Assessing multiple risk behaviors in primary care

Abstract

Abstract

The concept of behavioral risk refers to health behaviors that increase the likelihood of a variety of illness conditions. With increased scientific research, it has become clear that this concept is useful in understanding the linkage between behavior and health. This paper reviews scientific, conceptual, and practical issues related to the identification of health risk behaviors in primary care. It includes both a literature review and an analysis of the feasibility of screening and health risk appraisal from a public health perspective, giving special attention to four behavioral risk factors: cigarette smoking, alcohol misuse, physical inactivity, and unhealthy diet. The review indicates that there are a wide variety of acceptable screening tests that can be used for population screening programs, and a large number of health risk appraisal instruments to employ in medical and work settings where preventive health services are available. Given the variety of available assessment procedures, the choice of a given instrument will depend on the target population, the purpose of the program, the time available for assessment, and a number of other practical considerations, such as cost. Multiple risk factor screening is feasible, but there is no single instrument or procedure that is optimal for all risk factors or populations. Based on the results of this review, the specific test or combination of tests is less important than the use of screening to make both patients and healthcare providers more aware of the critical importance of monitoring behavioral risk factors on a routine basis. We conclude that while further research and development work needs to be done, sufficient progress has been made to warrant a more ambitious effort that would bring behavioral risk factor screening into the mainstream of preventive medicine and public health.

Introduction

During the past 25 years, the public health concepts of screening and early intervention have gained popularity in medical settings, in part because of the apparent success of preventive services for the early detection of diseases such as stroke, hypertension, cervical cancer, and phenylketonuria.1 With the progress in early intervention for specific diseases, there has been increasing interest in screening for behavioral risk factors in patients likely to develop a variety of preventable medical conditions resulting from poor health habits. By broadening the base of medical care to include behavioral risk factors, a considerable amount of mortality, morbidity, and disability could be prevented before serious health problems have time to develop.

This paper reviews scientific, conceptual, and practical issues related to the identification of behavioral risk factors in primary care. The paper includes both a literature review and an analysis of the feasibility of screening from a public health perspective, giving special attention to four health risk behaviors: cigarette smoking, alcohol misuse, physical inactivity, and unhealthy diet.

In this paper, screening is a procedure designed to identify people who have, or who are at risk of having, an illness, disease or disorder.2 It is important to distinguish screening from diagnosis, which is the process of identifying and labeling specific diseases or psychiatric disorders. Screening is a preliminary procedure to determine who is eligible for further assessment, but it can also be used to identify patients who are likely to benefit from immediate interventions (e.g., smoking cessation) or preventive counseling because they are considered to be at risk for serious medical problems. When screening results in the confirmed diagnosis of a medical condition, it is called screening for case finding. When screening identifies persons at risk, it is called screening for risk factors.2

The literature on the early identification of behavioral risk factors draws from two traditions that are important to distinguish. The first is the medical model, which is interested primarily in the presence or absence of specific disease conditions. The typical criteria for the evaluation of a screening test in this model are derived from the epidemiologic concepts of sensitivity, specificity, and positive predictive value. The second model is health risk appraisal (HRA), which is less related to clinical medicine than to the public health concepts of health promotion and disease prevention. HRA is interested primarily in the early identification of health risk factors that are linked to a variety of diseases and other medical conditions. The typical criteria for the evaluation of an HRA are reliability and validity, psychometric concepts drawn from psychological measurement. In contrast to the detection of the presence or absence of a risk factor, HRA usually measures multiple risk factors along a continuum of severity and combines them to produce a risk index.

In this paper, we focus on screening for the presence of four behavioral risk factors (risk behaviors) that have special relevance to the health of any population: cigarette smoking (and other forms of nicotine use); alcohol misuse; physical inactivity; and dietary patterns, including the amount and type of food intake. The rationale for selecting these four risk factors is both practical and theoretical. From a practical perspective, these behaviors account for a substantial proportion of the burden of disease and disability throughout the world. The World Health Organization3 estimates that tobacco smoking, alcohol misuse, physical inactivity, and poor diet are among the top five contributors to disease and injury worldwide. In the United States it has been estimated that behavioral factors are implicated in 50% of all deaths,4 with the “big four” accounting for most of the mortality. With advances in behavior change, it is now possible to achieve substantial improvements in health through the early identification of behavioral risk factors.5 Although there are a variety of ways to change health behavior (including product regulations, environmental design, and health communications), one of the most obvious approaches is the widespread application of clinical preventive services in healthcare settings.1

A second reason for selecting these four risk behaviors is their apparent concentration in individuals and populations where mortality rates are high. On an individual level, smoking and heavy drinking tend to co-occur,6 and inactivity is often associated with obesity and poor dietary habits.7 At the level of populations, these four behavioral risk factors are more prevalent in communities and population groups characterized by lower socioeconomic status, minority group membership, and other indicators of social disadvantage. Because these risk factors are concentrated in individuals and population groups, it may be possible to target public health programs more efficiently to achieve the greatest benefit for the greatest number of people.

A third reason for our focus on multiple risk behaviors is that in general, the risk of most chronic diseases and other medical conditions increases in proportion to the number of risk behaviors that the individual practices.8 For example, the effects of smoking and heavy drinking on oral cancer tend to be synergistic.9