Simultaneous vs Sequential Counseling for Multiple Behavior Change

Abstract

Background: Many patients in primary care settings present with multiple behavioral risk factors for cardiovascular disease. Research has provided little information on the most effective ways to approach multiple behavior change counseling in clinical settings. Methods:We implemented a randomized trial in a publicly funded primary care setting to test whether a sequential presentation of stage of change-based counseling to stop smoking, reduce dietary sodium level to less than 100 mEq/L per day, and increase physical activity by at least 10 000 pedometer steps per week would be more effective than simultaneous counseling. African Americans with hypertension, aged 45 to 64 years, initially nonadherent to the 3 behavioral goals, were randomized to the following conditions: (1) 1 in-clinic counseling session on all 3 behaviors every 6 months, supplemented by motivational interviewing by telephone for 18 months; (2) a similar protocol that addressed a new behavior every 6 months; or (3) 1-time referral to existing group classes ("usual care"). The pri-mary end point was the proportion in each arm that met at least 2 behavioral criteria after 18 months.Results: A total of 289 individuals (67.3% female) were randomized, and 230 (79.6%) completed the study. At 18 months, only 6.5% in the simultaneous arm, 5.2% in the sequential arm, and 6.5% in the usual-care arm met the primary end point. However, results for single behavioral goals consistently favored the simultaneous group. At 6 months, 29.6% in the simultaneous, 16.5% in the sequential, and 13.4% in the usual-care arms had reached the urine sodium goal (P=.01). At 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usualcare arms were urine cotinine negative (P=.08).Conclusions: Long-term multiple behavior change is difficult in primary care. This study provides strong evidence that addressing multiple behaviors sequentially is not superior to, and may be inferior to, a simultaneous approach.

What are successful recruitment and retention strategies for underserved populations? Examining physical activity interventions in primary care and community settings

“…However, other recent interventions in primary care or general medicine settings have been effective [7,[80][81][82][83], though challenging to implement [84], so this area may also be worthy of further study.…”

Multiple health behavior change research: An introduction and overview

“…Another study, targeting exercise, dietary sodium intake, and tobacco use using a stage-based approach concluded that sequential was not superior to, and may be inferior to, a simultaneous approach (Hyman, et al, 2007). The theoretical model employed and the types of behaviors targeted certainly may influence the efficacy of a simultaneous versus a sequential approach.…”

Integrative review: behavioral interventions for physical activity practice

“…The final sample consisted of 14 articles (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) , in compliance with literature, which recommends that at least 30% of articles attending to the established inclusion criteria be included (5) .…”

“…Instruments were frequently used to quantify the duration, intensity and frequency of PA. Most studies (64.3%) used biological markers, such as maximum oxygen consumption, serum cholesterol levels and body mass index (BMI) (7,11,(14)(15)(16)(17)(18)(19)20) and half of them applied physical tests, such as load and walking tests (8,11,(14)(15)(17)(18)20) (Table 1). …”

“…The result of the intervention was not reported in 28.6% (n=4) of the studies (12,15,(18)(19) . In the eight studies in which the intervention was considered effective, the assessed outcome was increased PA frequency (75%, n=6) (9)(10)(11)14,16,20) , increased PA frequency associated with another behavior (7.1%; n=1) (17) and improved Quality of Life (QoL) and muscle force (7.1%; n=1) (14) . No negative effects of the interventions were reported on.…”