Systematic review
Effects of organised follow-up of behaviour that may increase risk of disease in adults
Systematic review
|Updated
This systematic review is meant to answer questions about effects of organised follow-up on change of health behaviours (physical activity, diet, use of tobacco and alcohol).
Key message
In Norway, ‘frisklivssentraler’ – ‘healthy living centres’ have been introduced to support change of behaviours that have significance for health. This systematic review is meant to answer questions about effects of organised follow-up on change of health behaviours (physical activity, diet, use of tobacco and alcohol). We searched for and included studies of interventions corresponding to those given in Norwegian ‘frisklivssentraler’ – ‘healthy living centres’ during one period of organised follow-up (3 months).
We included 23 randomised controlled studies from literature searches finished in June 2012. Based on our summary of the findings and assessment of the quality of the documentation, we draw the following conclusions:
Physical activity
- Referral to a local center and follow-up, and training on one’s own with follow up probably increase physical activity in the intervention period and in the short term (3 months after the intervention period).
Diet and physical activity
- We lack documentation of sufficient quality about interventions to conclude about change of diet and physical activity.
Tobacco
- Self-help materials and follow-up may increase abstinence from smoking during the intervention period.
- Referral to a nurse may increase the number of persons who abstain from smoking 6 months after starting the intervention.
Alcohol
We did not find studies of interventions to reduce alcohol use that met our inclusion criteria.
Summary
Background
Preventive efforts aiming to support change of behaviours that have significance for health is an important task in order to reduce the incidence of cardiovascular diseases, type 2 diabetes, chronic lung diseases, cancer, and alcohol related damage. Advice and education can reduce mortality from cardiovascular diseases in persons with hypertension or diabetes, and diet and exercise can reduce the incidence of type 2 diabetes. Abstinence from smoking reduces the risk of cardiovascular disease and cancer within few years.
The Norwegian Directorate of Health has supported the development of ‘healthy living centres’ since 2004. These are centres managed by the municipalities where persons with increased risk of, or already diagnosed with disease can get guidance and follow-up concerning health behaviours. The Directorate of Health will revise their written guidance on establishment and organisation of healthy living centres in 2012, and has asked the Norwegian Knowledge Centre for the Health Services to conduct a systematic review of the effects of organized follow-up on change of risk-related health behaviours.
Objective
The objective is to answer the following question:
What are the effects of organised follow-up (10-14 weeks) on health behaviour change (i.e. physical activity, diet, use of tobacco and/or alcohol) compared to oral or written advice, usual care, or no intervention in adults with risk-related health behaviour or increased risk of disease?
Method
We searched systematically for research reports in 10 electronic databases and in reference lists of included publications to June 2012. We also hand searched searched relevant scientific journals. We searched for literature with the following research designs: overviews of systematic reviews, systematic reviews, randomised controlled studies, cluster-randomised controlled studies, quasi-randomised controlled studies, controlled before- and after studies, and interrupted time series analyses.
Two project workers made independent assessments of whether to include studies, and risk of bias in included studies. Check lists were used for this purpose. We summarised the results in text and tables. The quality of the evidence was assessed using GRADE.
Results
The search in electronic databases resulted in 10188 unique references. After assessment of titles, abstracts, and full texts we included 23 randomised controlled studies with 8674 participants. We did not find studies about reduction of alcohol consumption that were deemed relevant to ‘healthy living centres’.
The interventions for promoting physical activity included: supervised training in groups, referral to a local centre with follow-up, and training on one’s own with follow-up. The interventions for promoting smoking cessation included referral to a quit line, Internet-based smoking cessation with follow-up, self help materials and follow-up, and referral to a nurse trained in counselling for smoking cessation. The interventions for promoting change of life style included supervised program in groups and individual counselling and follow-up.
The reported outcomes were physical activity, abstinence from smoking, and energy intake.
After integration of the results with the assessment of quality of the evidence
(GRADE), we can say the following about effects of interventions to promote physical activity:
1) referral to local centres with follow-up probably increases
a) physical activity measured in points at the end of the intervention period
b) the number of persons who reach a goal of being active 90 minutes per week 3 months after the intervention, compared to advice
2) training on one’s own with follow-up probably increases
a) the number of persons who increase their physical activity at the end of the intervention period
b) the number of occasions with physical activity compared to baseline at the end of the intervention, and
c) the number of persons who reach a goal of being active 90 minutes per week 3 months after the intervention period, compared to advice
3) training on one’s own with follow-up probably increases
a) the number of steps per day at the end of the intervention and
b) physical activity measured in points 3 months after the intervention period, compared to no treatment
4) referral to walks led by an instructor may increase
a) the number of minutes with physical activity per week and
b) energy expenditure per week 3 months after the intervention period, compared to advice
5) referral to local centres with follow-up may increase
a) the mean number of occasions with physical activity 3 months after the intervention period and
b) energy expenditure per week 9 months after the intervention period, compared to advice
6) training on one’s own with follow-up may increase the number of persons who increase their physical activity at the end of the intervention period, compared to advice,
7) training on one’s own with follow-up may increase the number of minutes with physical activity per week at the end of the intervention period and 9 months after the intervention, compared to no treatment
8) other interventions to increase physical activity may give little or no change of physical activity, or the quality of the documentation is too low to conclude about effects.
We can say the following about interventions to promote smoking cessation:
1) self-help materials and follow-up may increase the number of persons who abstain from smoking, measured as point prevalence, at the end of the intervention period, compared to no treatment
2) referral to a nurse may increase the number of persons who abstain from smoking, measured as point prevalence, 6 months after start of the intervention, compared to advice
3) other interventions to promote smoking cessation may give little or no change of abstinence rates, or the quality of the documentation is too low to conclude about effects.
We can say the following about the intervention to promote an improved diet and increased physical activity:
1) individual counselling with follow-up may increase the number of persons who reach a goal of eating 5 servings of fruit and vegetables per day at the end of the intervention period, compared to no treatment
2) the quality of the documentation is too low to conclude about effects of supervised program in groups.
Discussion
Many different interventions can be used in ‘healthy living centres’. We found 10 different interventions that have been evaluated in studies. There is great variation within the field on what the important outcomes are, how they should be measured, and at what length of follow-up. We have evaluated altogether 61 outcomes distributed across 10 interventions. Due to the variation in outcome measures, it was not possible to summarize the available documentation in meta-analyses. Consequently, each of our results is based on one study only, which contributes to reduce our confidence in the findings.
All included outcomes are reported as positive or neutral - we found no negative results.
Conclusion
Based on our summary of the findings and assessment of the quality of the documentation, we draw the following conclusions:
Physical activity
- Referral to a local center and follow-up, and training on one’s own with follow up probably increase physical activity in the intervention period and in the short term (3 months after the intervention period).
Diet and physical activity
- We lack documentation of sufficient quality about interventions to conclude about change of diet and physical activity.
Tobacco
- Self-help materials and follow-up may increase abstinence from smoking during the intervention period.
- Referral to a nurse may increase the number of persons who abstain from smoking 6 months after starting the intervention.
Alcohol
- We did not find studies of interventions to reduce alcohol use that met our inclusion criteria.
Need for further research:
- We still need to study effects of interventions provided in ‘healthy living centres’ – concerning both physical activity, smoking cessation, use of alcohol, and interventions targeting physical activity and diet.
- We wish to emphasize the need for consensus among researchers about methods for measuring physical activity to prevent that this is being done in various different ways. There is also a general need for objective measurement methods that are economically ant ethically justifiable. For smoking cessation increased use of methods for measuring nicotine-exposure would be desirable. Finally, we want to emphasize the need for measuring long term-effects, i.e. a year or more.