French cardiologists are rarely involved in the management of smoking cessation. Their own smoking status influences their attitudes towards the management of smoking cessation.