Review and special article
Evaluating primary care behavioral counseling interventions: An evidence-based approach 1

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Abstract

Overview: Risky behaviors are a leading cause of preventable morbidity and mortality, yet behavioral counseling interventions to address them are underutilized in healthcare settings. Research on such interventions has grown steadily, but the systematic review of this research is complicated by wide variations in the organization, content, and delivery of behavioral interventions and the lack of a consistent language and framework to describe these differences. The Counseling and Behavioral Interventions Work Group of the United States Preventive Services Task Force (USPSTF) was convened to address adapting existing USPSTF methods to issues and challenges raised by behavioral counseling intervention topical reviews.

The systematic review of behavioral counseling interventions seeks to establish whether such interventions addressing individual behaviors improve health outcomes. Few studies directly address this question, so evidence addressing whether changing individual behavior improves health outcomes and whether behavioral counseling interventions in clinical settings help people change those behaviors must be linked. To illustrate this process, we present two separate analytic frameworks derived from screening topic tools that we developed to guide USPSTF behavioral topic reviews.

No simple empirically validated model captures the broad range of intervention components across risk behaviors, but the Five A’s construct—assess, advise, agree, assist, and arrange—adapted from tobacco cessation interventions in clinical care provides a workable framework to report behavioral counseling intervention review findings. We illustrate the use of this framework with general findings from recent behavioral counseling intervention studies. Readers are referred to the USPSTF (www.ahrq.gov/clinic/prevenix.htm or 1-800-358-9295) for systematic evidence reviews and USPSTF recommendations based on these reviews for specific behaviors.

Introduction

In 1998, the Agency for Healthcare Research and Quality (AHRQ) reconvened the U.S. Preventive Services Task Force (USPSTF) to update its recommendations for clinical preventive services. This Task Force represents primary care disciplines (nursing, pediatrics, family practice, internal medicine, and obstetrics/gynecology), preventive medicine, and behavioral medicine. Two evidence-based practice centers (EPCs)—Oregon Health & Science University and the Research Triangle Institute/University of North Carolina—were contracted to prepare systematic evidence reviews that the Task Force uses in developing its recommendations for preventive care. Although the USPSTF evidence-based methods are widely applicable throughout medicine, to date they have been used primarily to assess services, such as preventive screening, rather than those requiring behavioral counseling.1, 2 The current Task Force recognized a twofold need: (1) to expand its evidence-based approach to better assess behavioral counseling interventions, and (2) to formulate practical communication strategies for describing services that are effective in changing behavior.

The Counseling and Behavioral Interventions Work Group of the USPSTF adapted the USPSTF generic screening analytic framework, which guides systematic reviews, to address behavioral topics more specifically, and it has promoted a consistent organizational construct for describing behavioral counseling interventions. Clinicians are referred to current products of the USPSTF (www.ahrq.gov/clinic/or 1-800-358-9295) for systematic evidence reviews of specific behavioral counseling topics and related USPSTF evidence-based recommendations and clinical considerations beyond the scope of this paper.

This paper has three purposes:

  • 1.

    To promote a broader appreciation of the importance of behavioral counseling interventions in clinical care and the context for their delivery.

  • 2.

    To describe the generic analytic frameworks developed to guide the systematic review of behavioral counseling topics for the third USPSTF.

  • 3.

    To detail the practical organizational construct (the Five A’s) adopted by the USPSTF to describe intervention research more consistently in order to foster its application in clinical settings.

Section snippets

Background

Healthy People 20103 sets two major goals for the United States: (1) to increase quality and years of healthy life, and (2) to eliminate health disparities among different segments of the population. The next decade offers unprecedented opportunities for healthcare systems and providers to address these goals by promoting healthy lifestyles among the diverse populations they serve and by adopting policies that will institutionalize preventive services.

Changing the health behaviors of Americans

Rationale for behavioral counseling interventions in clinical care

Healthcare providers and their staff play a unique and important role in motivating and assisting patients’ healthy behavior changes. Patients report that primary care clinicians are expected sources of preventive health information and recommendations for patients.30 For instance, in a recent survey, the vast majority (92% to 98%) of adult members of health maintenance organizations indicated that they expected advice and help from the healthcare system in key behaviors, such as diet,

Objectives and scope of behavioral counseling interventions

Behavioral counseling interventions in clinical care are those activities delivered by primary care clinicians and related healthcare staff to assist patients in adopting, changing, or maintaining behaviors proven to affect health outcomes and health status. Common health-promoting behaviors include smoking cessation, healthy diet, regular physical activity, appropriate alcohol use, and responsible use of contraceptives.

Behavioral counseling interventions occur all or in part during routine

The potential impact of health behavior–change programs in clinical care

Appreciating behavioral counseling interventions requires a true population-based medicine perspective (i.e., intervening with individuals, but recognizing that the health benefits may not be as clinically visible individually as they are clinically meaningful when considered for the whole). Individually, brief behavioral counseling interventions that are feasible in healthcare settings often have only modest behavior change impacts. For example, only 5% to 15% of those receiving an

Practical approaches to overcome barriers to behavioral and counseling interventions

Numerous barriers to preventive service delivery continue to exist in present-day healthcare settings, most of which are still organized mainly around symptom-driven, acute illness care.67, 68 These barriers include a focus on more medically urgent issues; lack of time; inadequate clinician training, self-confidence, or reimbursement; low patient demand; and lack of supportive resources.3, 69 Further, feedback to clinicians about results of preventive care is largely non-existent or can even be

Evidence-based methods for evaluating behavioral counseling interventions

We developed two interrelated generic analytic frameworks to guide the systematic review of behavioral topics Figure 1, Figure 2. These analytic frameworks were derived from those developed for screening topics.2 They separately frame the two main questions to consider when systematically reviewing relevant clinical behavioral intervention research, namely: (1) Does changing individual health behavior improve health outcomes? Figure 1, Figure 2 Can interventions in the clinical setting

Background

The Four A’s construct (ask, advise, assist, arrange) was originally developed by the National Cancer Institute to guide physician intervention in smoking cessation.103 Recently, the Canadian Task Force on Preventive Health Care proposed that clinicians use a Five A’s construct (adding an agree step) to organize their general approach to assisting patients with behavioral counseling issues (W. Elford, Canadian Task Force on Preventive Health Care, personal communication, December 2000). The

Conclusions

Behavioral counseling interventions in clinical settings are an important means of addressing prevalent health-related behaviors, such as lack of physical activity, poor diet, substance (tobacco, alcohol, and illicit drug) use and dependence, and risky sexual behavior that underlie a substantial proportion of preventable morbidity and mortality in the United States. Important advances in the ways primary care interventions have been packaged have resulted from the past 2 decades of research.

Acknowledgements

This work was produced by the Oregon Health & Science University Evidence-Based Practice Center, under contract to the Agency for Healthcare Research and Quality (contract No. 290-97-0018), Rockville, Maryland.

We gratefully acknowledge early manuscript review and suggestions by outside experts Sue Curry, PhD; Russ Glasgow, PhD; Michael Goldstein, MD; and Pat Mullen, DrPH; as well as the support and critical review by other members of the work group (Karen Eden, PhD; Mark Helfand, MD, MPH; Peter

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