Improving Multiple Health Risk Behaviors in Primary Care: Lessons from the Prescription for Health COmmon Measures, Better Outcomes (COMBO) Study

Abstract

Background: Four health behaviors-smoking, risky drinking, physical inactivity, and unhealthy diets-contribute substantially to health care burden and are common among primary care patients. However, there is insufficient evidence to recommend broadly brief interventions to address all 4 of these in frontline primary care. This study took advantage of a multinetwork initiative to reflect on health behavior outcomes and the challenges of using a common set of measures to assess health behavior-change strategies for multiple health behaviors in routine primary care practice.Methods: Standardized, brief practical health behavior and quality of life measures used across 7 practice-based research networks (PBRNs) with independent primary care interventions in 54 primary care practices between August 2005 and December 2007 were analyzed. Mixed-effects longitudinal models assessed whether intervention patients improved diet, physical activity, smoking, alcohol consumption, and unhealthy days over time. Separate analyses were conducted for each intervention.Results: Of 4463 adults, 2199 had follow-up data, and all available data were used in longitudinal analyses. Adjusting for age, race/ethnicity, education, and baseline body mass index where available, diet scores improved significantly in 5 of 7 networks (P < .02). Physical activity improved significantly in 2 networks but declined in one network (P < .024). The likelihood of being a current smoker was reduced in 2 of 5 networks (P < .0001), and average alcoholic drinks per day was reduced in 2 network s (P < .02). Participants reported fewer unhealthy days at follow-up in 3 of 7 networks (P < .01). Details of implementation and the limitations in instrumentation help contextualize these modest outcomes.Conclusions: Although some patients in these 7 PBRNs improved in several health behaviors and quality of life, the strength of evidence for field-ready methods to address multiple health risk behaviors remains elusive. The use of common measures to assess changes in 4 unhealthy behaviors was achieved practically in PBRNs testing diverse strategies to improve behaviors; however, variations in implementation, instrumentation performance, and some features of study design overwhelmed potential cross-PBRN comparisons. For common measures to be useful for comparisons across practices or PBRNs, greater standardization of study designs and careful attention to practicable implementation strategies are necessary. (J Am Board Fam Med 2012;25:701-711.)

Advances in multiple health behavior change research

“…To achieve the population-wide impact on health and well-being that multiple behavior change is poised to accomplish, future research must address the public health challenge of translating research findings to real-world settings [26]. The recent Prescription for Health Common Measures, Better Outcomes Study exemplifies several challenges that were encountered when delivering a multiple behavior change intervention across 54 primary care practices [27]. These included difficulties with obtaining complete data using common data collection tools and challenges in consistently implementing interventions across practices [27].…”

“…The recent Prescription for Health Common Measures, Better Outcomes Study exemplifies several challenges that were encountered when delivering a multiple behavior change intervention across 54 primary care practices [27]. These included difficulties with obtaining complete data using common data collection tools and challenges in consistently implementing interventions across practices [27]. The authors conclude that "the strength of evidence for field-ready methods to address multiple health risk behaviors remains elusive."…”

Encouraging Innovation, Unintended Consequences, and Group-Level Research

“…9 It is important to recall, however, that in none of these studies is a cause-and-effect relationship established between the intervention and the unexpected outcome and that other factors, such as random variation, unrelated changes occurring in the groups, etc, could explain the fi ndings.…”

Primary Care Research Conducted in Networks: Getting Down to Business

“…In this seventh annual Journal of the American Board of Family Medicine PBRN theme issue, we observe an increase in the articles from PBRN collaboratives. 4,10,12,18,19,21 It is great to see that PBRNs are increasing in number, cooperating to harness their power to recruit larger samples and provide greater generalizability of findings, and getting down to business.…”

“…Fernald et al 19 analyzed data from the second wave of Robert Wood Johnson Foundation/ AHRQ-funded Prescription for Health projects to measure the degree of success achieved by 54 practices in 7 different PBRNs in helping patients reduce unhealthy behaviors. The results were mixed, with most unhealthy behaviors improved, but each in only a minority of networks.…”