ArticlePhysician screening for multiple behavioral health risk factors
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.
References (42)
- et al.
Smoking, exercise, and physical fitness
Prev Med
(1992) - et al.
Screening for health behaviors in ambulatory clinical settingsdoes smoking status predict hazardous drinking?
Addict Behav
(2002) - et al.
Correlates of high fat/calorie food intake in a worksite populationthe Healthy Worker Project
Addict Behav
(1993) - et al.
Will patient satisfaction set the preventive services implementation agenda?
Am J Prev Med
(1997) - et al.
Evaluating primary care behavioral counseling interventionsan evidence-based approach
Am J Prev Med
(2002) - et al.
One minute for preventionthe power of leveraging to fulfill the promise of health behavior counseling
Am J Prev Med
(2002) - et al.
Prevalence of multiple chronic disease risk factors2001 National Health Interview Survey
Am J Prev Med
(2004) - et al.
Are physicians less likely to recommend preventive services to low-SES patients?
Prev Med
(1997) - et al.
Patients' expectations of the family physician in health promotion
Am J Prev Med
(1991) - et al.
Interactive behavior change technologya partial solution to the competing demands of primary care
Am J Prev Med
(2004)
Translating what we have learned into practiceprinciples and hypotheses for addressing multiple behaviors in primary care
Am J Prev Med
Prevention and health promotion in primary carebaseline results on physicians from the INSURE project on lifecycle preventive health services
Prev Med
Actual causes of death in the United States
JAMA
Socioeconomic status and healththe challenge of the gradient
Am Psychol
Educational attainment and behavioral and biologic risk factors for coronary heart disease in middle-aged women
Am J Epidemiol
Socioeconomic status and healthhow education, income, and occupation contribute to risk factors for cardiovascular disease
Am J Public Health
Alcohol and cancer
Cancer Res
Does the chronic care model serve also as a template for improving prevention?
Milbank Q
National Ambulatory Medical Care Survey: 2000 summary. Advance data from vital and health statistics, no. 328
Healthy people 2010: Understanding and improving health and objectives for improving health
Guide to clinical preventive services
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2019, Preventive MedicineCitation Excerpt :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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2017, SSM - Population Health