Would primary health care workers give appropriate dietary advice after cholesterol screening?

Behavioral counseling for cardiovascular disease prevention in 36 low-income and middle-income countries

BACKGROUND

Given the substantial prevalence of cardiovascular disease (CVD) in low-income and middle-income countries (LMICs), evaluation of behavioral counseling for prevention of CVD is important.

METHODS

We pooled nationally representative cross-sectional surveys from 36 LMICs between 2013 and 2020. The population was divided into three groups according to CVD risk: the potential risk group, the risk group and the CVD group. We estimated the prevalence of six types of behavioral counseling among the three groups separately: smoking, salt reduction, fruit and vegetable intake, dietary fat reduction, physical activity and body weight.

RESULTS

There were 16,057 (25.4%) in the potential risk group, 43,113 (49.9%) in the risk group, and 7796 (8.6%) in the CVD group. The prevalence of receiving at least four types of counseling in the three groups was 15.6% (95% CI 13.9 to 17.5), 14.9% (95% CI 14.0 to 15.9), and 19.8% (95% CI 17.7 to 22.2), respectively. The lowest prevalence was for tobacco use counseling: 24.5% (95% CI 22.5 to 26.4), 23.2% (95% CI 22.1 to 24.3), and 32.1% (95% CI 29.5 to 34.8), respectively. The prevalence of counseling was higher in upper-middle-income countries than in lower-middle-income countries. Women, older people, those with more education, and those living in urban areas were more likely to receive counseling.

CONCLUSION

The prevalence of behavioral counseling for CVD is low in LMICs, especially among potentially at-risk populations and in low-income countries. These findings highlight the current urgent need to improve CVD prevention and management systems to enhance behavioral counseling and intervention.

Adherence to a guideline on cardiovascular prevention: a comparison between general practitioners and practice nurses

BACKGROUND

Patient non-compliance with prescribed treatment is an important factor in the lack of success in cardiovascular prevention. Another important cause is non-adherence of caregivers to the guidelines. It is not known how doctors and nurses differ in the application of guidelines. Patient compliance to treatment may vary according to the type of caregiver.

OBJECTIVE

To compare adherence to cardiovascular prevention delivered by practice nurses and by general practitioners.

SETTING

Six primary health care centres in the Netherlands (25 general practitioners, six practice nurses).

METHODS

701 high risk patients were included in a randomised trial. Half of the patients received nurse-delivered care and half received care by general practitioners. For 91% of the patients treatment concerned secondary prevention. The Dutch guideline on cardiovascular prevention was used as protocol. A structured self-administered questionnaire was sent by post to patients. Data were extracted from the practice database and the questionnaire.

RESULTS

Intervention was received by 77% of respondents who visited the practice nurse compared to 57% from the general practitioner group (OR = 2.56, p < 0.01). More lifestyle intervention was given by the practice nurse; 46% of patients received at least one lifestyle intervention (weight, diet, exercise, and smoking) compared to 13% in general practitioner group (OR = 3.24, p < 0.001). In addition, after one year more patients from the practice nurse group used cardiovascular drugs (OR = 1.9, p = 0.03). Nurses inquired more frequently about patient compliance to medical treatment (OR = 2.1, p < 0.01). Regarding patient compliance, no statistical difference between study groups in this trial was found.

CONCLUSION

Practice nurses adhered better to the Dutch guideline on cardiovascular prevention than general practitioners did. Lifestyle intervention advice was more frequently given by practice nurses. Improvement of cardiovascular prevention is still necessary. Both caregivers should inquire about patient adherence on a regular basis.

A cluster randomised trial to evaluate a nutrition training programme

BACKGROUND

The need for training to equip primary care staff with the knowledge and skills to provide dietary advice to the public has been acknowledged. Little is known about the effectiveness of such training at improving the dietary counselling skills of multidisciplinary practice teams.

AIM

To evaluate the effectiveness of a nutrition training programme, delivered to primary care teams by a dietitian.

DESIGN OF STUDY

A paired-cluster randomised trial.

SETTING

Twelve general practices in Sunderland, in the United Kingdom.

METHOD

A nutrition training programme, aimed at improving the quality of dietary consultations, was developed and delivered to six primary care teams by a dietitian. Main outcome measures were patients' recall of seven key consulting behaviours. Data were collected from patients in intervention and control practices, pre- and post-intervention. Change in knowledge and attitude of practitioners was also measured.

RESULTS

All 12 practices completed the trial. Data were collected from 251 patients pre-intervention and 228 patients post-intervention. Of the seven consulting behaviours targeted in the training, only the proportion of consultations where written information (diet sheets) was provided to patients was significantly higher (13% higher, 95% confidence interval [CI = 4 to 21, P = 0.004) in the intervention practices post-training. Some evidence of improved practitioner knowledge and attitude was detected.

CONCLUSION

This evaluation of a nutrition training intervention detected only a limited impact on the behaviour, knowledge, and attitudes of primary care practitioners in dietary consultations.

Nutrition interventions by primary care staff: a survey of involvement, knowledge and attitude

OBJECTIVE

To undertake a survey to investigate the quality and format of nutrition health promotion in UK primary care. Data from both primary care practitioners - i.e. level of nutritional knowledge and attitude towards nutrition interventions - and patients - i.e. the format and quality of dietary consultations - are presented.

DESIGN

A self-completion questionnaire was used to assess nutritional knowledge and attitude of primary care staff towards nutrition interventions. Data regarding the format and quality of the dietary consultation were collected from patients using a screening question and follow-up questionnaire.

SETTING

Twelve general practices in a city in north-east England.

SUBJECTS

One hundred and nine primary care staff, and 2400 consecutive patients recruited from the 12 practices.

RESULTS

Seventy-seven per cent of primary care staff completed the questionnaire. Sixty-five per cent of the knowledge questions were answered correctly by most practitioners. Questions containing complex nutritional terminology were answered poorly. Most practitioners believed primary care teams have an essential role in giving dietary advice. Thirteen per cent of patients reported that they had discussed diet. Of these, 40% were asked to make dietary changes; 20% discussed how they cooked or prepared food; and 33% were asked to make a follow-up appointment.

CONCLUSION

Encouraging signs included good levels of nutritional knowledge and belief amongst staff that they should be involved in nutrition interventions. Patients reported that they understood and felt able to achieve the dietary changes suggested. Less encouraging were little evidence of discussion about the practical aspects of food and fairly low rates of follow-up being arranged.

Diet-related knowledge, beliefs and actions of health professionals compared with the general population: an investigation in a community Trust

BACKGROUND

Dietary change is advocated for the prevention and treatment of a number of major diseases, and the implicit and explicit assumption is that health professionals have a major role in promoting diet change. Previous studies of doctors and nurses have shown their knowledge to be inadequate. Other health professionals have not been investigated.

METHODS

Parts of a questionnaire used in a national study of the general public were administered to groups of health professionals from a variety of disciplines working in a community Trust. The results were compared with those from the study of the general public, for which the questionnaire had been devised.

RESULTS

358 questionnaires were completed. There was little difference between the knowledge, beliefs and actions of health professionals and the general public.

CONCLUSION

If health professionals are to continue to be expected to promote healthy eating messages there will need to be a more systematic approach to their training about nutrition.

Assessing practice nurses' change in nutrition knowledge following training from a primary care dietitian

The expanding role of the Primary Health Care Team (PHCT) has led to more opportunities to offer dietary advice to patients. However, members of the PHCT appear to lack nutritional knowledge and confidence when giving dietary advice. This work assesses the changes in Practice Nurses' (PNs) nutrition knowledge and confidence when giving dietary advice to patients, following training from a dietitian. Base line nutrition knowledge of PNs and their confidence when giving dietary advice was assessed in 30 GP Practices by questionnaire. Following Practice-based training from a dietitian, change in knowledge and confidence was assessed using the same questionnaire. Paired and unpaired analysis was carried out on the PN's knowledge and confidence scores respectively. Nutrition knowledge increased significantly after training. The mean difference (95% confidence interval) pre- and post-training was 11.6 (7.8, 15.4). After training 88% of PNs reported having good or excellent confidence compared with 27% before training (chi-squared test p < 0.001). Nutrition training from a dietitian improves nutrition knowledge of PNs. It also improves their confidence and is recommended to support their role in providing accurate and consistent dietary advice to patients.

A randomized trial to evaluate the effectiveness of dietary advice by practice nurses in lowering diet-related coronary heart disease risk

BACKGROUND

Dietary factors are an important contribution to the high rates of coronary heart disease in the UK. One approach to achieving change is health-promoting advice in primary care.

AIM

To compare the effectiveness of structured dietary advice by practice nurses with standard health education in changing serum cholesterol, weight and diet.

METHOD

Randomized, controlled trial within eight general practices in England and Wales allocated within matched geographical pairs to 'dietary advice' or 'usual care'. Men and women aged 35-59 years, recruited opportunistically by their GPs, underwent health checks. In 'dietary advice' practices, subjects received dietary advice from specially trained nurses based on negotiated change principles, reinforced at follow up. In 'usual care' practices, subjects were only given standard health education materials.

RESULTS

A total of 956 patients were recruited: 473 in 'dietary advice' practices and 483 in 'usual care' practices. Compliance with annual follow up was 80%. Compared with 'usual care' practices, there was a mean 0.20 mmol/l lower serum cholesterol (95% CI -0.38 to -0.03 at 1 year) in 'dietary advice' practices. There was a small fall in weight of 0.56 kg (95% CI -1.04 to -0.07) and reductions in total and saturated fat. Factor VII coagulant activity fell by a mean of 6.7% of the standard (95% CI -15.4 to +2.0).

CONCLUSION

Provision of standard health education material alone as part of a health check had no effect on coronary heart disease risk factors. There were modest changes in diet and associated risk factors when a more intensive and individual approach to dietary advice was given by practice nurses. This is, however, probably an ineffective use of resources, except in those at high risk of coronary heart disease. Whole-population strategies to achieve dietary change are required.

The public view on cardiovascular risk factors and changes in lifestyle

OBJECTIVE

To investigate the public knowledge of cardiovascular risk factors including hyperlipidaemia, and attitudes to changes in lifestyle and to the role of the primary health care in preventive work.

DESIGN

Postal questionnaire.

SETTING

A physically defined area in south-western Stockholm.

SUBJECTS

1000 randomly selected individuals of both sexes 40 to 64 years, stratified into 5-year groups.

MAIN OUTCOME MEASURES

Knowledge of and attitudes to cardiovascular risk factors. Contact with the primary health care and expectancy of physicians' interest in patients' lifestyles.

RESULTS

Response rate was 75%. The awareness of cardiovascular risk factors was high, but only 51% knew what constitutes healthy food, and two thirds doubted that they could change their eating habits. Forty-eight percent had visited the primary health care during the previous year. Eighty-four percent thought that the physicians should know about their patients' smoking, 83% about drinking habits, and 75% about eating habits. Physicians were expected to spend 40% of their time on preventive work. Only 26% believed that press information about hyperlipidaemia and heart disease did more good than harm.

CONCLUSION

Knowledge was good about causative cardiovascular risk factors, but poor about healthy eating. Physicians were expected to have an interest in patients' lifestyle and in prevention. This type of knowledge is important for preventive work.

Diet and cancer

Accumulating data indicate that modifications in diet may reduce the risk of cancer by as much as one third and possibly by as much as two thirds. On the basis of the existing evidence, however, it is not possible to be certain which cancers are causally related to diet and what proportion of them are due to specific components of the diet. Diet is currently thought to be a major factor in the aetiology of cancers of the large bowel and stomach, and it may also be important in the aetiology of several other cancers. With the exception of strong and consistent evidence of the protective effect of fruit and vegetables, practical dietary interventions that reduce the risk of cancer are difficult to formulate as, in general, the evidence is theoretical or contradictory and too weak to justify specific intervention. Authoritative guidelines on dietary management in primary care are conspicuously absent because of lack of research. The success of an individual based strategy will depend on adequate education, training, and support being made available to the relevant members of primary care teams.

Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year. Imperial Cancer Research Fund OXCHECK Study Group

OBJECTIVE

To assess the effectiveness of health checks by nurses in reducing risk factors for cardiovascular disease in patients from general practice.

DESIGN

Randomised controlled trial.

SETTING

Five urban general practices in Bedfordshire.

SUBJECTS

2136 patients receiving an initial health check in 1989-91 and scheduled to be re-examined one year later in 1990-2 (intervention group); 3988 patients receiving an initial health check in 1990-2 (control group). All patients were aged 35-64 years at recruitment in 1989.

MAIN OUTCOME MEASURES

Serum total cholesterol concentration, blood pressure, body mass index, confirmed smoking cessation.

RESULTS

Mean serum total cholesterol was 2.3% lower in the intervention group than in the controls (difference 0.14 mmol/l (95% confidence interval 0.08 to 0.20)); the difference was greater in women (3.2%, P < 0.0001) than men (1.0%, P = 0.18). There was no significant difference in smoking prevalence, quit rates, or body mass index. Systolic and diastolic blood pressure were 2.5% and 2.4% lower respectively in the intervention group. The proportion of patients with diastolic blood pressure > or = 100 mm Hg was 2.6% (55/2131) in the intervention group and 3.4% (137/3987) in the controls (difference 0.9% (0.0 to 1.7)); the proportion with total cholesterol concentration > or = 8 mmol/l 4.8% (100/2068) and 7.6% (295/3905) (difference 2.7% (1.5 to 4.0)); and that with body mass index > or = 30 12.4% (264/2125) and 14.0% (559/3984) (difference 1.6% (-0.2 to 3.4)).

CONCLUSIONS

General health checks by nurses are ineffective in helping smokers to stop smoking, but they help patients to modify their diet and total cholesterol concentration. The public health importance of this dietary change depends on whether it is sustained.

Study of dietetic knowledge among members of the primary health care team

There is growing emphasis on health promotion in primary care. The success of this endeavour depends in part on the ability of members of the primary health care team to provide appropriate and practical advice and support, relating to lifestyle. A study of 58 primary health care professionals was carried out in the Grampian region of Scotland to assess their nutritional knowledge and their ability to provide practical dietary advice, particularly in relation to the prevention of coronary heart disease. Overall, the primary health care workers had a broad understanding of recommendations for healthy eating, but there was some confusion over specific aspects of these recommendations. Health professionals also found it difficult to translate knowledge into practical dietary advice tailored to an individual case. If health promotion in primary care is to work effectively, the infrastructure necessary for effective training and continuing education has to be addressed.

Prevalence of risk factors for heart disease in OXCHECK trial: implications for screening in primary care. Imperial Cancer Research Fund OXCHECK Study Group

OBJECTIVE

To describe the outcome of offering health checks systematically to a general practice adult population, in terms of age and sex specific prevalence of risk factors, follow up workload, and selective screening of cholesterol concentration.

DESIGN

Descriptive analysis of data obtained by postal questionnaire and by personal interview and clinical examination by a trained nurse.

SUBJECTS

2205 patients aged 35-64 who attended for a health check in 1989-90 from an invited random sample of 2777 patients from five urban general practices in Bedfordshire.

RESULTS

Overall, almost three quarters of patients (78% of men, 68% of women) needed specific advice or follow up. Smoking, a high fat diet, and being overweight (body mass index greater than or equal to 25 kg/m2) were common characteristics exhibited by 35%, 31%, and 55% respectively of men and 24%, 18%, and 48% of women. The total cholesterol concentration was greater than or equal to 6.5 mmol/l in 37% of patients and greater than or equal to 8 mmol/l in 8%. In terms of workload 13% needed dietary advice only, 15% needed only follow up of hyperlipidaemia or hypertension, and 9% needed advice on smoking only. A further 35% needed follow up for a combination of risk factors. The proportion of patients in whom cholesterol concentration would be measured if a selective screening policy were adopted would vary from 29% to 71%, according to different criteria, but (particularly in men) no combination would be much better than random testing as a means to detect patients with a total cholesterol concentration greater than or equal to 8 mmol/l.

CONCLUSIONS

If the entire adult population of a practice is offered health checks systematically the acceptance rate is lower and the follow up workload higher than previously understood. The resource implications depend on the age and sex of patients screened and the selective criteria adopted for cholesterol measurement. Health checks are only the beginning of a successful preventive programme--the challenge is to provide effective intervention and follow up.

Management of weight problems and obesity: knowledge, attitudes and current practice of general practitioners

A postal questionnaire was used to assess general practitioners' knowledge, attitudes and current practice of treatment regarding obesity and weight problems. Overall, 299 responses (75%) were received from general practitioners randomly selected from family practitioner committee lists in Portsmouth and Norwich. Currently 27% of the doctors were overweight and a further 3% obese. Many doctors (69%) had tried to lose weight at some time and 40% had been overweight and a further 12% obese in the past. The most popular methods used to educate overweight and obese patients were one to one counselling and giving out diet sheets and leaflets on healthy eating. The treatment advice to patients from the majority of doctors was to eat less in general (78%) (specifically to eat fewer calories 75%); to exercise (77%); or to attend a slimmers group (54%). Doctors thought that they were less effective than the media or the family in persuading overweight patients to lose weight. Doctors said they were prepared to counsel on weight reduction but felt they had little success in achieving weight loss in patients. Experience was ranked as the most important contributor to knowledge about managing obesity, and medical school was rated as least important. Further study is needed to discover how different practices and attitudes affect patient management and which ones are associated with greatest success. Medical schools and postgraduate centres could play a more important role in educating doctors about nutrition.

A heart health assessment programme in general practice in County Kilkenny, Ireland

The Kilkenny Faculty of the Irish College of General Practitioners and the Kilkenny Health Project have established a Health Assessment Programme (HAP) to standardise the examination and recording of coronary heart disease (CHD) risk factors in general practice. Criteria were agreed for classification and coding of demographic data, relevant medical history and risk behaviours. Height, weight and blood pressure are measured and venous blood sample is taken for total cholesterol estimation. The assessment is followed by appropriate counselling. The HAP was first targetted at men and women aged 40 to 49 years. During the first 16 months of the programme, 2102 assessments were carried out by 41 general practitioners, which represents 29% of the target group. Those taking part had a lower social class distribution when compared with participants in the KHP baseline survey in 1985. There were no significant differences between the two groups in smoking prevalence or in the distribution of body mass index. Median cholesterol was 5% lower in the HAP group than at the baseline survey. 16% of the HAP clients had diastolic blood pressures of 90 mm Hg or more. The HAP has demonstrated that it is feasible to measure CHD risk factors in a variety of general practice settings. The format facilitates a preventive orientation and has proved acceptable to patients.

Physicians' attitudes to the treatment of elevated serum cholesterol

A questionnaire was sent to 457 physicians (328 general practitioners, 129 hospital doctors) to assess their attitudes to and their knowledge and practice of the management of raised serum cholesterol. Replies were returned by 206 (63%) general practitioners and 95 (74%) hospital doctors. While smoking, hypertension, diabetes mellitus and elevated total serum cholesterol were recognised as major risk factors for coronary heart disease, a significant number of respondents considered serum triglycerides to be less important. Both groups of physicians start dietary management at similar total serum cholesterol levels, but hospital doctors were more likely to use dietetic services. The two groups had a similar threshold for the addition of drug therapy. A bile acid sequestrant was the favoured first choice as a cholesterol lowering agent, although a wide variety of other drugs were also chosen. The screening of high risk patients was preferred to whole population and opportunistic screening for identifying hypercholesterolaemic individuals. The findings have important implications in the delivery of services to hypercholesterolaemic patients.