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O'Connor EA, Evans CV, Rushkin MC, Redmond N, Lin JS. Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2020; 324:2076-2094. [PMID: 33231669 DOI: 10.1001/jama.2020.17108] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Cardiovascular disease is the leading cause of death in the US, and poor diet and lack of physical activity are major factors contributing to cardiovascular morbidity and mortality. OBJECTIVE To review the benefits and harms of behavioral counseling interventions to improve diet and physical activity in adults with cardiovascular risk factors. DATA SOURCES MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through September 2019; literature surveillance through July 24, 2020. STUDY SELECTION English-language randomized clinical trials (RCTs) of behavioral counseling interventions to help people with elevated blood pressure or lipid levels improve their diet and increase physical activity. DATA EXTRACTION AND SYNTHESIS Data were extracted from studies by one reviewer and checked by a second. Random-effects meta-analysis and qualitative synthesis were used. MAIN OUTCOMES AND MEASURES Cardiovascular events, mortality, subjective well-being, cardiovascular risk factors, diet and physical activity measures (eg, minutes of physical activity, meeting physical activity recommendations), and harms. Interventions were categorized according to estimated contact time as low (≤30 minutes), medium (31-360 minutes), and high (>360 minutes). RESULTS Ninety-four RCTs were included (N = 52 174). Behavioral counseling interventions involved a median of 6 contact hours and 12 sessions over the course of 12 months and varied in format and dietary recommendations; only 5% addressed physical activity alone. Interventions were associated with a lower risk of cardiovascular events (pooled relative risk, 0.80 [95% CI, 0.73-0.87]; 9 RCTs [n = 12 551]; I2 = 0%). Event rates were variable; in the largest trial (Prevención con Dieta Mediterránea [PREDIMED]), 3.6% in the intervention groups experienced a cardiovascular event, compared with 4.4% in the control group. Behavioral counseling interventions were associated with small, statistically significant reductions in continuous measures of blood pressure, low-density lipoprotein cholesterol levels, fasting glucose levels, and adiposity at 12 to 24 months' follow-up. Measurement of diet and physical activity was heterogeneous, and evidence suggested small improvements in diet consistent with the intervention recommendation targets but mixed findings and a more limited evidence base for physical activity. Adverse events were rare, with generally no group differences in serious adverse events, any adverse events, hospitalizations, musculoskeletal injuries, or withdrawals due to adverse events. CONCLUSIONS AND RELEVANCE Medium- and high-contact multisession behavioral counseling interventions to improve diet and increase physical activity for people with elevated blood pressure and lipid levels were effective in reducing cardiovascular events, blood pressure, low-density lipoproteins, and adiposity-related outcomes, with little to no risk of serious harm.
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Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Corinne V Evans
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Megan C Rushkin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Nadia Redmond
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Jennifer S Lin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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Oster C, Schoo A, Litt J, Morello A, Leibbrandt R, Antonello C, Powers D, Lange B, Maeder A, Lawn S. Supporting workforce practice change: protocol for a pilot study of a motivational interviewing virtual client software tool for health professionals. BMJ Open 2020; 10:e033080. [PMID: 32041854 PMCID: PMC7045188 DOI: 10.1136/bmjopen-2019-033080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/24/2019] [Accepted: 01/13/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Motivating behavioural change during client consultations is of crucial importance across all health professions to address the growing burden of chronic conditions. Yet health professionals often lack the skills and confidence to use evidence-based counselling interventions to support clients' behavioural change and mobilise clients' resources and self-efficacy for change to address their long-term needs. AIMS This pre-post pilot study will develop a motivational interviewing (MI) virtual client training tool for health professionals and test the effectiveness of the educational content and usability of the virtual client interaction. METHODS AND ANALYSIS Postgraduate students across a range of health disciplines will be recruited. Data assessing attitudes towards preventive healthcare will be collected using a modified version of the Preventive Medicine Attitudes and Activities Questionnaire. Conversations with the virtual client will be analysed using the Motivational Interviewing Treatment Integrity code to assess changes in MI skills. The System Usability Scale will be used to assess the usability of the virtual client training tool. ETHICS AND DISSEMINATION This protocol was approved by the Flinders University Social and Behavioural Research Ethics Committee in May 2019. The results of the pilot study will inform the development of an avatar-based mobile application consisting of MI teaching and interactions with a generic virtual client that can be easily adapted to multiple scenarios.
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Affiliation(s)
- Candice Oster
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Adrian Schoo
- Prideaux Centre for Research in Health Professions Education, Flinders University, Adelaide, South Australia, Australia
| | - John Litt
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Andrea Morello
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Richard Leibbrandt
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christopher Antonello
- College of Science & Engineering, Flinders University, Adelaide, South Australia, Australia
| | - David Powers
- College of Science & Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Belinda Lange
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Anthony Maeder
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Sharon Lawn
- College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
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Porter GC, Laumb K, Michaud T, Brito F, Petreca D, Schwieger G, Bartee T, Yeary KHK, Estabrooks PA. Understanding the impact of rural weight loss interventions: A systematic review and meta-analysis. Obes Rev 2019; 20:713-724. [PMID: 30633845 PMCID: PMC7565480 DOI: 10.1111/obr.12825] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/28/2018] [Accepted: 11/28/2018] [Indexed: 02/06/2023]
Abstract
Rural adults have a higher risk of developing obesity than urban adults. Several evidence-based interventions have targeted rural regions, but their impact, defined as reach (number and representativeness of participants) by effectiveness, has not been examined. The purpose of this review was to determine the impact of rural weight loss interventions and the availability of data across dimensions of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. A systematic review was conducted to identify rural weight loss interventions that targeted adults. RE-AIM-related data were abstracted from each article. We performed a meta-analysis to examine effectiveness. Sixty-four articles reported on rural weight loss interventions, describing 50 unique interventions. The median number of participants was 107. Median participation rate differed between values reported by the authors (62%) and values computed using a standard method (32%). Two studies reported on sample representativeness; none reported comparisons made between target and actual delivery settings. Median weight loss per participant was 3.64 kg. Meta-analyses revealed the interventions achieved a significant weight reduction, and longer-duration interventions resulted in greater weight loss. Rural weight loss interventions appear to be effective in supporting clinically meaningful weight loss but reach and cost outcomes are still difficult to determine.
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Affiliation(s)
- Gwenndolyn C Porter
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Karen Laumb
- Laumb Consulting, LLC, Minneapolis, Minnesota, USA
| | - Tzeyu Michaud
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fabiana Brito
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Daniel Petreca
- Nucleus of Research in Collective Health & Environment, University of Contestado, Mafra-SC, Brazil
| | - Gina Schwieger
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Todd Bartee
- Department of Kinesiology and Sport Sciences, University of Nebraska at Kearney, Kearney, Nebraska, USA
| | - Karen H K Yeary
- Department of Health Behavior and Health Education, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Paul A Estabrooks
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Harris MF, Parker SM, Litt J, van Driel M, Russell G, Mazza D, Jayasinghe UW, Smith J, Del Mar C, Lane R, Denney-Wilson E. An Australian general practice based strategy to improve chronic disease prevention, and its impact on patient reported outcomes: evaluation of the preventive evidence into practice cluster randomised controlled trial. BMC Health Serv Res 2017; 17:637. [PMID: 28886739 PMCID: PMC5591527 DOI: 10.1186/s12913-017-2586-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 08/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care. METHODS PEP Intervention practices received education, clinical audit and feedback and practice facilitation. Patients (40‑69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires. Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar's test and multilevel analysis was used to determine the effect of the intervention on follow-up scores. RESULTS Five hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes. CONCLUSIONS The lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.
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Affiliation(s)
- Mark Fort Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, NSW, Australia.
| | - Sharon M Parker
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, NSW, Australia
| | - John Litt
- Discipline of General Practice, Health Sciences Building, Flinders University, Adelaide, 5042, SA, Australia
| | - Mieke van Driel
- Academic Discipline of General Practice, School of Medicine, University of Queensland, Brisbane, 4072, QLD, Australia
| | - Grant Russell
- Southern Academic Primary Care Research Unit, Monash University, Melbourne, 3800, VIC, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary Health Care, Monash University, Melbourne, 3800, VIC, Australia
| | - Upali W Jayasinghe
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, NSW, Australia
| | - Jane Smith
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, 4229, QLD, Australia
| | - Chris Del Mar
- Health Sciences and Medicine, Bond University, Gold Coast, 4229, QLD, Australia
| | - Riki Lane
- Southern Academic Primary Care Research Unit, Monash University, Melbourne, 3800, VIC, Australia
| | - Elizabeth Denney-Wilson
- Sydney Nursing School and Sydney Local Health District, The University of Sydney , Sydney, 2006, NSW, Australia
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Physical Activity and Healthy Eating Promotion among Adults with Cardiovascular Metabolic Risk Factors: An Application of Intervention Mapping Framework. HEALTH SCOPE 2017. [DOI: 10.5812/jhealthscope.15167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Harris MF, Harris E. Partnerships between primary healthcare and population health: preventing chronic disease in Australia. LONDON JOURNAL OF PRIMARY CARE 2015; 4:133-7. [PMID: 26265951 DOI: 10.1080/17571472.2012.11493351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In Australia, partnership working between public health and primary healthcare for the prevention and management of chronic disease has been developing incrementally since the 2003 consensus statement developed by the Joint Advisory Group of the General Practice Partnership Advisory Council and the National Public Health Partnership Group. Australia's first national primary healthcare strategy (2010) provides a new opportunity to further develop this partnership, including multidisciplinary team-working in general practice for chronic disease prevention, and a new primary care organisation to oversee population health planning and health promotion. The needs of vulnerable and disadvantaged groups will be a central focus of the new planning structures. However, major barriers continue to frustrate collaborative population based planning and service development. Conclusion The jury is still out on how effective the partnership between state funded public health service and the new nationally funded primary care organisations will be. There is significant overlap in their functions, but few formal mechanisms for collaboration have been as yet established.
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Affiliation(s)
| | - Elizabeth Harris
- Senior Research Fellow Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
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Damman OC, Bogaerts NMM, van Dongen D, Timmermans DRM. Barriers in using cardiometabolic risk information among consumers with low health literacy. Br J Health Psychol 2015. [PMID: 26213137 DOI: 10.1111/bjhp.12149] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To identify the barriers from the perspective of consumers with low health literacy in using risk information as provided in cardiometabolic risk assessments. DESIGN A qualitative thematic approach using cognitive interviews was employed. METHODS We performed interviews with 23 people with low health literacy/health numeracy, who were recruited through (1) several organisations and snowball sampling and (2) an online access panel. Participants completed the risk test of the Dutch national cardiometabolic risk assessment and viewed the personalized information about their risk. They were asked to answer probing questions about different parts of the information. The qualitative data were analysed by identifying main themes related to barriers in using the information, using a descriptive thematic approach. RESULTS The four main themes identified were as follows: (1) People did not fully accept the risk message, partly because numerical information had ambiguous meaning; (2) people lacked an adequate framework for understanding their risk; (3) the purpose and setting of the risk assessment was unclear; and (4) current information tells nothing new: A need for more specific risk information. CONCLUSIONS The main barriers were that the current presentation seemed to provoke undervaluation of the risk number and that texts throughout the test, for example about cardiometabolic diseases, did not match people's existing knowledge, failing to provide an adequate framework for understanding cardiometabolic risk. Our findings have implications for the design of disease risk information, for example that alternative forms of communication should be explored that provide more intuitive meaning of the risk in terms of good versus bad. STATEMENT OF CONTRIBUTION What is already known on this subject? Online disease risk assessments have become widely available internationally. People with low SES and health literacy tend to participate less in health screening. Risk information is difficult to understand, yet little research has been carried out among people with low health literacy. What does this study add? People with low health literacy do not optimally use risk information in an online cardiometabolic risk assessment. The texts provided in the cardiometabolic risk assessment do not suit to their existing knowledge. The typical risk communication (numbers, bar graph, verbal label) seems to provoke undervaluation of risk.
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Affiliation(s)
- Olga C Damman
- Department of Public and Occupational Health and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Nina M M Bogaerts
- Department of Public and Occupational Health and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Diana van Dongen
- Department of Public and Occupational Health and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Danielle R M Timmermans
- Department of Public and Occupational Health and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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Partridge SR, Balestracci K, Wong AT, Hebden L, McGeechan K, Denney-Wilson E, Harris MF, Phongsavan P, Bauman A, Allman-Farinelli M. Effective Strategies to Recruit Young Adults Into the TXT2BFiT mHealth Randomized Controlled Trial for Weight Gain Prevention. JMIR Res Protoc 2015; 4:e66. [PMID: 26048581 PMCID: PMC4526902 DOI: 10.2196/resprot.4268] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/10/2015] [Accepted: 04/23/2015] [Indexed: 11/29/2022] Open
Abstract
Background Younger adults are difficult to engage in preventive health, yet in Australia they are gaining more weight and increasing in waist circumference faster than middle-to-older adults. A further challenge to engaging 18- to 35-year-olds in interventions is the limited reporting of outcomes of recruitment strategies. Objective This paper describes the outcomes of strategies used to recruit young adults to a randomized controlled trial (RCT), healthy lifestyle mHealth program, TXT2BFiT, for prevention of weight gain. The progression from enquiry through eligibility check to randomization into the trial and the costs of recruitment strategies are reported. Factors associated with nonparticipation are explored. Methods Participants were recruited either via letters of invitation from general practitioners (GPs) or via electronic or print advertisements, including Facebook and Google—social media and advertising—university electronic newsletters, printed posters, mailbox drops, and newspapers. Participants recruited from GP invitation letters had an appointment booked with their GP for eligibility screening. Those recruited from other methods were sent an information pack to seek approval to participate from their own GP. The total number and source of enquiries were categorized according to eligibility and subsequent completion of steps to enrolment. Cost data and details of recruitment strategies were recorded. Results From 1181 enquiries in total from all strategies, 250 (21.17%) participants were randomized. A total of 5311 invitation letters were sent from 12 GP practices—16 participating GPs. A total of 131 patients enquired with 68 participants randomized (68/74 of those eligible, 92%). The other recruitment methods yielded the remaining 182 randomized participants. Enrolment from print media was 26% of enquiries, from electronic media was 20%, and from other methods was 3%. Across all strategies the average cost of recruitment was Australian Dollar (AUD) $139 per person. The least expensive modality was electronic (AUD $37), largely due to a free feature story on one university Web home page, despite Facebook advertising costing AUD $945 per enrolment. The most expensive was print media at AUD $213 and GP letters at AUD $145 per enrolment. Conclusions The research indicated that free electronic media was the most cost-effective strategy, with GP letters the least expensive of the paid strategies in comparison to the other strategies. This study is an important contribution for future research into efficacy, translation, and implementation of cost-effective programs for the prevention of weight gain in young adults. Procedural frameworks for recruitment protocols are required, along with systematic reporting of recruitment strategies to reduce unnecessary expenditure and allow for valuable public health prevention programs to go beyond the research setting. Trial Registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000924853; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362872 (Archived by WebCite at http://www.webcitation.org/6YpNfv1gI).
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Volker N, Davey RC, Cochrane T, Williams LT, Clancy T. Improving the prevention of cardiovascular disease in primary health care: the model for prevention study protocol. JMIR Res Protoc 2014; 3:e33. [PMID: 25008232 PMCID: PMC4115264 DOI: 10.2196/resprot.2882] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 03/13/2014] [Accepted: 03/14/2014] [Indexed: 11/13/2022] Open
Abstract
Background Cardiovascular disease (CVD) is the leading cause of death globally, and accounted for nearly 31% of all deaths in Australia in 2011. The primary health care sector is at the frontline for addressing CVD, however, an evidence-to-practice gap exists in CVD risk assessment and management. General practice plays a key role in CVD risk assessment and management, but this sector cannot provide ongoing lifestyle change support in isolation. Community-based lifestyle modification services and programs provided outside the general practice setting have a key role in supporting and sustaining health behavior change. Fostering linkages between the health sector and community-based lifestyle services, and creating sustainable systems that support these sectors is important. Objective The objective of the study Model for Prevention (MoFoP) is to take a case study approach to examine a CVD risk reduction intervention in primary health care, with the aim of identifying the key elements required for an effective and sustainable approach to coordinate CVD risk reduction across the health and community sectors. These elements will be used to consider a new systems-based model for the prevention of CVD that informs future practice. Methods The MoFoP study will use a mixed methods approach, comprising two complementary research elements: (1) a case study, and (2) a pre/post quasi-experimental design. The case study will consider the organizations and systems involved in a CVD risk reduction intervention as a single case. The pre/post experimental design will be used for HeartLink, the intervention being tested, where a single cohort of patients between 45 and 74 years of age (or between 35 and 74 years of age if Aboriginal or Torres Strait Islander) considered to be at high risk for a CVD event will be recruited through general practice, provided with enhanced usual care and additional health behavior change support. A range of quantitative and qualitative data will be collected. This will include individual health and well being data collected at baseline and again at 12 months for HeartLink participants, and systems related data collected over the period of the intervention to inform the case study. Results The intervention is currently underway, with results expected in late 2015. Conclusions Gaining a better understanding of CVD prevention in primary health care requires a research approach that can capture and express its complexity. The MoFoP study aims to identify the key elements for effective CVD prevention across the health and community sectors, and to develop a model to better inform policy and practice in this key health priority area for Australia.
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Affiliation(s)
- Nerida Volker
- Center for Research and Action in Public Health, University of Canberra, Canberra, Australia.
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McKenzie SH, Jayasinghe UW, Fanaian M, Passey M, Harris MF. Analysis of the psychological impact of a vascular risk factor intervention: results from a cluster randomized controlled trial in Australian general practice. BMC FAMILY PRACTICE 2013; 14:190. [PMID: 24330347 PMCID: PMC3890522 DOI: 10.1186/1471-2296-14-190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 12/11/2013] [Indexed: 12/31/2022]
Abstract
Background Screening for vascular disease, risk assessment and management are encouraged in general practice however there is limited evidence about the emotional impact on patients. The Health Improvement and Prevention Study evaluated the impact of a general practice-based vascular risk factor intervention on behavioural and physiological risk factors in 30 Australian practices. The primary aim of this analysis is to investigate the psychological impact of participating in the intervention arm of the trial. The secondary aim is to identify the mediating effects of changes in behavioural risk factors or BMI. Methods This study is an analysis of a secondary outcome from a cluster randomized controlled trial. Patients, aged 40–65 years, were randomly selected from practice records. Those with pre-existing cardiovascular disease were excluded. Socio-demographic details, behavioural risk factors and psychological distress were measured at baseline and 12 months. The Kessler Psychological Distress Score (K10) was the outcome measure for multi-level, multivariable analysis and a product-of-coefficient test to assess the mediating effects of behaviour change. Results Baseline data were available 384 participants in the intervention group and 315 in the control group. Twelve month data were available for 355 in the intervention group and 300 in the control group. The K10 score of patients in the intervention group (14.78, SD 5.74) was lower at 12 months compared to the control group (15.97, SD 6.30). K10 at 12 months was significantly associated with the score at baseline and being unable to work but not with age, gender, change in behavioural risk factors or change in BMI. Conclusions The reduction of K10 in the intervention group demonstrates that a general practice based intervention to identify and manage vascular risk factors did not adversely impact on the psychological distress of the participants. The impact of the intervention on distress was not mediated by a change in the behavioural risk factors or BMI, suggesting that there must be other mediators that might explain the positive impact of the intervention on emotional wellbeing. Trial registration Australian New Zealand Clinical Trials Registry
ACTRN12607000423415.
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Affiliation(s)
- Suzanne Helen McKenzie
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW, Australia.
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Pierce BA, Chesney MA, Witt CM, Berman BM. Physician Perspectives on Comparative Effectiveness Research: Implications for Practice-based Evidence. Glob Adv Health Med 2013; 1:32-6. [PMID: 24278829 PMCID: PMC3833509 DOI: 10.7453/gahmj.2012.1.4.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Comparative effectiveness research (CER) is defined by the Institute of Medicine as “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.” The goal of CER is to provide timely, useful evidence to healthcare decision makers including physicians, patients, policymakers, and payers. A prime focus for the use of CER evidence is the interaction between physician and patient. Physicians in primary practice are critical to the success of the CER enterprise. A 2009 survey suggests, however, that physician attitudes toward CER may be mixed—somewhat positive toward the potential for patient care improvement, yet negative toward potential restriction on physician freedom of practice. CER methods and goals closely parallel those of practice-based research, an important movement in family medicine in the United States since the 1970s. This article addresses apparent physician ambivalence toward CER and makes a case for family medicine engagement in CER to produce useful practice-based evidence. Such an effort has potential to expand care options through personalized medicine, individualized guidelines, focus on patient preferences and patient-reported outcomes, and study of complex therapeutic interventions, such as integrative care. Academic medical researchers will need to collaborate with experienced family physicians to identify significant practice-based research questions and design meaningful studies. Such collaborations would shape CER to produce high-quality practice-based evidence to inform family and community medicine.
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Affiliation(s)
- Beverly A Pierce
- Beverly A. Pierce, RN, MLS, MA, is director of community programs at The Institute for Integrative Health, Baltimore, Maryland
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Petek D, Platinovsek R, Klemenc-Ketis Z, Kersnik J. Do family physicians advise younger people on cardiovascular disease prevention? A cross-sectional study from Slovenia. BMC FAMILY PRACTICE 2013; 14:82. [PMID: 23767793 PMCID: PMC3684536 DOI: 10.1186/1471-2296-14-82] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 05/29/2013] [Indexed: 11/26/2022]
Abstract
Background One of the main family practice interventions in the younger healthy population is advice on how to keep or develop a healthy lifestyle. In this study we explored the level of counselling regarding healthy lifestyle by family physicians and the factors associated with it. Methods A cross-sectional study with a random sample of 36 family practices, stratified by size and location. Each practice included up to 40 people aged 18–45 with low/medium risk for cardiovascular disease (CVD). Data were obtained by patient and practice questionnaires and semi-structured interviews. Several predictors on the patient and practice level for received advice in seven areas of CVD prevention were applied in corresponding models using a two-level logistic regression analysis. Results Less than half of the eligible people received advice for the presented risk factors and the majority of them found it useful. Practices with medium patient list-sizes showed consistently higher level of advice in all areas of CVD prevention. Independent predictors for receiving advice on cholesterol management were patients’ higher weight (regression coefficient 0.04, p=0.03), urban location of practice (regression coefficient 0.92, p=0.04), organisation of education by the practice (regression coefficient 0.47, p=0.01) and practice list size (regression coefficient 6.04, p=0.04). Patients who self-assessed their health poorly more frequently received advice on smoking (regression coefficient −0.26, p=0.03). Hypertensive patients received written information more often (regression coefficient 0.66, p=0.04). People with increased weight more often received advice for children’s lifestyle (regression coefficient 0.06, p=0.03). We did not find associations with patient or practice characteristics and advice regarding weight and physical activity. We did not find a common pattern of predictors for advice. Conclusions Counselling for risk diseases such as increased cholesterol is more frequently provided than basic lifestyle counselling. We found some doctors and practice factors associated with counselling behaviour, but the majority has to be explained by further studies.
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Affiliation(s)
- Davorina Petek
- Department of Family Medicine, Medical Faculty, University of Ljubljana, Poljanski nasip 58, 1000, Ljubljana, Slovenia.
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Laws RA, Fanaian M, Jayasinghe UW, McKenzie S, Passey M, Davies GP, Lyle D, Harris MF. Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial. BMC Health Serv Res 2013; 13:201. [PMID: 23725521 PMCID: PMC3702446 DOI: 10.1186/1472-6963-13-201] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 05/20/2013] [Indexed: 11/30/2022] Open
Abstract
Background Previous research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care. Methods This concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program. Results A total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance. Conclusion Barriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals’ health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation. Trial registration ACTRN12607000423415
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Affiliation(s)
- Rachel A Laws
- Prevention Research Collaboration, School of Public Health, University of Sydney, Sydney, NSW 2006, Australia.
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14
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Harris MF, Chan BC, Laws RA, Williams AM, Davies GP, Jayasinghe UW, Fanaian M, Orr N, Milat A. The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial). BMC Public Health 2013; 13:375. [PMID: 23607755 PMCID: PMC3653785 DOI: 10.1186/1471-2458-13-375] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 04/16/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge. METHODS The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an 'early intervention' and two to a 'late intervention' group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30-80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques. RESULTS 804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months. CONCLUSION The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses. TRIAL REGISTRATION ACTRN12609001081202.
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Affiliation(s)
- Mark F Harris
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Bibiana C Chan
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Rachel A Laws
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Anna M Williams
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Gawaine Powell Davies
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Upali W Jayasinghe
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Mahnaz Fanaian
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Neil Orr
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Andrew Milat
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
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Williams AM, Bloomfield L, Milthorpe E, Aspinall D, Filocamo K, Wellsmore T, Manolios N, Jayasinghe UW, Harris MF. Effectiveness of Moving On: an Australian designed generic self-management program for people with a chronic illness. BMC Health Serv Res 2013; 13:90. [PMID: 23497326 PMCID: PMC3605265 DOI: 10.1186/1472-6963-13-90] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 02/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper presents the evaluation of "Moving On", a generic self-management program for people with a chronic illness developed by Arthritis NSW. The program aims to help participants identify their need for behaviour change and acquire the knowledge and skills to implement changes that promote their health and quality of life. METHOD A prospective pragmatic randomised controlled trial involving two group programs in community settings: the intervention program (Moving On) and a control program (light physical activity). Participants were recruited by primary health care providers across the north-west region of metropolitan Sydney, Australia between June 2009 and October 2010. Patient outcomes were self-reported via pre- and post-program surveys completed at the time of enrolment and sixteen weeks after program commencement. Primary outcomes were change in self-efficacy (Self-efficacy for Managing Chronic Disease 6-Item Scale), self-management knowledge and behaviour and perceived health status (Self-Rated Health Scale and the Health Distress Scale). RESULTS A total of 388 patient referrals were received, of whom 250 (64.4%) enrolled in the study. Three patients withdrew prior to allocation. 25 block randomisations were performed by a statistician external to the research team: 123 patients were allocated to the intervention program and 124 were allocated to the control program. 97 (78.9%) of the intervention participants commenced their program. The overall attrition rate of 40.5% included withdrawals from the study and both programs. 24.4% of participants withdrew from the intervention program but not the study and 22.6% withdrew from the control program but not the study. A total of 62 patients completed the intervention program and follow-up evaluation survey and 77 patients completed the control program and follow-up evaluation survey. At 16 weeks follow-up there was no significant difference between intervention and control groups in self-efficacy; however, there was an increase in self-efficacy from baseline to follow-up for the intervention participants (t=-1.948, p=0.028). There were no significant differences in self-rated health or health distress scores between groups at follow-up, with both groups reporting a significant decrease in health distress scores. There was no significant difference between or within groups in self-management knowledge and stage of change of behaviours at follow-up. Intervention group attenders had significantly higher physical activity (t=-4.053, p=0.000) and nutrition scores (t=2.315, p= 0.01) at follow-up; however, these did not remain significant after adjustment for covariates. At follow-up, significantly more participants in the control group (20.8%) indicated that they did not have a self-management plan compared to those in the intervention group (8.8%) (X²=4.671, p=0.031). There were no significant changes in other self-management knowledge areas and behaviours after adjusting for covariates at follow-up. CONCLUSIONS The study produced mixed findings. Differences between groups as allocated were diluted by the high proportion of patients not completing the program. Further monitoring and evaluation are needed of the impact and cost effectiveness of the program. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12609000298213.
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Affiliation(s)
- Anna M Williams
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW 2052, Australia.
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Harris MF, Lloyd J, Litt J, van Driel M, Mazza D, Russell G, Smith J, Del Mar C, Denney-Wilson E, Parker S, Krastev Y, Jayasinghe UW, Taylor R, Zwar N, Wilson J, Bolger-Harris H, Waters J. Preventive evidence into practice (PEP) study: implementation of guidelines to prevent primary vascular disease in general practice protocol for a cluster randomised controlled trial. Implement Sci 2013; 8:8. [PMID: 23327664 PMCID: PMC3564812 DOI: 10.1186/1748-5908-8-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/11/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession. METHODS We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews. DISCUSSION We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.
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Affiliation(s)
- Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Jane Lloyd
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, NSW, 2052, Australia
| | - John Litt
- Discipline of General Practice, Flinders University, Adelaide, Australia
| | - Mieke van Driel
- Discipline of General Practice, University of Queensland, St Lucia, QLD, Australia
| | - Danielle Mazza
- School of Primary Health Care, Monash University, Melbourne, Australia
| | - Grant Russell
- School of Primary Health Care, Monash University, Melbourne, Australia
| | - Jane Smith
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Chris Del Mar
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | | | - Sharon Parker
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Yordanka Krastev
- Ethics Secretariate, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Upali W Jayasinghe
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Richard Taylor
- School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Nick Zwar
- School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW, 2052, Australia
| | - Jinty Wilson
- National Heart Foundation of Australia, Melbourne, Australia
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Tiessen AH, Smit AJ, Zevenhuizen S, Spithoven EM, Van der Meer K. Cardiovascular screening in general practice in a low SES area. BMC FAMILY PRACTICE 2012; 13:117. [PMID: 23228012 PMCID: PMC3564938 DOI: 10.1186/1471-2296-13-117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 11/15/2012] [Indexed: 11/10/2022]
Abstract
Background Lower social economic status (SES) is related to an elevated cardiovascular (CV) risk. A pro-active primary prevention CV screening approach in general practice (GP) might be effective in a region with a low mean SES. This approach, supported by a regional GP laboratory, was investigated on feasibility, attendance rate and proportion of persons identified with an elevated risk. Methods In a region with a low mean SES, men and women aged ≥50/55 years, respectively, were invited for cardiovascular risk profiling, based on SCORE 10-year risk of fatal cardiovascular disease and additional risk factors (family history, weight and end organ damage). Screening was performed by laboratory personnel, at the GP practice. Treatment advice was based on Dutch GP guidelines for cardiovascular risk management. Response rates were compared to those in five other practices, using the same screening method. Results 521 persons received invitations, 354 (68%) were interested, 33 did not attend and 43 were not further analysed because of already known diabetes/cardiovascular disease. Eventually 278 risk profiles were analysed, of which 60% had a low cardiovascular risk (SCORE-risk <5%). From the 40% participants with a SCORE-risk ≥5%, 60% did not receive medication yet for hypertension/hypercholesterolemia. In the other five GPs response rates were comparable to the currently described GP. Conclusion Screening in GP in a low SES area, performed by a laboratory service, was feasible, resulted in high attendance, and identification and treatment advice of many new persons at risk for cardiovascular disease.
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Affiliation(s)
- Ans H Tiessen
- University of Groningen, University Medical Center Groningen, Dept, General Practice, Groningen, The Netherlands.
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Damman OC, Timmermans DRM. Educating health consumers about cardio-metabolic health risk: what can we learn from lay mental models of risk? PATIENT EDUCATION AND COUNSELING 2012; 89:300-308. [PMID: 22878027 DOI: 10.1016/j.pec.2012.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 06/14/2012] [Accepted: 06/22/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To study lay conceptions of cardio-metabolic risk and compare them with those of experts, in order to formulate focal points for better educational risk information. METHODS 40 Dutch lay people were interviewed about the risks of developing cardio-metabolic diseases. Following a 'mental models approach', their conceptions were qualitatively analyzed and compared to an expert model. RESULTS We identified four key themes representing lay conceptions: (1) "same factors, different value" (e.g. the dominance of certain factors, such as stress); (2) "superficiality and incoherence" (e.g. a focus on health and illness in general); (3) "misjudged elevated risk concept" (e.g. either being sick or not); and (4) "no concept of a link between cardio-metabolic diseases" (e.g. separate links between causes and diseases). CONCLUSION Potential mismatches between lay and expert conceptions do not seem to indicate a lack of basic knowledge among consumers, but rather that certain risk factors are not effectively translated into a coherent risk picture. PRACTICE IMPLICATIONS In improving educational materials, we could more explicitly take into account factors that lay people find important. Additionally, effort should be made to produce a more coherent risk understanding among consumers, for example through an alternative information structure.
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Affiliation(s)
- Olga C Damman
- Department of Public and Occupational Health and the EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev 2012; 10:CD009009. [PMID: 23076952 DOI: 10.1002/14651858.cd009009.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND General health checks are common elements of health care in some countries. These aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is, therefore, important to assess whether general health checks do more good than harm. OBJECTIVES We aimed to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes such as blood pressure and serum cholesterol levels. SEARCH METHODS We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility and read reference lists. One author used citation tracking (Web of Knowledge) and asked trialists about additional studies. SELECTION CRITERIA We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening general populations for more than one disease or risk factor in more than one organ system. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias in the trials. We contacted authors for additional outcomes or trial details when necessary. For mortality outcomes we analysed the results with random-effects model meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible. MAIN RESULTS We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (CI) 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), risk ratio 1.03 (95% CI 0.91 to 1.17) and eight trials on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery. AUTHORS' CONCLUSIONS General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.
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Harris MF, Fanaian M, Jayasinghe UW, Passey ME, McKenzie SH, Powell Davies G, Lyle DM, Laws RA, Schütze H, Wan Q. A cluster randomised controlled trial of vascular risk factor management in general practice. Med J Aust 2012; 197:387-93. [DOI: 10.5694/mja12.10313] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
| | - Mahnaz Fanaian
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW
| | - Upali W Jayasinghe
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
| | - Megan E Passey
- University Centre for Rural Health North Coast, University of Sydney, Sydney, NSW
| | | | - Gawaine Powell Davies
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
| | - David M Lyle
- Broken Hill University Department of Rural Health, University of Sydney, Sydney, NSW
| | - Rachel A Laws
- Prevention Research Collaboration, School of Public Health, University of Sydney, Sydney, NSW
| | - Heike Schütze
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
| | - Qing Wan
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
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Passey ME, Laws RA, Jayasinghe UW, Fanaian M, McKenzie S, Powell-Davies G, Lyle D, Harris MF. Predictors of primary care referrals to a vascular disease prevention lifestyle program among participants in a cluster randomised trial. BMC Health Serv Res 2012; 12:234. [PMID: 22856459 PMCID: PMC3483009 DOI: 10.1186/1472-6963-12-234] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 07/30/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular disease accounts for a large burden of disease, but is amenable to prevention through lifestyle modification. This paper examines patient and practice predictors of referral to a lifestyle modification program (LMP) offered as part of a cluster randomised controlled trial (RCT) of prevention of vascular disease in primary care. METHODS Data from the intervention arm of a cluster RCT which recruited 36 practices through two rural and three urban primary care organisations were used. In each practice, 160 eligible high risk patients were invited to participate. Practices were randomly allocated to intervention or control groups. Intervention practice staff were trained in screening, motivational interviewing and counselling and encouraged to refer high risk patients to a LMP involving individual and group sessions. Data include patient surveys; clinical audit; practice survey on capacity for preventive care; referral records from the LMP. Predictors of referral were examined using multi-level logistic regression modelling after adjustment for confounding factors. RESULTS Of 301 eligible patients, 190 (63.1%) were referred to the LMP. Independent predictors of referral were baseline BMI ≥ 25 (OR 2.87 95%CI:1.10, 7.47), physical inactivity (OR 2.90 95%CI:1.36,6.14), contemplation/preparation/action stage of change for physical activity (OR 2.75 95%CI:1.07, 7.03), rural location (OR 12.50 95%CI:1.43, 109.7) and smaller practice size (1-3 GPs) (OR 16.05 95%CI:2.74, 94.24). CONCLUSIONS Providing a well-structured evidence-based lifestyle intervention, free of charge to patients, with coordination and support for referral processes resulted in over 60% of participating high risk patients being referred for disease prevention. Contrary to expectations, referrals were more frequent from rural and smaller practices suggesting that these practices may be more ready to engage with these programs. TRIAL REGISTRATION ACTRN12607000423415.
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Harris MF, Fanaian M, Jayasinghe UW, Passey M, Lyle D, McKenzie S, Davies GP. What predicts patient-reported GP management of smoking, nutrition, alcohol, physical activity and weight? Aust J Prim Health 2012; 18:123-8. [PMID: 22551834 DOI: 10.1071/py11024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 06/20/2011] [Indexed: 11/23/2022]
Abstract
This study aimed to describe patient-reported management of behavioural risk factors in Australian general practice. Six hundred and ninety-eight eligible patients from 30 general practices in two rural and three urban Divisions of General Practice responded to a mailed invitation to participate and completed a questionnaire. Data were analysed using univariate and multi-level multivariate methods. The prevalence of risk factors varied between 12.6% for smoking and 72.6% for at-risk diet (56.2% were overweight). Most patients were at the action or maintenance phases of their readiness to change their risky behaviours. General practitioners (GPs) provided education or advice to between one-quarter and one-third of those at risk for each risk factor; 9.2% and 9.6% of patients reported having been referred for diet or physical activity interventions. Patient body mass index was associated with increased likelihood of receiving GP advice or referral for diet and physical activity interventions. Having poor diet or physical activity levels and being more ready for change were not associated with the likelihood of GP referral. The major challenge for general practice is to ensure that effective lifestyle interventions are provided to those who will most benefit. Patient-reported GP behavioural risk factor advice and referral is less frequent than is optimal. Priority needs to be given to those most at risk and ready to change their behaviour.
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Affiliation(s)
- Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia.
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Schütze H, Rix EF, Laws RA, Passey M, Fanaian M, Harris MF. How feasible are lifestyle modification programs for disease prevention in general practice? Aust J Prim Health 2012; 18:129-37. [PMID: 22551835 DOI: 10.1071/py10106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 06/20/2011] [Indexed: 11/23/2022]
Abstract
Vascular disease is a leading cause of death and disability. While it is preventable, little is known about the feasibility or acceptability of implementing interventions to prevent vascular disease in Australian primary health care. We conducted a cluster randomised controlled trial assessing prevention of vascular disease in patients aged 40-65 by providing a lifestyle modification program in general practice. Interviews with 13 general practices in the intervention arm of this trial examined their views on implementing the lifestyle modification program in general practice settings. Qualitative study, involving thematic analysis of semi-structured interviews with 11 general practitioners, four practice nurses and five allied health providers between October 2009 and April 2010. Providing brief lifestyle intervention fitted well with routine health-check consultations; however, acceptance and referral to the program was dependent on the level of facilitation provided by program coordinators. Respondents reported that patients engaged with the advice and strategies provided in the program, which helped them make lifestyle changes. Practice nurse involvement was important to sustaining implementation in general practice, while the lack of referral services for people at risk of developing vascular disease threatens maintenance of lifestyle changes as few respondents thought patients would continue lifestyle changes without long-term follow up. Lifestyle modification programs to prevent vascular disease are feasible in general practice but must be provided in a flexible format, such as being offered out of hours to facilitate uptake, with ongoing support and follow up to assist maintenance. The newly formed Medicare Locals may have an important role in facilitating lifestyle modification programs for this target group.
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McKenzie SH, Jayasinghe UW, Fanaian M, Passey M, Lyle D, Davies GP, Harris MF. Socio-demographic factors, behaviour and personality: associations with psychological distress. Eur J Prev Cardiol 2011; 19:250-7. [DOI: 10.1177/1741826711399426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Suzanne Helen McKenzie
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Australia
- School of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Upali W Jayasinghe
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Australia
| | - Mahnaz Fanaian
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Australia
| | - Megan Passey
- Northern Rivers Department of Rural Health, University of Sydney, NSW, Australia
| | - David Lyle
- Broken Hill Department of Rural Health, University of Sydney, NSW, Australia
| | - Gawaine Powell Davies
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Australia
| | - Mark Ford Harris
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Australia
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