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Research ArticleMethodology

Practical and Relevant Self-Report Measures of Patient Health Behaviors for Primary Care Research

Russell E. Glasgow, Marcia G. Ory, Lisa M. Klesges, Maribel Cifuentes, Douglas H. Fernald and Larry A. Green
The Annals of Family Medicine January 2005, 3 (1) 73-81; DOI: https://doi.org/10.1370/afm.261
Russell E. Glasgow
PhD
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Marcia G. Ory
PhD, MPH
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Lisa M. Klesges
PhD
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Maribel Cifuentes
RN
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Douglas H. Fernald
MA
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Larry A. Green
MD
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  • Early Experiences from Diabetes Interventions
    Joseph A. Burton
    Published on: 31 December 2005
  • Interface with computer automated assessments and tracking
    Doriane C. Miller
    Published on: 03 March 2005
  • Re: Literacy as a Screening Measure Criterion
    Lisa M. Klesges
    Published on: 23 February 2005
  • Response to Fisher
    Russell E Glasgow
    Published on: 08 February 2005
  • Literacy as a Screening Measure Criterion
    M. Kim Marvel
    Published on: 07 February 2005
  • Response to Montori
    Russell E Glasgow
    Published on: 02 February 2005
  • MAKING GOOD USE OF HEALTH BEHAVIOR MEASURES
    Lawrence Fisher
    Published on: 28 January 2005
  • Tools for primary care and research
    Victor M Montori
    Published on: 26 January 2005
  • Published on: (31 December 2005)
    Page navigation anchor for Early Experiences from Diabetes Interventions
    Early Experiences from Diabetes Interventions
    • Joseph A. Burton, Waltham, MA

    These comments are based on experiences developing a survey questionnaire with similar items for the Robert Wood Johnson Foundation’s Diabetes Initiative (see http://diabetesnpo.im.wustl.edu), which aims to improve the health and quality of life of people with diabetes through advancing diabetes self management systems and services in primary care and community settings. The survey development process included a team of...

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    These comments are based on experiences developing a survey questionnaire with similar items for the Robert Wood Johnson Foundation’s Diabetes Initiative (see http://diabetesnpo.im.wustl.edu), which aims to improve the health and quality of life of people with diabetes through advancing diabetes self management systems and services in primary care and community settings. The survey development process included a team of researchers from RTI International, a not-for-profit research firm headquartered in Research Triangle Park, North Carolina; from the National Program Office housed in the Division of Health Behavior Research at the Washington University School of Medicine in St. Louis, Missouri; from the Robert Wood Johnson Foundation in Princeton, NJ; and several other researchers who served on the project’s National Advisory Committee, including the lead author.

    The need for short, user-friendly questionnaires related to health behaviors reaches beyond the primary care setting. Government, health care organizations, and private foundations actively seek to improve health care quality by funding and evaluating disease management programs, pay for performance initiatives, or other interventions that affect how primary care is delivered. Often assessments of new systems or demonstrations include survey-based measures. These are expensive to administer (in any mode) and patients are increasingly less likely to complete longer questionnaires. The recommended and supplemental items presented in this paper are thus likely to have broader applicability than in the primary care setting. The appeal of the recommended items should increase insofar as measures of health care quality further incorporate behavioral changes. The task of measuring four behavioral domains with a single, brief, questionnaire required the authors to make difficult choices for their final recommendations. My experience with the Diabetes Initiative support these choices; and I offer additional comments about questions related to physical activity and diet, below.

    In the first wave of the Diabetes Initiative survey, items related to physical activity both tested and performed poorly. We found wide variations in the interpretation of “moderate” physical activity. Elderly persons who walked slowly in their neighborhoods reported similar activity levels as others with vigorous, structured workouts. The written, self- administered format of this questionnaire, complete with graphical representations should minimize variations in interpretation and improve reliability over text-only definitions. A second measurement problem we encountered when testing the Diabetes Initiative survey was inconsistency in capturing physical activity at work. Some participants included work activities in their self-reports; others did not. Supplementing the RAPA with an item related to physical activity at work—such as the item from the BRFSS that appears in Appendix 2, Secondary Recommendations for Adult Measures—might be an important addition for persons whose work includes manual labor.

    The diet questions chosen for the Diabetes Initiative are similar to the items recommended here. Our experience confirms the authors’ beliefs that items should focus on food groups and eating patterns because of the difficulty in measuring fat, caloric, or nutritional intakes. Our early results also imply that eating behaviors are multi-faceted. Efforts to limit portion sizes, decrease snacks between meals, avoid sugary drinks, or eat more fruits and vegetables can be interpreted as distinct behaviors. Some persons attempt to change one or two dietary patterns only rather than following all recommended guidelines. Consequently, respondents might be inconsistent across the questions.

    One area that warrants further research is an assessment of the potential biases resulting from patients’ efforts to provide socially desirable or correct responses. Participants in interventions or demonstration programs often receive formal or informal instruction on the importance of lifestyle changes and the benefits associated with improving eating, smoking, drinking, and exercise behaviors. Comparison with the “gold standard” assessments, as suggested in the article, will be particularly important moving forward.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (3 March 2005)
    Page navigation anchor for Interface with computer automated assessments and tracking
    Interface with computer automated assessments and tracking
    • Doriane C. Miller, Chicago, IL

    The increasing use of the electronic medical record (EMR) may create challenges in the use of many of these health behavior assessment tools. Programs that can incorporate these tools into the EMR, including easy links so that results can be documented and tracked are sorely needed.

    Competing interests:   None declared

    Competing Interests: None declared.
  • Published on: (23 February 2005)
    Page navigation anchor for Re: Literacy as a Screening Measure Criterion
    Re: Literacy as a Screening Measure Criterion
    • Lisa M. Klesges, Rochester, MN USA
    • Other Contributors:

    Dr. Marvel has highlighted a key area for further consideration in assessing the recommended behavioral measures in our article. Given that a large and growing proportion of the US population reads English as a second language and many others are at or below the 5th grade reading level, we readily agree that literacy and cultural meaning of any practice -based measure is a critical consideration and challenge to inclusiv...

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    Dr. Marvel has highlighted a key area for further consideration in assessing the recommended behavioral measures in our article. Given that a large and growing proportion of the US population reads English as a second language and many others are at or below the 5th grade reading level, we readily agree that literacy and cultural meaning of any practice -based measure is a critical consideration and challenge to inclusive delivery of care. Our purpose for this project was to expeditiously identify existing measures and so we were reliant on the availability of brief assessments that had already considered low-literacy forms or had been translated into languages other than English. Several instruments such as the adult physical activity assessment gave special consideration to these matters and have used pictorial prompts, as well as offering translations in several languages. Other measures are arguably more problematic in addressing cultural meaning and literacy issues; especially problematic is addressing these needs in children’s self-reported behaviors. In general, published information on reading level was unavailable, in part we believe because there are complexities in making these determinations. We certainly agree that much more information is needed in this area and we encourage our colleagues to take up the challenge of designing methods and measures that are sensitive to cultural meaning and literacy needs of patients.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (8 February 2005)
    Page navigation anchor for Response to Fisher
    Response to Fisher
    • Russell E Glasgow, Denver, CO
    • Other Contributors:

    We thank Dr. Fisher for his thoughtful and perceptive comments, which discuss the next steps in the use of brief practical measures of behavior change in primary care. We concur with essentially all the directions and recommendations that he makes, and below respond to and provide slight elaborations on each of his three main points.

    1. We concur that a small set of additional measures should be added to round...

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    We thank Dr. Fisher for his thoughtful and perceptive comments, which discuss the next steps in the use of brief practical measures of behavior change in primary care. We concur with essentially all the directions and recommendations that he makes, and below respond to and provide slight elaborations on each of his three main points.

    1. We concur that a small set of additional measures should be added to round out these measures of behavior change (which was the specific task we were given). We also agree that the PHQ-9 would be one of our top choices in expanding the measures to include mental health issues. We would also suggest inclusion of a brief health related quality of life measure, such as the CDC Health Days measure (www.cdc.gov/hrqol) as another important addition.

    Extending this line of reasoning a bit further, it could also be beneficial to have available parallel brief practical measures of clinician and staff behaviors related to delivering evidence-based behavior change interventions. In the same way that HEDIS measures are used in many settings, brief, validated measures of staff actions congruent with, for example, the Chronic Care Model or delivery of the 5 A’s of behavior change endorsed by the USPSTF could be useful performance measures, and the focus of quality improvement interventions.

    2. We also concur that the way in which information from these brief behavioral assessments is formatted and reported back to providers and patients is important, so that it informs and enhances patient- clinician communication and shared decision-making. Methods to provide print outs or displays that are simple to interpret and understandable by low literacy (and low numeracy) patients, is an important endeavor to improve linkage of these assessments to prompt behavior change.

    3. Finally, we agree that there is great potential for automated administration, scoring, and feedback reports tailored to patient ‘profiles’ of results. Such automation, if offered in a patient-centered collaborative manner, holds great potential to extend what the busy clinical team can do in the office. There is a growing and generally encouraging literature on such ‘tailored behavior change interventions’. In the article cited below, we discuss some of our specific thoughts about how interactive technology can be used to facilitate measurement and intervention to address behavioral risk factors.

    We share Dr. Fisher’s enthusiasm regarding the future uptake and opportunity of implementing these health behavior assessments in the reality of primary care practice.

    Glasgow RE, Bull SS, Piette JD, Steiner JF. Interactive behavior change technology: A partial solution to the competing demands of primary care. Amer J Prev Med, 2004, 27, S80-87.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (7 February 2005)
    Page navigation anchor for Literacy as a Screening Measure Criterion
    Literacy as a Screening Measure Criterion
    • M. Kim Marvel, Ft Collins, CO USA

    The article by Glasgow, et al, makes an important contribution for assessing behavior change. There is a clear need for practical self- report measures to briefly assess health behaviors. In the article, the authors outline the criteria used to select items. A question that occurred to me is whether literacy received adequate attention in the selection criteria. The authors list "Cultural and Literacy Issues" as a se...

    Show More

    The article by Glasgow, et al, makes an important contribution for assessing behavior change. There is a clear need for practical self- report measures to briefly assess health behaviors. In the article, the authors outline the criteria used to select items. A question that occurred to me is whether literacy received adequate attention in the selection criteria. The authors list "Cultural and Literacy Issues" as a secondary criterion, citing the need for measures to have been translated into other languages. Consideration of the reading level of items should also be included. Limited literacy skills have a significant affect on patients' ability to accurately complete self-report measures. As I scanned the items listed in the article, I questioned whether all items could be understood by patients with limited literacy, especially the items on risky drinking. The article would be strengthened by providing information about the reading levels of the selected items.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (2 February 2005)
    Page navigation anchor for Response to Montori
    Response to Montori
    • Russell E Glasgow, Denver, CO

    I thank Dr. Montori for his comments on our article above and essentially agree with all of them. I would like to elaborate on two points raised. The first is that many clincians do not feel equipped to intervene on these health behaviors, and especially not on mulitple behaviors. This is certainly true, and I would hope that assessment and tracking of health behavior status is only the first step in implementing a p...

    Show More

    I thank Dr. Montori for his comments on our article above and essentially agree with all of them. I would like to elaborate on two points raised. The first is that many clincians do not feel equipped to intervene on these health behaviors, and especially not on mulitple behaviors. This is certainly true, and I would hope that assessment and tracking of health behavior status is only the first step in implementing a practical, primary care based system to also assist patients and their families in improving their health behaviors. Detailed discussion of such approaches is beyond the scope of this discussion, but I refer readers to the article below on the potential of applying the evidence- based 5 As model of behavior change and interactive technology as one way to address this need.

    Second, I could not agree more that one of, if not the key issue, in identifying practical and useful measuresfor primary care is sensitivity to change due to intervention. Such responsiveness is a different, and I feel more important, criterion than the more typically emphasized criterion of internal consistency , and I refer readers to the article referenced below by Kristal and colleagues on this topic. My colleagues and I did include senstivity to change as one of our primary criteria, but more research on and more consistent reporting of sensitivity to change is certainly needed.

    Glasgow RE, Bull SS, Piette J, Steineer J. Interactive behavior change technology: A partial solution to thhe competing demands of primary care. Amer J Prev Med, 2004, 27, S80-87.

    Kristal AR, Beresfoird SA, Lazovich D. Assessing change in diet- intervention research. Amer J Clin Nutrit, 1994, 59, 1855 ff.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (28 January 2005)
    Page navigation anchor for MAKING GOOD USE OF HEALTH BEHAVIOR MEASURES
    MAKING GOOD USE OF HEALTH BEHAVIOR MEASURES
    • Lawrence Fisher, San Francisco, CA

    The paper by Glasgow, et al. makes a number of very important contributions to the primary care literature: it highlights the need to include health behaviors as an important target of care for patients with or without major acute or chronic disease, it emphasizes the need to create measures that fit within the primary care context, it provides criteria for evaluating health behavior measures, and, lastly, it identifie...

    Show More

    The paper by Glasgow, et al. makes a number of very important contributions to the primary care literature: it highlights the need to include health behaviors as an important target of care for patients with or without major acute or chronic disease, it emphasizes the need to create measures that fit within the primary care context, it provides criteria for evaluating health behavior measures, and, lastly, it identifies an initial set of patient behaviors and measures to begin the process. Several issues come to mind in this paper about how behaviorally related lifestyle issues are addressed in primary care, both for patients with defined diseases and for patients without defined diseases, how they are included as an essential aspect of a patient’s health, and how they are assessed over time, if at all.

    Hopefully, an essential contribution of this paper, as it is digested by the primary care community, will be a continuation of what I like to call the ‘PHQ-9 effect.’ In the late 90’s several publications revealed that depression was infrequently recognized in primary care, despite its prevalence, and that it was poorly treated even when recognized. In addition to the professional concern expressed about this problem and a number of continuing education programs, patient registries and other important and effective mechanisms to increase physician awareness, patient treatment, patient tracking, and patient follow-up, there was the introduction of a simple, easy to use and easy to interpret paper and pencil scale to assess depression in the office that meshed well with the primary care context. It arrived carrying with it only nine items, it had well-defined cut points for diagnosis, and it led to a choice of specific treatments based on patient and physician preference, e.g., medication, psychotherapy, a combination of both. To put it simply, the scale worked and physicians felt comfortable using it. In this sense, the PHQ-9 became both a means to an end and an end in itself. As a means to an end, it improves care by accurately assessing depression, perhaps as a screen, but certainly as a solid first step in addressing this major clinical problem. But in my view, the presence of the PHQ-9 in the primary care office also became an end in itself. The scale made a major contribution simply by making depression and its care visible within primary care. It is like having the blood pressure gauge on the exam room wall. It is hard to ignore, impossible to forget, and difficult to avoid. In this sense, the presence of this easy to use scale itself highlighted depression care and seated it squarely into the general stream of primary care practice. Assessing depression no longer was something one considered only in special cases.

    My hope is that this same sequence of events emerges with the introduction of these consolidated measures of health behaviors within primary care. In many ways, health behavior assessment and intervention is to primary care now what depression care was prior to the late 90’s. Although primary care practices need to gear up to address behavioral lifestyle and disease risk issues, like diet, physical activity, etc., on a practical but comprehensive basis, having a useful set of readily available measures that are easily interpretable (e.g., recognizable cut- off scores) and that lead to clear courses of action brings this realm of intervention into the physician’s purview in ways that are sensible and do -able in a busy practice.

    It seems to me, however, that we need to take three additional steps before these scales will have widespread utility, again following the PHQ- 9 metaphor. First, we need to add to these scales, refine them and integrate them in ways that broaden their usefulness without burdening patients. This might include adding to the battery the PHQ-9 or other mood scale, and perhaps adding a scale for non health-generated stress (family, work, economic, etc.). These two domains of behavioral health are missing from the current battery, and their inclusion makes the scales more useful for the vast majority of patients. Second, we need to format the scales in ways that make them easy to complete, score and interpret, perhaps using a simple, single page graphic that compares each score to a set of relevant norms or to the patient’s last reported behavior to observe change. Then the scales can be used in a doctor-patient dialogue about behavior and health to identify where changes need to occur and what barriers to change may exist, following traditional behavioral principles. The consolidation of a comprehensive set of measures also opens the door to developing computer-assisted administration and scoring systems that are inexpensive and efficient, and that allow both the patient and the physician to keep the current record and to compare it to a later one to assess change. Third, we need to link specific treatment or action options to specific score configurations. The options are available, but they have not as yet been organized in ways that facilitate their use in the office, nor have primary care physicians been trained well in their application. As in depression care, we have learned that assessment without good treatment options leads to no assessment at all.

    In these ways, the Glasgow, et al. paper introduces health behavior assessment and intervention into the real world of primary care. It will be very interesting to watch its up-take over time.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (26 January 2005)
    Page navigation anchor for Tools for primary care and research
    Tools for primary care and research
    • Victor M Montori, United States

    My comment centers on the clinical and research implications of this paper. Glasgow and colleagues propose criteria for the selection of tools for the assessment of four key health behaviors in primary care and identify “best” tools among commonly used ones. These investigators and colleagues should be commended for a timely and quality effort.

    While clinicians clearly value the need to assess and interv...

    Show More

    My comment centers on the clinical and research implications of this paper. Glasgow and colleagues propose criteria for the selection of tools for the assessment of four key health behaviors in primary care and identify “best” tools among commonly used ones. These investigators and colleagues should be commended for a timely and quality effort.

    While clinicians clearly value the need to assess and intervene on these four key behaviors (activity, diet, smoking, alcohol use), they are ambivalent about their ability to facilitate positive changes. Time constraints and lack of skills may be among the cited reasons. To some extent, simple self-reported patient assessments may provide a metric that clinicians can use to gauge and document their efforts and those of their patients. However, I am particularly concerned about the responsiveness of these tools: would they reflect important changes in the target behavior in response to an effective intervention?

    Translational researchers often struggle to weigh the different features of behavior metrics and to select the best tools to ascertain the effectiveness of interventions targeting key health behaviors. The criteria and the selected tools are very helpful in this task, if nothing else, to facilitate comparisons across studies and meta-analyses. Further, developers of new metrics can use the framework presented here to ensure that their new tools satisfy its criteria.

    The research agenda identified through this effort is, in my opinion, correct and urgent. Also, greater opportunity for connection between the researchers and the users (patients and primary care clinicians) may uncover challenges and new opportunities to refine the tools put forward here.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 3 (1)
The Annals of Family Medicine: 3 (1)
Vol. 3, Issue 1
1 Jan 2005
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Practical and Relevant Self-Report Measures of Patient Health Behaviors for Primary Care Research
Russell E. Glasgow, Marcia G. Ory, Lisa M. Klesges, Maribel Cifuentes, Douglas H. Fernald, Larry A. Green
The Annals of Family Medicine Jan 2005, 3 (1) 73-81; DOI: 10.1370/afm.261

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Practical and Relevant Self-Report Measures of Patient Health Behaviors for Primary Care Research
Russell E. Glasgow, Marcia G. Ory, Lisa M. Klesges, Maribel Cifuentes, Douglas H. Fernald, Larry A. Green
The Annals of Family Medicine Jan 2005, 3 (1) 73-81; DOI: 10.1370/afm.261
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  • Use of a Website to Accomplish Health Behavior Change: If You Build It, Will They Come? And Will It Work If They Do?
  • Improving Multiple Health Risk Behaviors in Primary Care: Lessons from the Prescription for Health COmmon Measures, Better Outcomes (COMBO) Study
  • Patient-Reported Measures Of Psychosocial Issues And Health Behavior Should Be Added To Electronic Health Records
  • Coordination of Health Behavior Counseling in Primary Care
  • A Medical Assistant-Based Program to Promote Healthy Behaviors in Primary Care
  • Personal Health Behaviors are Associated with Physical and Mental Unhealthy Days: A Prescription for Health (P4H) Practice-based Research Networks Study
  • Introduction
  • Patients' Commitment to Their Primary Physician and Why It Matters
  • Is Self-Efficacy Associated With Diabetes Self-Management Across Race/Ethnicity and Health Literacy?
  • 'Another Compelling Idealized Model That Is Drastically Altered by the Ugly Facts on the Ground'
  • RE-AIMing Research for Application: Ways to Improve Evidence for Family Medicine
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  • Joint Display of Integrated Data Collection for Mixed Methods Research: An Illustration From a Pediatric Oncology Quality Improvement Study
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