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What are the health education strategies used by physical therapists to promote behavioural modification… Alexander, Julie; Veronneau, Rochelle; Bambury, Erin; Mendoza, Andrea; Reynolds, Jason Aug 31, 2011

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What are the health education strategies used by physical therapists to promote behavioural modification in people with lifestyle-related conditions? A scoping review  RSPT 572: Group # 8: Julie Alexander, Rochelle Veronneau, Erin Bambury, Andrea Mendoza, Jason Reynolds Outline ? Background ? Methods ? Search Strategy ? Data Abstraction ? Quality Assessment ? Results ? Discussion ? Implications ? Limitations Canadian Health Care System ? Current health care system developed to prevent and treat illness and disease 1  ? Decrease in the number of deaths has shown the effectiveness of this system 1  ? However, a new wave of health threatening conditions exist  ? Current health care system may not be equipped to manage this2 Lifestyle-Related Conditions 3 ? Health disorders caused by modifiable behaviours ? Include: ? Obesity ? Cardiovascular disease ? Cerebrovascular disease ? Cancer ? Type II diabetes ? Smoking-related conditions ? Recently these have threatened to exhaust resources   Statistics ? Include: ? Obesity  ? In 2007 more than half of population obese or overweight 4 ? Cost $4.3 billion in 2005 5 ? Cardiovascular and cerebrovascular disease ? 1.3 million reported cases in Canada 5 ? 317,500 Canadians living post-stroke5 ? Diabetes ? 3.7 million by year 2020 in Canada 6 ? Associated costs increased by $5.9 billion over past 10 years 4 ? Smoking-related diseases ? 5 million Canadians still smoke 8 ? $4.4 billion in direct health care costs annually 7 ? Cancer ? 40% of women and 45% of men will develop cancer in their lifetime 9 ? Expected to be cause of ? of all Canadian deaths 9 Physical Therapists and Behavioural Change ? Health care professionals have been shown to influence behaviour change through counseling 10  ? Physical therapists are in an ideal position to foster this change 10  ? Patients often do not consult physical therapists until after illness has occurred 11  Evolution of Health Care ? A change in the roles of health care service providers is paramount3,12  ? Evolve the role of health care professionals toward prevention and patient self-management13  Aim of Systematic Review ? Scope the peer-reviewed literature to determine what health education strategies are being used by physical therapists to promote behavioural modifications in people with lifestyle-related conditions Methods: Search Strategy Cochrane Database of SR?s (n= 234 ) CINAHL (n= 2410) EMBASE (n= 607) Psyc INFO (n=  189 ) Medline  (n= 291) Reference mining (n= 316) Potentially relevant studies identified and screened for retrieval (n= 4047 ) Studies included in systematic review (n= 8) Title & Abstract Stage -  Studies excluded with reasons:    -Inappropriate population  ? examined condition is not lifestyle related   -Intervention does not include education   -Physical therapy does not have role (n = 3955)  Full Text Stage -  Studies excluded with reasons: - 3 duplicates - 9 lifestyle condition not targeted for education - 18 physical therapist not the educator - 9 inappropriate patient population - 39 no description of education strategy - 6 no access to article   (n = 84)  Studies retrieved for abstract evaluation with screening tool (n= 92 ) Methods: Search Strategy  ? Search organized into 3 blocks of terms ? Education Strategies ? Physical Therapy ? Lifestyle Related Conditions  ? Search terms/key words determined from ? Discussion ideas  ? Supervisor & librarian ? Relevant MeSH terms ? Review of articles keywords  ? Blocks  summed using Boolean Operator ?or? then combined using ?and?  Methods: Search Strategy  ? Searches  ? Search terms carried over to appropriate databases, modified as needed/applicable ? Reference-mining of relevant articles   ? Grey Literature ? Not considered appropriate as we are interested in published materials only  Cochrane Database of SR?s (n=  234 ) CINAHL (n= 2410) EMBASE (n= 607) Psyc INFO (n=  189) Medline  (n= 291) Reference mining (n= 316 ) ? Examine title and abstracts  ? Apply inclusion screening criteria ? Adult patient population ? Lifestyle-related condition ? Obesity ? Cardiovascular disease ? Cerebrovascular disease ? Smoking-related conditions ? Type II diabetes ? Cancer ? Education intervention ? Physical therapist involved   Methods: Search Strategy  ? Remove duplicates then examine full text articles ? Confirm inclusion screening criteria ? Apply data abstraction  Methods: Data Abstraction ? Overview: ? Open-ended answers ? Narrative synthesis ? Examined various study designs ? Oxford Levels of Evidence Methods: Data Abstraction Quality Assessment ? PEDro ? Validated, Physiotherapy directed 14,15 ? Most studies scored poorly ? Surveys ? Uncommon study designs ? Quasi-experimental ? Prospective Interventional Study Results ? 8 articles were retrieved ? 5 from search of databases ? 3 from reference-mining  ? Study Design ? 3 RCTs ? 3 Surveys ? 1 quasi-experimental study ? 1 prospective interventional study   Included Articles Author Year Molenaar et al.16 2010 Laitakari et al.17 1997 Taylor et al.18 2009 Shirley et al.19 2010 Miilunpalo et al.20 1995 Hollis et al.21 2005 Sheedy et al.22 2000 Eriksson et al.23 2006 Results ? Publication dates ? 1995 ? 2010  ? Location of study ? 2 Finland, the Netherlands, Sweden, England ? United States of America ? 2 Australia Participants ? 4 papers focused on patients16,18,21,23 ? 3 papers focused on physiotherapists 17,19,20 ? 1 paper looked at both patient and physiotherapist 22   Results: Interventions Role of the Physical Therapist ? Primarily educators for exercise-based interventions 16-23 ? Increasing physical activity for better health19-22 ? Using exercise as a treatment to reduce risk factors 16-23 Educational Strategy Components Theories ? Transtheoretical Model of Change ? Identified in 3 studies19, 22, 23 ? Can be used as assessment to tailor intervention and outcome measure ? 5As strategy for health behaviour counseling 18 ? Address the agenda, assess, advise, assist and arrange follow up  Timing: Pre-Assessment  ? Strength, exercise capacity, anthropometrics16,18,21,23  ? Used as outcome measures ? Used to create individualized exercise programs ? Previous physical activity habits16,18,22,23 ? Stage of Change18,22,23 ? Smoking habits23    Timing: Pre-Assessment ? Physical therapists reported being more comfortable with assessment for exercise-related interventions than for general healthy lifestyle counseling17 Timing: Follow-up ? Varied between studies ? Some only re-evaluated outcome measures16,21,22 ? Others provided more comprehensive telephone or group counseling sessions18,23 Timing: Follow-up ? More than 60% of professionals surveyed rated follow-up as difficult ? only 5% rated this item as easy17 Session Structure: Brief Advice and Discussion ? Educational counseling provided as a brief addendum to other intervention sessions ? Found in four studies17,19,20,22   ? The majority of physical therapists use short advice and encouragement for health education daily or nearly daily17  ? 97% of physical therapists* believe brief counseling is feasible to improve physical activity levels19  Session Structure: Counseling Methods ? Face-to-face or one-on-one counseling was found in three studies16,18,23 ? Group counseling found in two studies 21,23 ?   Physical therapists rated feasibility19 ? Separate consultations (63%) vs. group sessions (60%) Technique: Motivational Prompts ? Found in five Studies16,17,18,22,23  ? Prompts used most frequently17: ? Health and general fitness enhancement ? Prevention of disease and reduction of risks ? Decreasing symptoms and feeling well ? Work and functional capacity ? Enjoyment of life and recreation Technique: Identification of Barriers and Problem Solving ? Found in two studies22,23  ? Counseling sessions included identification of barriers to activity and exploration of strategies to handle threats22,23  Technique: Individualized Plans and Goal Setting ? Developing personalized exercise programs was found in five studies16,17,18,21,23 ? Goal-setting was found in three studies16,22,23  ? Perceived ease17: ? 40% of physical therapists reported ?devising a personal program to change health habits? as difficult ? However, most thought that devising a personal exercise plan as easy Delivery Media: Handouts, Brochures and Diaries ? Found in six studies17,18,19,20,21,22  ? Participants were provided with:  ? Written copies of prescribed exercise program18,21,22 ? Brochures for promotion of physical activity22 ? Physical activity diaries22  ? Frequency: ? Handing out written materials occurred in 14% of patient contacts20 ? The majority of physical therapists gave and explained handouts to patients at least once a week17 Delivery Media: Brochures and Diaries ? 52% of participants who were given a brochure recalled receiving it and 48% reported reading it22  ? 80% of those participants who were given an exercise diary recalled receiving it ? Median completion time 3 weeks (total possible 6 weeks)22 Delivery Medium: Skills Training ? Found in five studies17,18,20,21,23  ? Skill training regarding proper exercise technique18,21,23  ? Physical therapist reported use of skill training:  ? Is included in  45% of patient contacts involving counseling20 ? Most physical therapists used skills training daily or nearly daily17 Delivery Media: Visual Model/Presentation ? Found in three studies17,20,21 ? Video demonstrating technique21  ? Frequency: ? Used as a method of counseling in 23% of patient contacts20 ? 60% reported using visual models or demonstrations at least once a week17  Theory Timing Session Structure Technique Delivery Medium Transtheoretical Model 5 A?s Strategy Pre-Ax Post-Ax Follow-Up Brief Advice / Discussion One-on-one Group Session Telephone Motivational Prompts Individualized Programs Goal-Setting Brochures / Handouts Diaries A/V or Video Skills Demonstration RCTs Eriksson et al. (2006) ? ? ? ? ? ? ? ? Molenaar et al. (2010) ? ? ? ? ? Taylor et al. (2009) ? ? ? ? ? ? ? ? ? ? Surveys Laitakari et al. (1997) ? ? ? ? ? ? ? ? ? Miilunpalo et al. (1995) ? ? ? ? Shirley et al. (2010) ? ? ? ? Other Hollis et al. (2004) ? ? ? Sheedy et al. (2000) ? ? ? ? ? ? ? Discussion ? Educational strategies only listed in methods ? No detailed descriptions ? Surveys provided more detail ? Self-reported information  ? Information is lacking in its ability to guide clinical practice  Is exercise enough?  ? Physical therapists identified as exercise specialists16-23  ? Physical therapists may not address other lifestyle-related conditions as frequently17  ? The goals of our educational interventions must be broadened beyond exercise    Changing the focus of education ? Well-recognized3,12,13  ? Educational strategies used by other health professionals are similar to what was found in our review   ? Further research to determine if physical therapy training is suitable  Brochures ? Educational strategy favored by physical therapists19   ? Only half of participants who received brochures recalled receiving them21  ? Further research to determine effectiveness Future Research ? What strategies are actually being used in practice  ? Effectiveness of educational strategies  ? Cost-effectiveness of various strategies  ? Adequate training to utilize strategies employed by other health professionals  Limitations ? Full text limit applied ? Inconsistent application of inclusion criteria at full text evaluation stage ? Data abstraction was not applied to all full texts ? Quality assessment tool was not appropriate for all included studies Thank You! Ms. Charlotte Beck and  Dr. Elizabeth Dean   ?The smallest act of kindness is worth more than the grandest intention.?  Questions? References ? (1) Pruitt SD, Epping-Jordan JE. Preparing the 21st century global healthcare workforce. BMJ 2005 March 19;330(7492):637-639.  ? (2) Romanow RJ. Building on values: the future of health care in Canada. : Commission on the Future of Health Care in Canada; 2002.  ? (3) Dean E. Physical therapy in the 21st century (Part I): Toward practice informed by epidemiology and the crisis of lifestyle conditions. Physiotherapy Theory and Practice 2009;25(5-6):330-353.  ? (4) Public Health Agency of Canada (2009a). Obesity in Canada - Snapshot. Retrieved from: <accessed July 24, 2010>.  ? (5) Public Health Agency of Canada (2009b). Tracking Heart Disease & Stroke In Canada 2009. Retrieved from: <accessed July 24, 2010>.  ? (6) Canadian Diabetes Association (2009). An economic tsunami: the cost of diabetes in Canada December 2009. Retrieved from: <accessed July 28 2010>.  ? (7) Reid, J.L. & Hammond, D. (2009) Tobacco Use in Canada: Patterns and Trends, 2009 Edition (V2). Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. Retrieved from <accessed July 25, 2010>.  ? (8) Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004 March 10;291(10):1238-1245.  ? (9) Canadian Cancer Society (May 19, 2009). General Cancer Statistics for 2010. Retrieved from: lang=en. <accessed July 29, 2010>.  ? (10) Bodner ME, Dean E. Advice as a smoking cessation strategy: A systematic review and implications for physical therapists. Physiotherapy Theory and Practice 2009 01/01;25(5-6):369-407.  ? (11) Rollnick S, Mason P, Butler C. Health behavior change: a guide for practitioners. : Elsevier Health Sciences; 1999.  ? (12) Dean E. Physical therapy in the 21st century (part II): evidence-based practice within the context of evidence-informed practice. PHYSIOTHER THEORY PRACT 2009 07;25(5-6):354-368.   References ? (13) Verhagen E, Engbers L. The physical therapist's role in physical activity promotion. BJSM online 2009 Feb;43(2):99-101.  ? (14) Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 2003 08;83(8):713-721.  ? (15) de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 2009;55(2):129-133.  ? (16) Molenaar EA, van Ameijden EJ, Vergouwe Y, Grobbee DE, Numans ME. Effect of nutritional counselling and nutritional plus exercise counselling in overweight adults: a randomized trial in multidisciplinary primary care practice. Fam Pract 2010 Apr;27(2):143-150.  ? (17) Laitakari J, Miilunpalo S, Vuori I. The process and methods of health counseling by primary health care personnel in Finland: a national survey. Patient Educ Couns 1997 Jan;30(1):61-70.  ? (18) Taylor JD, Fletcher JP, Tiarks J. Impact of physical therapist-directed exercise counseling combined with fitness center-based exercise training on muscular strength and exercise capacity in people with type 2 diabetes: a randomized clinical trial. Phys Ther 2009 Sep 2009;89(9):884-892.  ? (19) Shirley D, van der Ploeg HP, Bauman AE. Physical activity promotion in the physical therapy setting: perspectives from practitioners and students. Phys Ther 2010 Sep;90(9):1311-1322.  ? (20) Miilunpalo S, Laitakari J, Vuori I. Strengths and weaknesses in health counseling in Finnish primary health care. Patient Educ Couns 1995 7;25(3):317-328.  ? (21) Hollis J, Corden E, Williams PF. Longitudinal evaluation of a weight reduction program for patients on peritoneal dialysis. Peritoneal Dialysis International 2005;25(SUPPL. 3) (pp S152-S154):ate of Pubaton: Feb 2005.  ? (22) Sheedy J, Smith B, Bauman A, Barnett A, Calderan A, Culbert J, et al. A controlled trial of behavioural education to promote exercise among physiotherapy outpatients. Australian Journal of Physiotherapy 2000 2000;46(4):281-289.  ? (23) Margareta Eriksson K, Westborg C, Eliasson MCE. A randomized trial of lifestyle intervention in primary healthcare for the modification of cardiovascular risk factors. Scand J Public Health 2006 10;34(5):453-461.   


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