ReviewCommunication-related behavior change techniques used in face-to-face lifestyle interventions in primary care: A systematic review of the literature
Introduction
Patients’ lifestyle behavior is significant for their physical and mental health. A healthy lifestyle (e.g. non smoking, minimal alcohol use, healthy diet and being physically active) can prevent or reduce the burden of chronic diseases such as type 2 diabetes, cardiovascular diseases, kidney diseases and chronic obstructive pulmonary disease (COPD) [1], [2], [3]. Regardless of the growing evidence of these preventive and therapeutic effects, the prevalence of unhealthy lifestyle behaviors remains high. In the USA and many European countries the number of obese or overweight patients even increased in recent years [4] and tobacco dependency and alcohol misuse continue to be major problems [5]. The high prevalence of unhealthy behaviors and chronic diseases has led to increased attention for a healthy lifestyle by governments around the world [6], [7]. In the Netherlands for example, there is a renewed attention for the prevention of chronic diseases as stated in the prevention bill, aimed at reducing the incidence of smoking, alcohol abuse, obesity, type 2 diabetes and depression [8], [9], by offering counseling to high risk patients in primary care.
A general practitioner (GP) is the primary provider for patients at risk of developing lifestyle-related chronic illnesses. Interventions aimed at changing unhealthy lifestyles should therefore primarily take place in general practice [10]. In the UK, GPs have a contract since 1990 to promote health, which has encouraged a new structure of general practice, with practice nurses (PN) and nurse practitioners (NP) working alongside GPs [11]. Within the Dutch general practice this collaborative system is also common since 1999 [12]. This enables GPs in the UK, the Netherlands and other Western countries to delegate tasks, regarding patients with chronic diseases and their lifestyle, to practice nurses and nurse practitioners or assistants [12], [13]. Nowadays, a PN is employed in about 80% of the general practices in the Netherlands [14]. Dutch patients with chronic diseases visit the PN more often than the GP (from 2% in 2003 to 39% in 2008), while the total number of general practice visits remains stable [15].
Yet, changing lifestyle behavior is difficult and requires effort, time and motivation from both health care provider and patient. Besides, patients are often ambivalent about behavior change [16], [17]. Providing advice about behavior change to patients is a common approach used by health care providers, although previous studies show that the effectiveness of advice giving is uncertain [16], [18]. Insight into effective behavior change techniques (BCTs) can help health care providers in primary care to contribute to a better lifestyle and improved health for patients and eventually reduce health care costs [17], [19]. Michie and colleagues [20] listed 137 BCTs that are used by health care providers in daily practice or can be used as an intervention to change behavior, such as goal setting, screening and motivational interviewing. So far, it is not clear which of these face-to-face communication-related BCTs are most effective in changing a patient's unhealthy lifestyle behavior and which provider is more effective in using these face-to-face communication-related BCTs. Many studies in the field of lifestyle interventions focus on one single aspect of behavior such as smoking [21], [22] or physical activity [23], [24]; included studies are often of low quality [25], [26] and interventions are seldom theory based [20]. Many studies into BCTs do appear to be inspired by theories, as for example Prochaska's and DiClemente's transtheoretical model, or Bandura's social cognitive theory [20].
Previous studies show that GPs and nurses (PN or NP) differ in their approach to patients and disease management; nurses spend more time on counseling patients than GPs and during the education and training of nurses there is more emphasis on patient education, lifestyle and disease prevention [27], [29]. GPs, on the other hand, may traditionally be considered to have more authority to deliver care to patients. Nevertheless, several studies [27], [30], [31] suggest that care from GPs and nurses results in similar patient outcomes.
The current review study was set up to answer the following questions:
- 1.
Which face-to-face communication-related behavior change techniques (BCTs) used in interventions are (most) effective for primary health care providers to intervene on patients’ lifestyle behavior, i.e. smoking, alcohol, nutrition, weight and physical activity?
- 2.
Which health care provider in primary care (physician or nurse) is more effective in using face-to-face communication-related BCTs?
Section snippets
Inclusion criteria
A study was included in the review if (1) it concerned a randomized controlled trial (RCT) (2) the study was published in English, (3) the study population consisted of patients of 18 years or older, (4) the study focused on lifestyle communication about smoking behavior, alcohol use, nutrition intake (or diet/eating habits), weight or physical activity (exercise) and, in case of secondary prevention the following lifestyle related diseases: type II diabetes, COPD, asthma, cardiovascular
Results
In Table 1 an overview of the characteristics and quality of the 50 included studies (from 58 articles) is given.
Discussion
The present review shows that behavioral counseling, motivational interviewing, education and advice are most frequently evaluated as effective face-to-face communication-related BCTs. This overall conclusion could be drawn on the basis of finding relative many high quality studies in which communication-related BCTs prove to be effective. However, these techniques were also found in less successful studies due to differences in context, as design of the study and patient population, and to
Conflict of interest
The authors declare that they have no competing interests.
Acknowledgements
We thank Harm-Wouter Snippe and William Verheul for creating a very useful digital tool which helped us to easily select our references based on title and abstract. We also thank Linda Schoonmade for her help in creating a proper search strategy and Patriek Mistiaen for his advice about methodological aspects of our review. This study was funded by the Dutch Ministry of Health, Welfare and Sport.
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