Article
Physician screening for multiple behavioral health risk factors

https://doi.org/10.1016/j.amepre.2004.04.021Get rights and content

Abstract

Background

Screening rates in primary care for single behavioral health risk factors are widely documented. However, such risk factors cluster in individuals and populations. This article examines the number and types of behavioral risk factors that U.S. adults reported, and reported having been screened for in their last routine medical checkup.

Methods

The sample consisted of 16,818 adults from the 1998 National Health Interview Survey who reported having a routine checkup in the past year. Respondents completed questions regarding four behavioral risk factors (physical inactivity, overweight, cigarette smoking, risky drinking), and provider screening for behaviors related to these risk factors.

Results

Half of the sample (52.0%) reported having two or more of the four risk factors, and more than half (59.4%) were screened for two or more risk behaviors during their last routine checkup, although 28.6% reported being screened for none of them. Respondents reporting at least one risk factor were screened for an average of 57.7% of their own risk factors. Women, adults with lower levels of income and education, and those aged 65 and older, reported being screened for fewer of their risk factors.

Conclusions

While guidelines for risk factor screening and intervention typically focus on single behavioral risk factors, most primary care patients present with, and are screened for, more than one. Behavioral risk factor screening tools and interventions must be expanded to cover multiple risks. Additionally, efforts are needed to reduce the substantial missed opportunities for screening, and to eliminate demographic disparities in screening practices and accuracy.

Introduction

A considerable portion of preventable chronic disease morbidity and mortality in the United States is attributable to modifiable behavioral health risk factors. The leading behavioral contributors to mortality are tobacco use, poor diet, physical inactivity, and risky alcohol use.1 Reducing the prevalence of these behaviors has the potential to improve quality of life, promote health, prevent disease, and extend the lives of millions of Americans.

Behavioral risk factors cluster in individuals. For example, compared to nonsmokers, smokers have poorer diets, are less physically active, and consume more alcohol.2, 3, 4 Behavioral risk factors also cluster in populations, particularly among people of low socioeconomic status.5, 6, 7 Further, the adverse health effects of behavioral risk factors are often synergistic,8 and the prevention and management of many chronic illnesses require attention to multiple behavioral risk factors.9

The primary care setting provides an opportunity for healthcare providers to identify and address individuals' behavioral risk factors. On average, Americans visit a physician's office three times per year, with more than half of these visits being to a primary care physician.10 Patients expect to receive information and assistance regarding preventive health issues from healthcare providers,11 placing providers—particularly those in primary care—in the position to screen and counsel individuals with regard to their risky health behaviors. The national prevention guidelines of Healthy People 201012 and the U.S. Preventive Services Task Force13, 14 recommend that healthcare providers routinely provide counseling for many health risk behaviors. Yet largely as a result of categorical funding streams, most research has developed and evaluated interventions for single risks (for instance, tobacco use, healthy diet, physical activity, or risky drinking), rather than interventions that would address multiple risks, providing guidance on how best to integrate their efforts or prioritize when more than one of these risks is present. As a result, few models or tools have been developed, tested, or promoted to help primary care patients, providers, or practices address multiple behavioral risk factors (either sequentially or simultaneously).

Recent analyses suggest that a single overarching framework—the “5A's”—can be used to guide screening and intervention efforts across a variety of behavioral risk factors, raising prospects for integrated approaches. The 5A's framework, which was originally developed for primary care tobacco-cessation interventions, entails (1) Assessing the behavioral risk factor; (2) Advising the patient about personal health risks and benefits of behavior change; (3) Agreeing on treatments goals and methods; (4) Assisting individuals by providing behavior change techniques and medical treatment, as appropriate; and (5) Arranging follow-up assessment and support.15, 16

The first critical step of the 5A's is behavioral risk factor screening. To assess the need and prospects for models and tools to tackle the multiple health risks patients present with in primary care, we analyzed data from the National Health Interview Survey (NHIS) to document the prevalence of multiple behavioral risk factors, and the rate of screening for multiple risk behaviors during patients' last routine checkup. We focused on four behavioral risk factors: physical inactivity, overweight, cigarette smoking, and risky alcohol consumption. We considered screening for four health risk behaviors related to these risk factors: physical activity, diet/eating habits, tobacco use, and alcohol use. Although screening for multiple risks can take place in many types of provider visit,17 the routine checkup is an ideal occasion. We also examined the degree of concordance between the risk factors individuals presented, and the health risk behaviors that they reported being screened for. Finally, we explored demographic and healthcare covariates of this concordance.

Section snippets

Procedure

The data for this study are from the 1998 NHIS. The annual NHIS is a representative survey of U.S. adults. A detailed description of the survey design and data collection procedure is available elsewhere.18, 19, 20 In brief, the NHIS uses a multistage clustered cross-sectional design, with state-level stratification, and over-sampling of black and Hispanic populations. Respondents are interviewed in their own homes by trained interviewers from the U.S. Bureau of the Census.

Sample selection

Of the 32,440 people

Behavioral risk factor prevalence and screening rates: single risk factors

The prevalence of each behavioral risk factor for the full sample is shown in Table 2. Over two thirds (69.5%) of the sample reported being physically inactive and slightly more than one half (55.3%) were overweight (reported BMI≥25). Reported levels of cigarette smoking (20.4%) and risky drinking (8.1%) were considerably lower.

Table 2 also shows the concordance between having a particular risk factor and being screened for a related risk behavior. Concordance rates represent an index of

Discussion

This study examined the number and types of behavioral risk factors U.S. adults reported, and reported having been screened for in their last routine checkup. A majority of respondents reported insufficient physical activity or overweight. The rates of physical inactivity and overweight in this study are comparable with those reported in other studies, including Fine et al.,22 and are consistent with the nation's current obesity epidemic.23 One fifth of respondents reported that they were

Acknowledgements

This research was supported by The Robert Wood Johnson Foundation, and conducted while EJC was a predoctoral research and evaluation fellow and AG was a research assistant at the Foundation.

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      A widely recommended model of preventive care is the ‘5As’ framework (Harris and Lloyd, 2012; Glasgow et al., 2004; Coups et al., 2004; Carroll et al., 2012; Whitlock et al., 2002), where clinicians provide care in five steps: ask, advise, assess, assist, and arrange/follow-up (Harris and Lloyd, 2012; Glasgow et al., 2004; Coups et al., 2004). Developed to guide the provision of smoking cessation interventions (Glasgow et al., 2004; Coups et al., 2004), the 5As model has been successfully applied to other behaviours such as diet, alcohol consumption, and physical activity (Ockene et al., 1995; Ockene et al., 1997; Pinto et al., 2005; Harrison et al., 2012), and is consistently reported to be effective in reducing health risk behaviours (Harris and Lloyd, 2012; Goldstein et al., 2004; Whitlock et al., 2002; Pinto et al., 2005; Harrison et al., 2012; Fiore et al., 2008). However, competing clinical priorities, large clinical loads and time constraints are frequently reported as barriers for the delivery of preventive care (Ministry of Health, 2007; Revell and Schroeder, 2005), and it is often not delivered opportunistically as recommended (Royal Australian College of General Practitioners, 2009; US Department of Health and Human Services, 2009; National Institute for Health and Care Excellence, 2011; National Institute for Health and Care Excellence, 2013; National Institute for Health and Care Excellence, 2014; National Institute for Health and Care Excellence, 2018; National Preventive Health Taskforce, 2010).

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