Nurses in primary health care PHC provide an increasing proportion of chronic disease management and preventive lifestyle advice.
Thirty-one articles describing 28 studies were analysed by comparison group which revealed: The evidence supports the effectiveness of lifestyle interventions delivered by nurses in PHC to affect positive changes on outcomes associated with the prevention of chronic disease including: The strength of recommendations is limited by the small number of studies within each comparison group and the high risk of bias of the majority of studies. The international rise in obesity rates over the last three decades has been accompanied by an increase in preventable chronic diseases, such as type 2 diabetes, cardiovascular disease, stroke, arthritis and some cancers 1.
Internationally, chronic diseases are managed in a variety of health care settings and their prevention is increasingly becoming a priority for primary health care PHC which is the first point of contact with the health system. Nurses are an integral part of any multidisciplinary PHC team and have roles that continue to develop and expand in response to financial incentive, medical practitioner shortages and an imperative to decrease pressure on hospitals 2 — 5.
Nurses in PHC are assuming an increasing proportion of the chronic disease management and preventive health advice 6. A systematic review of the literature of PHC nursing interventions provides strong international evidence to support the effectiveness of PHC nurses in a diverse range of roles including chronic disease management, illness prevention, health promotion and achievement of good patient compliance in treating chronic conditions, when assessed using quality of care measures mortality, quality of care, compliance, knowledge, satisfaction , and use of resources 7.
Lifestyle change interventions focus on increasing healthy behaviours at the individual level and reducing chronic disease risk by controlling physiological variables known to be associated with chronic disease onset. Systematic reviews provide strong evidence that lifestyle interventions are effective in: Little is known to inform the components of PHC nursing interventions for the prevention and management of chronic diseases associated with obesity.
This is the first systematic review to compile the evidence regarding lifestyle change intervention effect, when delivered by PHC nurses, without restricting outcomes to those of cardiovascular disease risk The aims of this research were to: This systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 11 , The key question informing this systematic review was: What does the published literature report on the effectiveness of interventions for adults which aim to affect change in lifestyle risk factors for chronic diseases that are associated with overweight and obesity, when these are delivered by a PHC nurse in a PHC setting?
Articles were eligible if they: Papers were limited to primary sources, published in English. Articles were excluded if they: Studies reporting effect on smoking cessation or alcohol intake were excluded where this was the main focus of intervention, and included, if there were lifestyle change outcomes of interest, as interventions focused on smoking cessation have been reported elsewhere No restrictions were placed on the primary outcome measure, the year of publication, length of intervention, follow-up period or format of the comparison group.
To the best of our knowledge, all articles were peer reviewed. The bibliographies of included articles were hand searched to locate articles not catalogued in these databases. The database search strategy Supporting Information Table S1 was constructed with the assistance of a specialist librarian, using medical subject headings MeSH , and five groups of keywords. Articles retrieved by the search strategy had at least one term from each of the five groupings: A sixth group limited results by excluding articles outside the scope of the review.
Word truncation and wildcards allowed for variations in spelling and word endings. Database limits for English full text were applied. Search terms were adjusted slightly for each database. A reference management program EndNote X1.
The search function was used to exclude articles when the title contained the following keywords that were outside the scope of this review: Non-concordant articles were resolved by consensus or retained for full-text review if agreement was not reached. Full-text articles were reviewed GS and LF using an eligibility checklist. Further library searches were conducted using the names of authors of included studies to identify subsequent or preliminary papers for those studies.
The paper reporting the post-intervention outcome measures was regarded as the primary source. Data from publication describing included studies were extracted systematically by one reviewer GS into a database described elsewhere 14 , No further information was sought from the authors.
Data describing interventions that were reported in more than one article were extracted together. A second reviewer LF verified outcome tables.
The following components of each intervention were recorded for comparative purposes: The risk of bias was assessed for individual studies according to adequate control of: Each study was scored for methodological limitations and risks of bias during data extraction Table 1 and Supporting Information Table S2. An overall indication of quality according to the methodological limitations and risk of bias is also indicated.
Randomized and non-randomized trials were assessed using the same criteria and studies were not excluded on the basis of risk of bias. Outcomes reporting smoking cessation and change in alcohol consumption were not extracted. Because of the heterogeneity of outcome measures, neither a meta-analysis nor evidence profile on outcomes was appropriate.
Results are instead synthesized, presented and discussed according to comparison group. The methodological limitations and risk of bias are presented for each study in the outcome tables and are discussed descriptively. The database search identified 3, papers. The review process identified 31 articles describing 28 studies that were eligible for inclusion Fig.
Three studies reported strong methodological rigour with no serious limitations and a low risk of bias 17 — About 14 of the 28 studies described nurses delivering behavioural counselling in an appointment between 5 and 30 min using theoretically based behaviour change techniques such as stage matching, motivational interviewing to enhance readiness for change or goal setting. Most of these described providing training prior to intervention delivery. One study with no serious limitations and a low risk of bias 17 and one study with serious limitations and a high risk of bias 21 directly compared delivery of the same intervention by different health professionals in a PHC setting Table 2.
The interventions involved either two 17 or nine 21 contacts with a health professional. Significant changes were seen within all six treatment groups for anthropometric outcome measures over the short term with no adverse effects reported. There was no evidence that delivery by a PHC nurse, following brief training, affected outcomes differently compared to delivery by a dietitian 17 , a psychologist or a social worker 21 each with prior experience in delivering weight reduction counselling.
There is good evidence Table 3 from one high-quality study with a low risk of bias that behavioural counselling delivered by a nurse is significantly more effective than screening alone to increase physical activity levels and improve quality of life over a 1-year intervention, and that these may be maintained at a 2-year follow-up 18 , This study did however observe more falls and injuries in the group of participants that undertook more physical activity and did not record significant anthropometric or physiological outcomes.
One study with moderate risk of bias 22 indicated that 1 month of behavioural counselling may significantly affect positive changes in readiness and intent for physical activity when compared with screening alone.
Two further studies, with a high risk of bias, offer supporting evidence that behavioural counselling is more effective than screening alone across a variety of outcomes 23 , Interventions involved between 1 5 min and 20 counselling sessions and follow-up measures were taken between 3 months and 17 years from baseline.
All intervention arms that involved nurse counselling following screening demonstrated significantly higher post-intervention changes in anthropometric, physiological or behaviour change outcomes, compared to screening. Significant changes were reported for: Significant intervention effect was not maintained at year follow-up Four studies with a high risk of bias reported testing PHC nurse delivery of the same dose of counselling comparing traditional counselling with counselling based on behaviour change theory 31 — Three interventions were delivered in three to five contacts, each reported significantly greater intervention effect for participants who received behavioural counselling than traditional counselling Table 5.
No intervention effect was reported when 5 min of counselling tailored to the participants' stage of change was compared to usual care or provision of written material only Four studies with a low 20 and high 35 — 37 overall risk of bias compared a low dose of traditional counselling with a higher dose of behavioural counselling Table 6. High-quality evidence with a low risk of bias supports the use of a high dose 13 contacts of behavioural counselling to improve patient satisfaction The studies with a high risk of bias indicate that higher doses of counselling based on theories of behaviour change may result in significantly higher changes than low doses of traditional counselling, and these are evidenced by changes in: Self-reported dietary intake was significantly improved when three additional brief 3—5 min counselling sessions were delivered Adherence to recommendations and self-reported physical activity were significantly higher when up to 20 additional contacts were delivered A prescription for physical activity was delivered by a nurse in one study with a low risk of bias 18 group 1.
However, the treatment effect may not be attributable to this prescription component, hence this group was excluded from further analysis. One intervention, with a moderate risk of bias, reported that the immediate provision of cholesterol readings using point-of-care equipment did not result in significantly different cholesterol readings at 3-month follow-up 42 Table 8.
Another supports the provision of a written prompt regarding high-fibre dietary choices and reduced fat options to improve fruit and vegetable intake and reduce weight 43 group 3. The provision of high potassium, low sodium table salt to encourage reduction of sodium chloride intake resulted in adverse side effects and was not recommended 43 group 2.
A RCT with a high risk of bias supported dietary counselling by nurses, providing some evidence that training nurses in the use of a dietary risk assessment tool resulted in significant effects on dietary intake and weight change of participants over 3 months, with changes in dietary intake maintained over 12 months Another study with a high risk of bias reported that nurse delivery of a written prompt did encourage participants to seek health-related information from their general practitioner This is the first systematic review to synthesize the international evidence regarding the effectiveness of non-pharmaceutical lifestyle interventions for adults with the aim of reducing risk factors for preventable chronic diseases associated with obesity that were delivered by PHC nurses in a PHC setting.
This synthesis contributes to the existing knowledge regarding the effectiveness of: Preventive Services Task Force USPSTF concludes that changes in physiological measures such as glucose metabolism, lipid levels, blood pressure, as well as weight loss provide indirect evidence of intervention effect on long-term health outcomes 57 , and these diverse measures are reflected in the interventions included in this review.
The significant outcomes indicate that healthy lifestyle interventions delivered by PHC nurses can be effective over a variety of anthropometric, physiological and behavioural risk factors for chronic diseases associated with obesity.
The effectiveness of lifestyle interventions delivered by nurses, given appropriate training, is comparable to delivery by other PHC professionals with no adverse effects 17 , This is consistent with existing literature regarding the effectiveness of nurses in PHC when compared to a PHC physician 7 , 9 , 58 — However, the provision of coronary risk information, with or without counselling, has proven effective in increasing intent to commence therapy In any prospective controlled trial, the process of data collection and screening for eligibility is likely to act as an intervention in itself; hence, it is very difficult to assess the effect of an intervention compared with no intervention.
Screening for risk is an essential antecedent to intervention in PHC 55 , hence an essential component of lifestyle intervention to prevent chronic diseases associated with obesity. However, evidence in this review, although of mixed quality, consistently supports the provision of some dose of counselling 1—20 contacts by nurses compared to screening alone. The results of this systematic review support this, as results indicate that delivery of counselling in three or more contacts may result in significantly higher change in self-reported behaviour change for dietary and physical activity behaviours.
However, there was insufficient evidence to support the use of a higher dose of intervention when assessed using anthropometric or physiological outcomes such as weight, blood pressure, cholesterol profile or fitness. There was little evidence to support low intensity counselling; however, take-home written prompts may be a useful adjunct to nurse counselling interventions in PHC. Counselling for lifestyle change in PHC has traditionally taken the form of advice regarding recommendations to meet guidelines.
More recently, behavioural counselling in lifestyle interventions has been based on psychological theoretical frameworks such as the theory of planned behaviour 66 , concepts such as the transtheoretical model of health behaviour change 67 , and the use of strategies such as motivational interviewing 68 and goal setting Results of this review indicate that behavioural counselling strategies delivered by nurses in PHC have an effect on increasing participants' readiness for change and establishing intent for behaviour change.
Those interventions that conducted a sub-analysis on participant stage of change reported that the greatest benefit was gained in the subgroup of participants that moved from an early stage of change pre-contemplation of contemplation to a later stage action or maintenance.
This review lends further support to the building literature describing the outcomes of counselling in PHC 50 , 54 , 70 —More...