SIMULTANEOUS VS SEQUENTIAL COUNSELING FOR MULTIPLE BEHAVIOR CHANGE
Hyman DJ, Pavlik VN, Taylor WC, Goodrick GK, Moye L
Arch Intern Med. 2007;167:1152-1158.
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 to 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 primary 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% women) 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 level goal (P = .01). At 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usual-care arms were found negative for urine cotinine level (P = .08).
Conclusions
Counseling for long-term multiple behavior change is difficult in primary care settings. This study provides strong evidence that addressing multiple behaviors sequentially is not superior to, and may be inferior to a simultaneous approach.
Editor's Comment. Every day, cardiovascular rehabilitation programs touch many patients with multiple risk factors and their families. There has been little research aimed at the best and most effective methods to counsel patients with multiple risk factors. Generally, in both inpatient and outpatient cardiovascular rehabilitation, length of stay is short and programs are usually forced to address health behaviors in a simultaneous manner, that is, all at one time. Hyman et al designed a randomized trial for patients with hypertension or who smoke. They set out to determine whether health behavior counseling in a primary care setting is more effective when performed in a serial or a simultaneous manner. They counseled patients on smoking cessation, sodium reduction, and physical activity. Patients were followed for 18 months. It is important to understand that this study is not conclusive, nor should it be considered "seminal" research. Inherent weakness exists in this type of research in the clinical setting. For clinicians, however, the results are interesting and worth considering. This study provides some evidence that simultaneous counseling is more effective than serial counseling for these health behaviors. The practical conclusion for cardiovascular rehabilitation programs and professionals seems to be that even with short lengths of stay, we must address all behavioral risk factors that are present. In addition, doing this in a simultaneous manner does not seem to negatively affect the outcome. This study does have a negative side-after 18 months, there were no significant differences between the groups or from baseline to 18 months. Unfortunately, it takes more than the minimal amount of counseling and education to effect permanent behavior change. This does not change the necessity and importance of addressing each risk factor and counseling behavior change.