Introduction
Addressing multiple behavioral risk factors in primary care: A synthesis of current knowledge and stakeholder dialogue sessions

https://doi.org/10.1016/j.amepre.2004.04.024Get rights and content

Abstract

Background

Addressing behavioral risk factors in primary care has become a pressing concern due to the increasing burden of behavioral risk factors on disease, healthcare costs, and public health. Risk factors considered include smoking, risky drinking, sedentary lifestyle, and unhealthy diet—singly or in combination. The already burdened primary care system needs a practical approach to efficiently and effectively address any combination of multiple risk factors. Multiple perspectives and broad insight are urgently needed to gain a deeper understanding of the interacting scientific, systems, and policy issues associated with multiple risk factor interventions (MRFIs).

Purpose

This paper synthesizes findings from literature reviews, epidemiologic analyses, and structured interactive dialogue sessions, and includes a set of recommendations designed to stimulate further action.

Methods

Several papers were produced to document current knowledge, research evidence, and salient issues related to multiple risk factor assessment and intervention. Structured interactive dialogue sessions were then conducted with clinician, health system, and health policy leaders regarding what advantage or energy would be liberated by a multiple risk factor approach (rather than separate single risk factor approaches), and how to build a policy framework or constituency for MRFIs. This information is synthesized in this paper.

Results

There is a clear need to address MRFIs among multiple stakeholders, including patients, purchasers, payers, clinicians, health system leaders, and policy-level stakeholders. MRFIs need to bring with them a compelling value proposition for all stakeholders, and a vision of practical and systematic ways to make it a reality in already-pressed primary care practices. Involving stakeholders in dialogue aimed at helping them see the world through each other's eyes helps overcome discouragement and generates energy for jointly designing new approaches. Recommendations for further action include the creation of multistakeholder dialogue, creation of a policy agenda, development of a translation or integration agenda that connects researchers and practitioners in a two-way exchange, initiation of a series of demonstration projects around MRFIs, and support for research on multiple (rather than only single) risk factor interventions.

Conclusions

The need to address multiple behavioral risk factors in primary care is increasingly urgent. Whereas stakeholders by themselves may be willing to address multiple risk factors, they agree that it can only be done successfully with a collaborative approach. Findings based on evidence reviews, hypotheses generation, and stakeholder dialogue provide guidance for appropriate further action that, based on what is known already, can be initiated right away.

Introduction

Health risk behaviors such as smoking, risky drinking, sedentary lifestyle, and unhealthy diet are among the leading causes of mortality, morbidity, and impaired functioning.1, 2 Despite increasing evidence suggesting that primary care practitioners can effectively intervene for specific health behaviors, rates of screening and implementation of brief intervention in the primary care setting remain low.3 In addition, research has shown that many of these health risk behaviors occur in combination, that is, they tend to cluster within individuals.4, 5, 6 In the primary care setting, challenges and barriers exist to addressing behavioral health risk factors, singly or in combination, yet despite these challenges, an increasingly urgent need to address multiple health risk behaviors is emerging.

Addressing multiple risk factors in primary care has important advantages that align with major efforts to redesign the healthcare system in the United States based on recommendations that stem from the Institute of Medicine (IOM).7 Since many patients present with multiple health risk behaviors, integrated approaches to health risk assessment and intervention may be more patient centered, holistic, and timely, thereby generating greater patient satisfaction. An integrated approach to addressing multiple risk factors that allows patients to choose behaviors to work on may be more effective because patients are more ready to act on behaviors that they are already contemplating to change,8 and a primary care practitioner can directly influence and support a patient's decision to initiate change.9 A unified, integrated approach to addressing multiple health risk behaviors may also be more efficient than focusing on one risk factor at a time, saving the healthcare system time, effort, and resources. Furthermore, integrated and unified approaches to addressing multiple health risk behaviors may identify solutions that address and align the interests and concerns of multiple stakeholders, such as patients, employers, health systems, and policymakers. Finally, the underlying motivational and intervention models, principles, and infrastructure for modifying these behaviors are similar and offer the promise of not having to reinvent the wheel for each behavior.

For this project, we focused on four risk behaviors: smoking, risky drinking, sedentary lifestyle, and unhealthy diet, also referred to as the “big four.” Clearly, there are many other health risk behaviors that could be considered as well, such as not using seat belts and cycle helmets, failure to obtain immunizations, practicing unsafe sex, failure to change batteries in smoke alarms, involvement in violent relationships, and recreational psychoactive substance use. The big four outlined in this paper were not chosen because they are the only important or worthy health risk behaviors, but because they are a highly significant cluster of related health risk behaviors.1, 2, 3, 4, 5, 6

The four behavioral risk factors carry a significant burden of illness and are particularly challenging for patients to change. This cluster is a well-suited package for moving forward the concept and practice of multiple health risk assessment and intervention that may itself require significant change in the behavior on the part of clinicians, health systems, and policymakers. There is a reasonably good knowledge base on each individual behavior in this cluster—prevalence, burden of illness, and how to intervene—along with overlap in prevalence among the components in the cluster.11 Moreover, one has to start somewhere—with something large and important enough to make a real difference, but not so full of elements that the early efforts become unmanageable from the outset. If a platform of intervention and evaluation can be created for these four behaviors, it is reasonable to suggest that it can be extended to include other health risk behaviors as well.

In order to gain a deeper understanding, additional perspective, and broader insight into this issue, the Addressing Multiple Behavioral Risk Factors in Primary Care project was initiated with funding from the Robert Wood Johnson Foundation. The project team identified two approaches designed to gain such insights. First, several papers were produced to document current knowledge, research evidence, and salient issues related to addressing multiple risk factor intervention.10, 11, 12, 13, 14 In addition, two structured interactive dialogue sessions (hereafter referred to as “dialogue sessions”) were conducted with clinician, health system, and health policy leaders. The main objectives of the dialogue sessions included listening, hearing, and synthesizing the variety of viewpoints, perspectives, and opinions about the importance, challenges, and opportunities for creating integrated platforms of clinical method and system infrastructure to address any combination of the four health risk behaviors in primary care settings. This paper presents a synthesis of these two approaches and a set of recommendations designed to stimulate further action.

Section snippets

Prevalence of multiple behavioral risk factors

Fine et al.11 conducted a descriptive study using 2001 National Health Interview Survey data to examine the prevalence and clustering of multiple risk factors among adults aged ≥18 in the United States. The four risk factors examined were smoking (at least some days); alcohol consumption (problematic weekly drinking or heavy episodic consumption one or more times per month); low levels of physical activity (PA) (less than five times per week of ≥30 minutes of moderate or vigorous PA), and being

Process description

Two dialogue sessions were held with participants (n =36 at each) representing three groups of stakeholders: clinician leaders, health system and healthcare organization leaders, and leaders in creating and shaping health policy. The purpose of the dialogue sessions was to discover how leaders in the clinical, health systems, and policy fields look at the MRFI issue, and what those leaders can learn from each other when presented with the opportunity to speak and listen to each other.

Recommendations

The following recommendations are based on the results of the two dialogue sessions and findings of the four background papers produced for this project.11, 12, 16, 19

A call to action

As is so often the case, we know more than we apply in practice. Even with gaps or unanswered questions in the research literature flagged in this and the other papers, we do know enough to act now. At the very least, we can let our actions catch up with what we know. We know health risk behaviors are a major and growing threat—and we know we can do something about it—even if our scientific and practical knowledge is incomplete. More boldly, we know enough to begin action and demonstrations

Acknowledgements

This work was supported by a grant from the Robert Wood Johnson Foundation. We greatly appreciate the contributions made by the Planning Committee of the Addressing Multiple Behavioral Risk Factors in Primary Care Project and by the individuals participating in the structured interactive dialogue sessions. The Project Planning Committee included Thomas Babor, PhD, Helen Burstin, MD, MPH, Elliot Coups, PhD, Lawrence Fine, MD, Russell Glasgow, PhD, Michael Goldstein, MD, Jessie Gruman, PhD, Susan

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