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research-article2014
CNU0010.1177/1474515114521725European Journal of Cardiovascular NursingYlimäki et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original Article
The effects of a counselling intervention on lifestyle change in people at risk of cardiovascular disease
European Journal of Cardiovascular Nursing 2015, Vol. 14(2) 153–161 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515114521725 cnu.sagepub.com
Eeva-Leena Ylimäki1, Outi Kanste2, Hanna Heikkinen1, Risto Bloigu1 and Helvi Kyngäs1,3
Abstract Background: The study assessed the effects of a counselling intervention on lifestyle changes in certain-aged people at risk of cardiovascular disease. Design and methods: This was an intervention study at baseline and six- and 12-month follow-ups. The participants were 40 years old (n= 53 at baseline, n=33 at six months and n=34 at 12 months). The main outcomes were cardiovascular health parameters, such as weight, BMI, waist circumference, blood pressure, cholesterol (total, high density lipoprotein, low density lipoprotein), blood glucose, and self-assessed and reported lifestyle and adherence to lifestyle changes. The counselling intervention was Internet-based and carried out via Skype or face-to-face in small groups (on average, six participants). Results: There were statistically significant differences between the baseline and the 12-month follow-up with respect to the consumption of fat and snacks. Some positive cardiovascular health improvements were detected between baseline and six months, but not as clearly between baseline and 12 months. The participants reported having a healthier diet at 12 months than at baseline. At 12 months, BMI measurements indicated that all participants were overweight (mean BMI 29.8), but according to the self-assessed data, only 25% considered themselves to be so. Conclusions: Changes in lifestyle were detected as a result of the intervention. These lifestyle changes may improve cardiovascular health in the long term. Discrepancies were found between the measured indicators of cardiovascular health and information obtained from questionnaires and diary records. In order to achieve sustainable lifestyle changes, long-term support is required. Keywords Cardiovascular health, cardiovascular risk, adherence, lifestyle, counselling intervention Received 22 April 2013; revised 27 November 2013; revised manuscript accepted 30 December 2013
Introduction Counselling is a very common intervention method used to encourage individuals to adopt a healthier lifestyle. Most interventions are focused on diet, exercise and smoking. People at risk of cardiovascular disease need to change their lifestyle. They are a special target group for counselling interventions because by changing their lifestyle, their risk of cardiovascular disease can be decreased. However, there is no consensus about the type of intervention that is most effective. According to some studies, short interventions are effective in achieving changes in lifestyle, while others recommend long-lasting interventions.1–4 However,
it is known that a successful lifestyle change intervention includes self-monitoring, feedback and problem-solving, as well as motivation and support.4,5 Some studies question 1University
of Oulu, Finland Institute for Health and Welfare, Oulu, Finland 3Northern Ostrobothnia Hospital District, Finland 2National
Corresponding author: Eeva-Leena Ylimäki, University of Oulu, Institute of Health Sciences, Peikontie 1B19, 90550 OULU, Finland. Email: [email protected]
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the possibility of achieving a large number of lifestyle changes at the same time and during a single intervention.5,6 In this study, the emphasis is on minor step-by-step changes and two follow-ups. Adherence to a healthy lifestyle decreases the risk of cardiovascular disease.4,7–9 People who commit to lifestyle changes can positively influence their cardiovascular health. High self-efficacy is associated with good adherence, but high self-efficacy is also required to begin to change one’s lifestyle.10–13
Purpose of the study In Finnish basic health care, new and more advanced health practices are usually introduced and developed through specially designed projects. These projects aim at improving preventative care in order to improve overall health. This study setup was determined by such a specific cardiovascular health project implemented in Lapland, Finland. This study assessed the effects of a counselling intervention on lifestyle change in certain-aged people at risk of cardiovascular disease. The research took the form of an evaluating intervention study, which consisted of health parameter measurements, lifestyle questionnaires and records at baseline, six-month follow-up and 12-month follow-up set by the project. The goal of the intervention was to help participants recognize the factors which maintain and threaten their health and to motivate and support them to adopt lifestyle changes that would lead to a healthier life.
Methods Study population This study material was gathered from a cardiovascular health project in Lapland, Finland, which aimed at identifying certain-aged individuals at risk of cardiovascular disease via a screening process. Twenty-one municipalities were invited to take part in the project and eight of them decided to participate. Those inhabitants who turned 40 years during the project in these municipalities (n=571) were invited by health centres and the Heart Disease Association to attend screenings. Of these, 286 (51%) participated in the screening, and 98 participants were identified with a risk of cardiovascular disease. These 98 participants with the identified risk were then invited to take part in the intervention. Of these, 76 (78%) volunteered for the intervention, and of these, 53 participants also agreed to take part in this research (Figure 1). Table 1 lists the study material and Table 2 shows background information about the participants.
Screening In the screening appointment, cardiovascular health was measured using blood tests for cholesterol (total,
high-density lipoprotein (HDL) and low-density lipoprotein (LDL)) and plasma glucose and by measuring blood pressure. In addition, weight, height, waist circumference and calculated body mass index (BMI) were measured. All measurements were carried out by health care professionals.
Counselling intervention Public health nurses and nurses in the municipalities were trained to deliver the counselling. The counselling intervention method used in this study was based on a constructivist learning approach. The intervention participants (n=76) were divided into nine groups (on average six members each). An Internet-based learning environment and Skype were used for counselling because Lapland is very sparsely populated (about four people per square kilometre) and therefore it was not convenient to arrange faceto-face meetings for all groups. However, two groups had face-to-face counselling due to technical problems. Nevertheless, the intervention protocol was exactly the same in all groups, irrespective of the delivery method. The groups had counselling sessions once a week for 10 weeks. Each of them lasted 60–90 minutes, depending on the activity of group members. The sessions addressed the following subjects: diet, exercise, cardiovascular health, smoking, alcohol consumption and emotional well-being. In the learning environment, new information about these subjects and new standardized tests to be completed by the participants were posted every week. The goal of the tests, which were related to diet, alcohol and tobacco use and exercise, was to help participants recognize their current lifestyle and the need for the change.
Self-assessed lifestyle In this study, self-assessment refers to a situation where participants choose the most suitable answer of the given options in the questionnaire according to their own feeling. The lifestyle questionnaire measured participants’ perceptions regarding their weight and how it changed, exercise, health condition, diet, alcohol consumption and cigarette use. The questionnaire was based on the Finrisk questionnaire, which is commonly used in Finland to evaluate lifestyle. Questions were multiple-choice with two to five alternatives.
Adherence to lifestyle change Another self-assessment questionnaire was also used. The 41-item adherence to lifestyle change questionnaire used a Likert-type scale. It included items on the following topics: adherence to instructions to achieve a healthy lifestyle, responsibility and voluntary nature of lifestyle change, the significance of lifestyle change, desire to adopt a healthy
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571 were invited to screening by the project
268 par cipated in screening
98 were iden fied with a risk of cardiovascular disease
76 of those with the iden fied risk wanted to take part in the interven on
22 did not take part in the interven on (due to lack of me or not seeing the benefit)
53 volunteered for the study and gave permission to u lize data in the study
12-month follow-up
6-month follow-up
33 par cipated in the six-month follow-up
20 did not par cipate in the six-month follow-up
23 took part in the interven on but did not want to commit to the study
34 par cipated in the 12- month follow-up
19 did not par cipate in the 12-month follow-up
Figure 1. Forming the study population as part of the cardiovascular health project. Table 1. Study material at baseline, six-month follow-up and 12-month follow-up. Measurements Blood tests Lifestyle questionnaire Adherence to lifestyle change questionnaire Record of exercise Record of diet
lifestyle, self-efficacy, readiness for change and prejudice against change, support from family members, friends and leaders of the counselling group and motivation for lifestyle change. The adherence to lifestyle change questionnaire instrument had been tested and used in earlier studies
to evaluate adherence of patients with a chronic disease and to assess their lifestyle. The construct validity and reliability of the adherence questionnaire have been found to be good.14,15 In the present study, reliability based on Cronbach alpha values varied between .65 and .75.
Self-reporting Self-reporting in this study refers to participants’ records on physical activity and diet based on the actualized amounts. A record of diet was kept for four days, of which one had to be at the weekend. Participants reported in the diary meal times, situation and location, what was consumed, the amount of fruit eaten and the size of portions according to the commonly used plate model. The plate
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Table 2. Distribution of socio-demographic characteristics (n=53).
Marital status Married/cohabiting Other Education level Low Medium High Employment status Manual paid work Non-manual paid work Unemployed Work situation at the moment At work Does not work Medical consultation during the last year 0 1–2 >3 During the past year diagnosed with a medical condition and/or manages condition ardiovascular disease and C associated risks Other conditions (e.g. cancer, spinal injury) No illnesses Number of children 0 1–2 >3
n
%
46 7
87 13
27 17 9
51 32 17
16 24 13
31 46 23
40 13
76 25
18 19 14
35 37 27
14
29
8
17
26
54
12 26 15
23 49 28
model is formed so that half of the plate is filled with vegetables or salad, one fourth with rice, potato or pasta and one fourth with meat, fish or chicken. The participants also kept a record of physical activity for four weeks (28 days). Physical activity was a combination of everyday physical activity and physical fitness.
Outcome measures The main outcomes were the parameters measuring cardiovascular health, self-assessed lifestyle characteristics, self-reported diet and physical activity records and level of adherence to lifestyle change. We obtained information on cardiovascular health from 53 participants at baseline, from 33 at six months and from 34 at 12 months. At baseline, 53 participants returned the lifestyle questionnaire; the figures at six months and 12 months were 20 and 28, respectively. The adherence to lifestyle change questionnaire was returned by 45 participants at baseline, by 24 at six months and 25 at 12 months. In addition, diet and
physical activity records were both returned by the same participants (n=39 at baseline, n=26 at six months, n=19 at 12 months).
Statistical analyses The analysis was conducted using SPSS 15.0 (SPSS for Windows, Rel. 15.0.1. 2008. SPSS Inc., Chicago, USA). Means and medians were calculated. The background information of men and women was compared using Fisher’s Exact Test. A paired sample t-test was used to compare the baseline with the six-month and 12-month followup scores. In addition, the differences between variables at baseline and follow-up were examined using Fisher’s Exact Test, the Wilcoxon signed rank test, the Mann–Whitney test and the Marginal Homogeneity test. The threshold for statistical significance was set at p=0.05. Significance values between 0.05 and 0.1 were treated as suggestive. Diet records were analysed by a dietician using the Micro-Nutrica Nutritional Analysis Program. Exercise records were analysed by physiotherapists with an MA in sport sciences.
Results Cardiovascular health Table 3 shows the values of the parameters relating to cardiovascular health. No statistically significant differences were found in these parameters between baseline and six or 12 months. However, weight and diastolic blood pressure were lower at 12 months than at baseline. The overall trend was that indicators of cardiovascular health improved between baseline and six months to some extent, but the values between baseline and 12 months were very close to each other (Table 3).
Self-assessed lifestyle At 12 months, there were more participants who considered themselves to be overweight (p=0.083) than at baseline and at six months. Participants assessed that their health condition (p=0.025) and physical condition (p=0.034) were better at 12 months than at six months. Everyday activity increased between baseline and six months (p=0.035) and between baseline and 12 months (p=0.072) (Table 4). Table 4 shows that participants assessed that they ate a healthier diet at 12 months than at baseline. There was a statistically significant difference in lifestyle at baseline and at 12 months with respect to eating snacks (p=0.019), using the plate model to create a healthy meal (p=0.003) and in the number of participants who read through the product description on grocery packages (p=0.025). Participants assessed that they were eating at least 500 g of
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Ylimäki et al. Table 3. Cardiovascular health at baseline (n=53), six months (n=33) and 12 months (n=34).
Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Total cholesterol (mmol/l) HDL-cholesterol (mmol/l) LDL-cholesterol (mmol/l) Diabetes risk score Glucose (mmol/l) Weight (kg) BMI
Variable
Baseline
Six months
12 months
Mean
Median
±SD
Mean
Median
± SD
Mean
Median
± SD
132 87 5.2 1.32 3.26 9 5.35 89.7 30.4
129 86 5.2 1.28 3.26 10 5.35 88.6 30.4
16.5 12.6 1.0 0.31 0.66 4.3 0.48 19.8 5.4
131 85 4.9 1.36 3.14 10 5.49 87.1 29.5
133 86 4.9 1.32 2.99 11 5.47 82.8 28.4
16.5 1.2 0.8 0.36 0.78 4.05 0.50 22.2 5.7
131 83 5.0 1.36 3.19 9 5.43 88.1 29.8
132 82 5.0 1.36 3.09 9 5.4 84.3 30.3
16.5 9.2 0.7 0.35 0.71 4.05 0.49 22.9 5.9
HDL: high-density lipoprotein; LDL: low-density lipoprotein; BMI: body mass index.
vegetables per day (p=0.058) and using more soft fat (p=0.070) at six months than at baseline. In addition, between six months and 12 months the participants assessed that they were using more low fat cheese (p=0.096) but smaller amounts of low fat cold cuts (p=0.083). Participants assessed that they consumed alcohol more than three times a week at six months and at 12 months (p=0.083) (Table 4).
Self-reported diet and physical activity records According to the exercise records, the amount of everyday activity decreased. More time was allocated to fitness activities at 12 months compared with the baseline. Based on the diet records, the overall trend was that diet was healthier at six months than at baseline, but at 12 months it was very similar to that recorded at baseline. Based on the records, participants consumed more fibre (p=0.020) and berries (p =0.041) at 12 months than at baseline. Folate intake was significantly increased between baseline and 12 months (p= 0.006) (Table 5).
Adherence to lifestyle changes Table 6 shows participants’ adherence to lifestyle changes. Participants had a great urge to take care of themselves and they felt responsibility for their personal health at baseline. Preparedness for change increased between the baseline and 12-month follow-up. Adherence to the given advice and guidance on lifestyle changes was significantly decreased when compared between the baseline and 12-month follow-up (baseline 52%, 12-month follow-up 4%). At the 12-month follow-up, 15% of the participants felt concern over their way of life whereas 39% of the participants were concerned at baseline. In comparison with the baseline, participants experienced a significant decrease in family and friends’ support at six months (baseline 75%, six months 4%), whereas the support increased again at 12 months. However, participants felt
more ready and open-minded about the change at 12 months (Table 6).
Discussion and conclusions Discussion The results of the study are very similar to those reported in earlier studies.1,2,4,7 In the present study, like previous studies, minor changes in lifestyle have been achieved with a counselling intervention. An interesting finding was that participants assessed that they adhered well to lifestyle change and that they were ready for it and willing to do it. The intervention aimed to support participants’ selfmanagement; indeed, in some studies, this kind of intervention has had positive effects on cardiovascular health.16,17 There was health-improving progress in selfassessed health condition and physical activity. In addition, an increased number of participants considered that diet affects well-being and that they were applying the plate model in everyday diet. Nevertheless, some indicators of cardiovascular health, for example, cholesterol level, improved between the baseline and the six-month follow-up, but were very close to the baseline values at 12 months. A positive trend at six months but no longer at 12 months may be an indication of people having initial enthusiasm towards the change. Most participants assessed in the lifestyle questionnaire that they were in good health although the measured cardiovascular health parameters did not indicate that. Only 25% of the participants considered themselves to be obese at the 12-month follow-up although their BMI indicated that they were obese; 75% considered themselves to be normal weight or slightly overweight although they were obese. It is known that one crucial factor motivating people to adopt lifestyle change is that they feel unhealthy.18 This may be the most important finding in this research. The main reason why the applied lifestyle changes were not more significant and sustainable is that people were
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Table 4. Participants' self-assessed lifestyle at baseline (n=53), six months (n=20) and 12 months (n=28). Variable
Baseline
Six months
12 months
p-value
%
%
%
Baseline– Six months– six months 12 months
Baseline– 12 months
54.9 37.3
70.0 10.0
57.1 25.0
42.6 38.3 19.1
31.6 26.3 42.1
22.2 33.3 44.4
NS NS NS NS NS NS NS
0.083 NS NS NS NS NS NS
57.7 54.7 32.7 28.3
50.0 55.0 45.0 60.0
75.0 57.1 57.1 42.9
NS 0.035 NS NS
0.025 NS NS 0.034
41.5 45.3 84.9 64.2 13.2 54.7 51.9 34.0 56.6 26.4 43.3 24.5 62.3
40.0 40.0 90.0 90.0 25.0 45.0 61.9 40.0 75.0 21.1 25.0 45.0 90.0
48.1 22.2 92.9 89.3 32.1 53.6 57.1 50.0 57.1 25.9 21.4 42.9 78.6
NS NS NS 0.058 0.058 NS 0.070 NS NS NS NS NS 0.046
NS NS NS NS NS NS NS 0.096 0.083 NS NS 0.096 NS
51.9 30.8
40.0 35.0
39.3 35.7
38.8 28.6
44.4 44.4
30.8 38.5
NS NS NS NS NS NS
0.083 NS NS NS NS NS
40.0 28.0
16.7 16.7
46.2 23.1
NS NS
NS NS
NS NS NS NS NS NS NS NS 0.072 NS NS NS NS NS NS NS NS NS NS NS NS 0.019 0.003 0.025 NS NS NS NS NS NS NS NS
Opinion on weight Slightly overweight Obese Changes in weight Has increased in the last year Has stayed the same in the last year Has decreased in the last year Exercise and health Very or quite good 3–4 hours of everyday activities a week 2–3 hours of fitness activities a week for 20–60 min Satisfactory physical condition Diet 1–2 meals and snacks a day 3–4 meals and snacks a day Diet affects well-being Eats a fairly healthy diet, or a rather healthy diet Eats 500 g of vegetables a day Uses light and soft fat products on bread Uses soft fats when preparing food Mainly uses low-fat cheese Mainly uses low-fat cold-cuts Uses bread with fibre content above 10 g/100 g Eats sugary and fatty snacks daily Uses the plate model when putting together a meal Reads through the descriptions on grocery packages Alcohol Alcohol usage Once a month or less often 2–4 times a month Amount consumed when drinking 0–1 units 3–4 units Alcohol percentage of drink 2.9–4.7% >4.4%
p-value
p-value
*Marginal Homogeneity test.
not aware of their true health condition. Also socio-economic status and amount of stress have an impact on how willing one is to adopt treatment and lifestyle change. After the intervention, concern over the current way of life decreased strongly, particularly at 12-month follow-up. According to earlier studies, support from friends and family is necessary to help people adopt lifestyle changes and maintain a healthy lifestyle.11,19 During the present study, support from family members and friends was good at the beginning but decreased during the study period. It should be noted that initially group members were the more important source of support but after intervention,
the role of the health care provider leading the group was emphasized. At the end of the intervention, all participants felt that they received support from other group members. Since the beginning of the intervention, participants felt the urge to take care of themselves and felt personal responsibility for their health. Adherence to the advice and guidance was significantly decreased after the intervention, together with the experienced self-efficacy. Experienced self-efficacy has been shown to have a strong correlation with implementing a healthy lifestyle, such as reduction of fat and better physical performance.20,21 However, following advice and instructions may be felt to
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Ylimäki et al. Table 5. Diet according to diary records (baseline, n=39; six months, n=33; 12 months, n=19). Variable
Baseline
Six months
12 months
0–12
Mean
Median
±SD
Mean
Median
±SD
Mean
Median
±SD
p-value*
Total energy (kcal) Total fats (E%) Saturated fats (E%) Monounsaturated fats (E%) Polyunsaturated fats (E%) Protein (E%) Carbohydrates (E%) Fibre (g) Cholesterol (mg) Vitamin C (mg) Vitamin D (mg) Folic acid (µg) Sodium (mg) Vegetables (g) Fruit (g) Berries (g) Root vegetables (g) Green vegetables (g) Nuts and pulses (g) Potatoes (g)
1692 35 13 11 5.5 19 44 19.5 242 71 6.1 227 3941 261 106 19 25 97 2 87
1669 7.01 3.58 3.03 1.3 2.9 8.09 6.9 107.3 36,6 3.6 64.8 941 126.5 70.75 31.8 31 61.53 3.84 56.2
486 34 13 11 6 19.5 44 19.6 230 72 5.6 214 2690 265.6 102 0 17 88 0.5 78.5
1553 34 11 11 6 19 46 20 203 82 5.7 236 2766 290 112 25 27 106 6 80
1489 6 6.6 3.5 2.1 1.52 3.9 7.1 7.09 85,4 61.3 4.21 87.7 920 157.7 95.9 33.4 31.9 75.3 13.3 48.0
451 32 11 11 5 19 47 20 184 64 4.8 202 2572 273 98.5 18 17 87 0 89
1713 35 14 11 5 19 44 22 290 85 5.3 270 2849 284 105 26 36 103 6.4 84
1696 6.7 3.32 2.85 1.88 2.98 8.85 9 130.7 66.6 2.2 88.1 1035 170.4 131.2 35.98 45.9 68.5 16.1 51.9
531 34 13 11 5 20 42 22 257 65 5.2 253 2703 260 33 11 25 61 0.8 52
NS NS NS NS NS NS NS 0.020 NS NS NS 0.006 NS NS NS 0.041 NS NS NS NS
*Wilcoxon signed rank test.
Table 6. Adherence to lifestyle change (baseline, n=45; six months, n =24; 12 months, n=25). Average adherence per item
Adherence to instructions Voluntary nature of lifestyle change Significance of lifestyle change Desire to take care of oneself Responsibility for personal health Self-efficacy Readiness for change Open-mindedness about change Support of family and friends Expectations on leader’s support and motivation Expectations on group’s support and motivation Motivation for lifestyle change and self-treatment Concerned about the current ways of life
Baseline
Six months
12 months
(%)*
(%)*
(%)*
52 82 80 95 93 66 82 84 75 75 86 80 39
8 64 44 96 92 48 88 88 4 72 76 76 36
4 69 77 89 96 42 89 88 23 77 50 69 15
*At least 4 in scale 1–5.
be an overload if trying to implement several changes at the same time5,6 and, consequently, self-efficacy may be affected. From a methodological perspective, an interesting finding was that there was a discrepancy between the measured cardiovascular health and self-assessed health. There was also a discrepancy between diary and physical activity records and the self-assessed questionnaire answers.
Earlier studies have come up with the same finding.22 It has been suggested that overweight people tend to evaluate the level of physical activity as much higher and diet healthier than they actually are when recorded.23–26 This also reflects the situation in the current study. These conflicts raise questions about how to collect data in order to study lifestyle due to the possibility of under-reporting and over-reporting. However, self-assessment information is
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very important because it represents people’s own perspectives of their lifestyles. It is known that personal perspective underlies the choices that people make. Method-wise, another issue to take into account in intervention studies is the possible Hawthorne effect, which refers to the effect of being under observation.27 This may affect result interpretation and generalization. Some studies question the feasibility of having a large number of lifestyle changes implemented at the same time and during the same intervention.5,6 Generally, lifestyle change interventions focus on gradual step-by-step changes with a long follow-up time. In the present study, the follow-up time was 12 months. Several interventions and longer follow-up periods may be required in order to integrate lifestyle changes in everyday life. Between the baseline and the end of the intervention there were some statistically significant changes in the participants’ self-assessed lifestyles. However, these changes were not observed in the direct measurement parameters, such as weight or cholesterol level. Consequently, it is unknown whether the self-assessed changes can improve cardiovascular health over the long term. Alternatively, this may be an indication that people are able to implement gradual changes and progress step by step. Overall, one of the biggest challenges in intervention studies and the effectiveness of intervention as a method is how to motivate people with the highest health risk to participate and commit to lifestyle change. The intervention model used in the project and in this study has shown positive experiences and implementations in preventative health care in Finland. It has become a sustainable health care practice in several Finnish municipalities.
Strengths and limitations of the study One strength of the study was the multifaceted data collection approach, which provides a versatile view on lifestyle changes and effects of counselling intervention. The questionnaires had been used previously and were found to have high validity and reliability. The cardiovascular health parameters are also valid because they were measured and collected by dedicated health care professionals at official laboratories according with the Finnish health care standards. Overall, the project setup affected the study population due to the voluntary nature. First, lack of health care resources limited the number of participating municipalities. Second, people who took part in the initial screenings, in the intervention and in this study showed interest and motivation towards their health. This all may have an effect on the generalization of the results. Some of the participants did not join the six- and 12-month follow-ups but these participants were consistent in their absence from all follow-ups. These absent participants were mostly highrisk patients who were directed to special individual care.
Few participants dropped out of the follow-up meetings due to the scheduling of the meetings. However, the background information of the participants and the dropouts were compared and no significant differences were found. Consequently, the loss of participants during the study period did not have an effect on the interpretation of the results. Due to the type of study and the project setup, there was no intention to set up a control group. Indeed, the purpose was to evaluate the effect of counselling intervention on all volunteering participants with identified risk.
Ethical aspects Permission to conduct this study was given by the medical director of participating municipalities. The principles of the Declaration of Helsinki were followed. In the covering letter attached to the questionnaire it was emphasized that participation in the study was voluntary.
Conclusions We found that the intervention had significant effects on lifestyle changes with respect to eating snacks, using the plate model to create healthy meals and reading the product descriptions on grocery packages. Furthermore, some positive cardiovascular health improvements were detected between baseline and six months, but not as clearly between baseline and 12 months. Participants assessed that they had a healthier diet at 12 months than at baseline and that their motivation and self-efficacy were good, although there were only minor changes in diet. This indicates that eating behaviour and habits are likely to change gradually. Making lifestyle changes is a big challenge for individuals who consider that they do not have any health problems, which is possibly the biggest challenge in the effectiveness of counselling intervention. In order to achieve adherence to lifestyle change, people need both long-term support from family and friends and counselling from specialized health care professionals.
Implications for practice •• Current Internet technology provides effective means of counselling intervention, for example, Skype calls and Internet-based questionnaires can be used regardless of time or place. •• People at risk of cardiovascular disease benefit from counselling intervention, that is, the risk can be decreased and overall health improved. Conflict of interest The authors declare that there is no conflict of interest.
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Ylimäki et al. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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14. Kyngäs HA, Skaar-Chandler CA and Duffy ME. The development of instrumental to measure the compliance of adolescents with a chronic disease. J Adv Nurs 2000; 32: 1499–1506. 15. Lunnela J, Kyngäs H and Hupli M. Compliance of a patient with glaucoma and associated factors (Finnish) Hoitotiede 2006; 18: 151–159. 16. Sol BGM, van der Graaf Y, Brouwer B, et al. The effect of a self-management intervention to reduce vascular risk factors in patients with manifestations of vascular diseases. Eur J Cardiovasc Nurs 2010; 9: 132–139. 17. Ferrier S, Blanchard CM, Vallis M, et al. Behavioural interventions to increase the physical activity of cardiac patients: A review. Eur J Cardiovasc Prev Rehabil 2011; 18: 15–32. 18. Lakerveld J, Ijzelenberg W, van Tulder M, et al. Motives for (not) participating in a lifestyle intervention trial. BMC Med Res Methodol 2007; 34: 304–312. 19. Fischer Aggarwal BA, Liao M and Mosca L. Physical activity as a potential mechanism through which social support may reduce cardiovascular disease risk. J Cardiovasc Nurs 2008; 23: 90–96. 20. Aljasem LI, Peyrot M, Wissow L, et al. The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes. Diabetes Educ 2001; 27: 393–404. 21. Richman RM, Loughnan GT, Droulers AM, et al. Self-efficacy in relation to eating behavior among obese and non-obese women. Int J Obes Relat Metab Disord 2001; 25: 907–913. 22. Näslindh-Ylispangar A. Men’s health behavior, health beliefs and need for health counseling. Academic dissertation, University of Helsinki, Finland, 2008. 23. Lichtman SW, Pisarska K, Raynes Berman E, et al. Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. N Engl J Med 1992; 27: 1893–1898. 24. Brener ND, Billy JOG and Grady WR. Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: Evidence from the scientific literature. J Adolesc Health 2003; 33: 436–457. 25. Baily RL, Mitchell DC and Miller C. Assessing the effect of underreporting energy intake on dietary patterns and weight status. J Am Diet Assoc 2007; 107: 64–71. 26. Schelling S, Munsch S, Meyer AH, et al. Increasing the motivation for physical activity in obese patients. Int J Eating Disord 2009; 42: 130–138. 27. Polit DF and Beck CT. Nursing research: Appraising evidence for nursing practice. Philadelphia: Wolter Kluwer Health/Lippincot Williams & Wilkins, 2010, pp.222–257.
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research-article2014
CNU0010.1177/1474515114521725European Journal of Cardiovascular NursingYlimäki et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original Article
The effects of a counselling intervention on lifestyle change in people at risk of cardiovascular disease
European Journal of Cardiovascular Nursing 2015, Vol. 14(2) 153–161 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515114521725 cnu.sagepub.com
Eeva-Leena Ylimäki1, Outi Kanste2, Hanna Heikkinen1, Risto Bloigu1 and Helvi Kyngäs1,3
Abstract Background: The study assessed the effects of a counselling intervention on lifestyle changes in certain-aged people at risk of cardiovascular disease. Design and methods: This was an intervention study at baseline and six- and 12-month follow-ups. The participants were 40 years old (n= 53 at baseline, n=33 at six months and n=34 at 12 months). The main outcomes were cardiovascular health parameters, such as weight, BMI, waist circumference, blood pressure, cholesterol (total, high density lipoprotein, low density lipoprotein), blood glucose, and self-assessed and reported lifestyle and adherence to lifestyle changes. The counselling intervention was Internet-based and carried out via Skype or face-to-face in small groups (on average, six participants). Results: There were statistically significant differences between the baseline and the 12-month follow-up with respect to the consumption of fat and snacks. Some positive cardiovascular health improvements were detected between baseline and six months, but not as clearly between baseline and 12 months. The participants reported having a healthier diet at 12 months than at baseline. At 12 months, BMI measurements indicated that all participants were overweight (mean BMI 29.8), but according to the self-assessed data, only 25% considered themselves to be so. Conclusions: Changes in lifestyle were detected as a result of the intervention. These lifestyle changes may improve cardiovascular health in the long term. Discrepancies were found between the measured indicators of cardiovascular health and information obtained from questionnaires and diary records. In order to achieve sustainable lifestyle changes, long-term support is required. Keywords Cardiovascular health, cardiovascular risk, adherence, lifestyle, counselling intervention Received 22 April 2013; revised 27 November 2013; revised manuscript accepted 30 December 2013
Introduction Counselling is a very common intervention method used to encourage individuals to adopt a healthier lifestyle. Most interventions are focused on diet, exercise and smoking. People at risk of cardiovascular disease need to change their lifestyle. They are a special target group for counselling interventions because by changing their lifestyle, their risk of cardiovascular disease can be decreased. However, there is no consensus about the type of intervention that is most effective. According to some studies, short interventions are effective in achieving changes in lifestyle, while others recommend long-lasting interventions.1–4 However,
it is known that a successful lifestyle change intervention includes self-monitoring, feedback and problem-solving, as well as motivation and support.4,5 Some studies question 1University
of Oulu, Finland Institute for Health and Welfare, Oulu, Finland 3Northern Ostrobothnia Hospital District, Finland 2National
Corresponding author: Eeva-Leena Ylimäki, University of Oulu, Institute of Health Sciences, Peikontie 1B19, 90550 OULU, Finland. Email: [email protected]
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the possibility of achieving a large number of lifestyle changes at the same time and during a single intervention.5,6 In this study, the emphasis is on minor step-by-step changes and two follow-ups. Adherence to a healthy lifestyle decreases the risk of cardiovascular disease.4,7–9 People who commit to lifestyle changes can positively influence their cardiovascular health. High self-efficacy is associated with good adherence, but high self-efficacy is also required to begin to change one’s lifestyle.10–13
Purpose of the study In Finnish basic health care, new and more advanced health practices are usually introduced and developed through specially designed projects. These projects aim at improving preventative care in order to improve overall health. This study setup was determined by such a specific cardiovascular health project implemented in Lapland, Finland. This study assessed the effects of a counselling intervention on lifestyle change in certain-aged people at risk of cardiovascular disease. The research took the form of an evaluating intervention study, which consisted of health parameter measurements, lifestyle questionnaires and records at baseline, six-month follow-up and 12-month follow-up set by the project. The goal of the intervention was to help participants recognize the factors which maintain and threaten their health and to motivate and support them to adopt lifestyle changes that would lead to a healthier life.
Methods Study population This study material was gathered from a cardiovascular health project in Lapland, Finland, which aimed at identifying certain-aged individuals at risk of cardiovascular disease via a screening process. Twenty-one municipalities were invited to take part in the project and eight of them decided to participate. Those inhabitants who turned 40 years during the project in these municipalities (n=571) were invited by health centres and the Heart Disease Association to attend screenings. Of these, 286 (51%) participated in the screening, and 98 participants were identified with a risk of cardiovascular disease. These 98 participants with the identified risk were then invited to take part in the intervention. Of these, 76 (78%) volunteered for the intervention, and of these, 53 participants also agreed to take part in this research (Figure 1). Table 1 lists the study material and Table 2 shows background information about the participants.
Screening In the screening appointment, cardiovascular health was measured using blood tests for cholesterol (total,
high-density lipoprotein (HDL) and low-density lipoprotein (LDL)) and plasma glucose and by measuring blood pressure. In addition, weight, height, waist circumference and calculated body mass index (BMI) were measured. All measurements were carried out by health care professionals.
Counselling intervention Public health nurses and nurses in the municipalities were trained to deliver the counselling. The counselling intervention method used in this study was based on a constructivist learning approach. The intervention participants (n=76) were divided into nine groups (on average six members each). An Internet-based learning environment and Skype were used for counselling because Lapland is very sparsely populated (about four people per square kilometre) and therefore it was not convenient to arrange faceto-face meetings for all groups. However, two groups had face-to-face counselling due to technical problems. Nevertheless, the intervention protocol was exactly the same in all groups, irrespective of the delivery method. The groups had counselling sessions once a week for 10 weeks. Each of them lasted 60–90 minutes, depending on the activity of group members. The sessions addressed the following subjects: diet, exercise, cardiovascular health, smoking, alcohol consumption and emotional well-being. In the learning environment, new information about these subjects and new standardized tests to be completed by the participants were posted every week. The goal of the tests, which were related to diet, alcohol and tobacco use and exercise, was to help participants recognize their current lifestyle and the need for the change.
Self-assessed lifestyle In this study, self-assessment refers to a situation where participants choose the most suitable answer of the given options in the questionnaire according to their own feeling. The lifestyle questionnaire measured participants’ perceptions regarding their weight and how it changed, exercise, health condition, diet, alcohol consumption and cigarette use. The questionnaire was based on the Finrisk questionnaire, which is commonly used in Finland to evaluate lifestyle. Questions were multiple-choice with two to five alternatives.
Adherence to lifestyle change Another self-assessment questionnaire was also used. The 41-item adherence to lifestyle change questionnaire used a Likert-type scale. It included items on the following topics: adherence to instructions to achieve a healthy lifestyle, responsibility and voluntary nature of lifestyle change, the significance of lifestyle change, desire to adopt a healthy
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571 were invited to screening by the project
268 par cipated in screening
98 were iden fied with a risk of cardiovascular disease
76 of those with the iden fied risk wanted to take part in the interven on
22 did not take part in the interven on (due to lack of me or not seeing the benefit)
53 volunteered for the study and gave permission to u lize data in the study
12-month follow-up
6-month follow-up
33 par cipated in the six-month follow-up
20 did not par cipate in the six-month follow-up
23 took part in the interven on but did not want to commit to the study
34 par cipated in the 12- month follow-up
19 did not par cipate in the 12-month follow-up
Figure 1. Forming the study population as part of the cardiovascular health project. Table 1. Study material at baseline, six-month follow-up and 12-month follow-up. Measurements Blood tests Lifestyle questionnaire Adherence to lifestyle change questionnaire Record of exercise Record of diet
lifestyle, self-efficacy, readiness for change and prejudice against change, support from family members, friends and leaders of the counselling group and motivation for lifestyle change. The adherence to lifestyle change questionnaire instrument had been tested and used in earlier studies
to evaluate adherence of patients with a chronic disease and to assess their lifestyle. The construct validity and reliability of the adherence questionnaire have been found to be good.14,15 In the present study, reliability based on Cronbach alpha values varied between .65 and .75.
Self-reporting Self-reporting in this study refers to participants’ records on physical activity and diet based on the actualized amounts. A record of diet was kept for four days, of which one had to be at the weekend. Participants reported in the diary meal times, situation and location, what was consumed, the amount of fruit eaten and the size of portions according to the commonly used plate model. The plate
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Table 2. Distribution of socio-demographic characteristics (n=53).
Marital status Married/cohabiting Other Education level Low Medium High Employment status Manual paid work Non-manual paid work Unemployed Work situation at the moment At work Does not work Medical consultation during the last year 0 1–2 >3 During the past year diagnosed with a medical condition and/or manages condition ardiovascular disease and C associated risks Other conditions (e.g. cancer, spinal injury) No illnesses Number of children 0 1–2 >3
n
%
46 7
87 13
27 17 9
51 32 17
16 24 13
31 46 23
40 13
76 25
18 19 14
35 37 27
14
29
8
17
26
54
12 26 15
23 49 28
model is formed so that half of the plate is filled with vegetables or salad, one fourth with rice, potato or pasta and one fourth with meat, fish or chicken. The participants also kept a record of physical activity for four weeks (28 days). Physical activity was a combination of everyday physical activity and physical fitness.
Outcome measures The main outcomes were the parameters measuring cardiovascular health, self-assessed lifestyle characteristics, self-reported diet and physical activity records and level of adherence to lifestyle change. We obtained information on cardiovascular health from 53 participants at baseline, from 33 at six months and from 34 at 12 months. At baseline, 53 participants returned the lifestyle questionnaire; the figures at six months and 12 months were 20 and 28, respectively. The adherence to lifestyle change questionnaire was returned by 45 participants at baseline, by 24 at six months and 25 at 12 months. In addition, diet and
physical activity records were both returned by the same participants (n=39 at baseline, n=26 at six months, n=19 at 12 months).
Statistical analyses The analysis was conducted using SPSS 15.0 (SPSS for Windows, Rel. 15.0.1. 2008. SPSS Inc., Chicago, USA). Means and medians were calculated. The background information of men and women was compared using Fisher’s Exact Test. A paired sample t-test was used to compare the baseline with the six-month and 12-month followup scores. In addition, the differences between variables at baseline and follow-up were examined using Fisher’s Exact Test, the Wilcoxon signed rank test, the Mann–Whitney test and the Marginal Homogeneity test. The threshold for statistical significance was set at p=0.05. Significance values between 0.05 and 0.1 were treated as suggestive. Diet records were analysed by a dietician using the Micro-Nutrica Nutritional Analysis Program. Exercise records were analysed by physiotherapists with an MA in sport sciences.
Results Cardiovascular health Table 3 shows the values of the parameters relating to cardiovascular health. No statistically significant differences were found in these parameters between baseline and six or 12 months. However, weight and diastolic blood pressure were lower at 12 months than at baseline. The overall trend was that indicators of cardiovascular health improved between baseline and six months to some extent, but the values between baseline and 12 months were very close to each other (Table 3).
Self-assessed lifestyle At 12 months, there were more participants who considered themselves to be overweight (p=0.083) than at baseline and at six months. Participants assessed that their health condition (p=0.025) and physical condition (p=0.034) were better at 12 months than at six months. Everyday activity increased between baseline and six months (p=0.035) and between baseline and 12 months (p=0.072) (Table 4). Table 4 shows that participants assessed that they ate a healthier diet at 12 months than at baseline. There was a statistically significant difference in lifestyle at baseline and at 12 months with respect to eating snacks (p=0.019), using the plate model to create a healthy meal (p=0.003) and in the number of participants who read through the product description on grocery packages (p=0.025). Participants assessed that they were eating at least 500 g of
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Ylimäki et al. Table 3. Cardiovascular health at baseline (n=53), six months (n=33) and 12 months (n=34).
Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Total cholesterol (mmol/l) HDL-cholesterol (mmol/l) LDL-cholesterol (mmol/l) Diabetes risk score Glucose (mmol/l) Weight (kg) BMI
Variable
Baseline
Six months
12 months
Mean
Median
±SD
Mean
Median
± SD
Mean
Median
± SD
132 87 5.2 1.32 3.26 9 5.35 89.7 30.4
129 86 5.2 1.28 3.26 10 5.35 88.6 30.4
16.5 12.6 1.0 0.31 0.66 4.3 0.48 19.8 5.4
131 85 4.9 1.36 3.14 10 5.49 87.1 29.5
133 86 4.9 1.32 2.99 11 5.47 82.8 28.4
16.5 1.2 0.8 0.36 0.78 4.05 0.50 22.2 5.7
131 83 5.0 1.36 3.19 9 5.43 88.1 29.8
132 82 5.0 1.36 3.09 9 5.4 84.3 30.3
16.5 9.2 0.7 0.35 0.71 4.05 0.49 22.9 5.9
HDL: high-density lipoprotein; LDL: low-density lipoprotein; BMI: body mass index.
vegetables per day (p=0.058) and using more soft fat (p=0.070) at six months than at baseline. In addition, between six months and 12 months the participants assessed that they were using more low fat cheese (p=0.096) but smaller amounts of low fat cold cuts (p=0.083). Participants assessed that they consumed alcohol more than three times a week at six months and at 12 months (p=0.083) (Table 4).
Self-reported diet and physical activity records According to the exercise records, the amount of everyday activity decreased. More time was allocated to fitness activities at 12 months compared with the baseline. Based on the diet records, the overall trend was that diet was healthier at six months than at baseline, but at 12 months it was very similar to that recorded at baseline. Based on the records, participants consumed more fibre (p=0.020) and berries (p =0.041) at 12 months than at baseline. Folate intake was significantly increased between baseline and 12 months (p= 0.006) (Table 5).
Adherence to lifestyle changes Table 6 shows participants’ adherence to lifestyle changes. Participants had a great urge to take care of themselves and they felt responsibility for their personal health at baseline. Preparedness for change increased between the baseline and 12-month follow-up. Adherence to the given advice and guidance on lifestyle changes was significantly decreased when compared between the baseline and 12-month follow-up (baseline 52%, 12-month follow-up 4%). At the 12-month follow-up, 15% of the participants felt concern over their way of life whereas 39% of the participants were concerned at baseline. In comparison with the baseline, participants experienced a significant decrease in family and friends’ support at six months (baseline 75%, six months 4%), whereas the support increased again at 12 months. However, participants felt
more ready and open-minded about the change at 12 months (Table 6).
Discussion and conclusions Discussion The results of the study are very similar to those reported in earlier studies.1,2,4,7 In the present study, like previous studies, minor changes in lifestyle have been achieved with a counselling intervention. An interesting finding was that participants assessed that they adhered well to lifestyle change and that they were ready for it and willing to do it. The intervention aimed to support participants’ selfmanagement; indeed, in some studies, this kind of intervention has had positive effects on cardiovascular health.16,17 There was health-improving progress in selfassessed health condition and physical activity. In addition, an increased number of participants considered that diet affects well-being and that they were applying the plate model in everyday diet. Nevertheless, some indicators of cardiovascular health, for example, cholesterol level, improved between the baseline and the six-month follow-up, but were very close to the baseline values at 12 months. A positive trend at six months but no longer at 12 months may be an indication of people having initial enthusiasm towards the change. Most participants assessed in the lifestyle questionnaire that they were in good health although the measured cardiovascular health parameters did not indicate that. Only 25% of the participants considered themselves to be obese at the 12-month follow-up although their BMI indicated that they were obese; 75% considered themselves to be normal weight or slightly overweight although they were obese. It is known that one crucial factor motivating people to adopt lifestyle change is that they feel unhealthy.18 This may be the most important finding in this research. The main reason why the applied lifestyle changes were not more significant and sustainable is that people were
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Table 4. Participants' self-assessed lifestyle at baseline (n=53), six months (n=20) and 12 months (n=28). Variable
Baseline
Six months
12 months
p-value
%
%
%
Baseline– Six months– six months 12 months
Baseline– 12 months
54.9 37.3
70.0 10.0
57.1 25.0
42.6 38.3 19.1
31.6 26.3 42.1
22.2 33.3 44.4
NS NS NS NS NS NS NS
0.083 NS NS NS NS NS NS
57.7 54.7 32.7 28.3
50.0 55.0 45.0 60.0
75.0 57.1 57.1 42.9
NS 0.035 NS NS
0.025 NS NS 0.034
41.5 45.3 84.9 64.2 13.2 54.7 51.9 34.0 56.6 26.4 43.3 24.5 62.3
40.0 40.0 90.0 90.0 25.0 45.0 61.9 40.0 75.0 21.1 25.0 45.0 90.0
48.1 22.2 92.9 89.3 32.1 53.6 57.1 50.0 57.1 25.9 21.4 42.9 78.6
NS NS NS 0.058 0.058 NS 0.070 NS NS NS NS NS 0.046
NS NS NS NS NS NS NS 0.096 0.083 NS NS 0.096 NS
51.9 30.8
40.0 35.0
39.3 35.7
38.8 28.6
44.4 44.4
30.8 38.5
NS NS NS NS NS NS
0.083 NS NS NS NS NS
40.0 28.0
16.7 16.7
46.2 23.1
NS NS
NS NS
NS NS NS NS NS NS NS NS 0.072 NS NS NS NS NS NS NS NS NS NS NS NS 0.019 0.003 0.025 NS NS NS NS NS NS NS NS
Opinion on weight Slightly overweight Obese Changes in weight Has increased in the last year Has stayed the same in the last year Has decreased in the last year Exercise and health Very or quite good 3–4 hours of everyday activities a week 2–3 hours of fitness activities a week for 20–60 min Satisfactory physical condition Diet 1–2 meals and snacks a day 3–4 meals and snacks a day Diet affects well-being Eats a fairly healthy diet, or a rather healthy diet Eats 500 g of vegetables a day Uses light and soft fat products on bread Uses soft fats when preparing food Mainly uses low-fat cheese Mainly uses low-fat cold-cuts Uses bread with fibre content above 10 g/100 g Eats sugary and fatty snacks daily Uses the plate model when putting together a meal Reads through the descriptions on grocery packages Alcohol Alcohol usage Once a month or less often 2–4 times a month Amount consumed when drinking 0–1 units 3–4 units Alcohol percentage of drink 2.9–4.7% >4.4%
p-value
p-value
*Marginal Homogeneity test.
not aware of their true health condition. Also socio-economic status and amount of stress have an impact on how willing one is to adopt treatment and lifestyle change. After the intervention, concern over the current way of life decreased strongly, particularly at 12-month follow-up. According to earlier studies, support from friends and family is necessary to help people adopt lifestyle changes and maintain a healthy lifestyle.11,19 During the present study, support from family members and friends was good at the beginning but decreased during the study period. It should be noted that initially group members were the more important source of support but after intervention,
the role of the health care provider leading the group was emphasized. At the end of the intervention, all participants felt that they received support from other group members. Since the beginning of the intervention, participants felt the urge to take care of themselves and felt personal responsibility for their health. Adherence to the advice and guidance was significantly decreased after the intervention, together with the experienced self-efficacy. Experienced self-efficacy has been shown to have a strong correlation with implementing a healthy lifestyle, such as reduction of fat and better physical performance.20,21 However, following advice and instructions may be felt to
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Ylimäki et al. Table 5. Diet according to diary records (baseline, n=39; six months, n=33; 12 months, n=19). Variable
Baseline
Six months
12 months
0–12
Mean
Median
±SD
Mean
Median
±SD
Mean
Median
±SD
p-value*
Total energy (kcal) Total fats (E%) Saturated fats (E%) Monounsaturated fats (E%) Polyunsaturated fats (E%) Protein (E%) Carbohydrates (E%) Fibre (g) Cholesterol (mg) Vitamin C (mg) Vitamin D (mg) Folic acid (µg) Sodium (mg) Vegetables (g) Fruit (g) Berries (g) Root vegetables (g) Green vegetables (g) Nuts and pulses (g) Potatoes (g)
1692 35 13 11 5.5 19 44 19.5 242 71 6.1 227 3941 261 106 19 25 97 2 87
1669 7.01 3.58 3.03 1.3 2.9 8.09 6.9 107.3 36,6 3.6 64.8 941 126.5 70.75 31.8 31 61.53 3.84 56.2
486 34 13 11 6 19.5 44 19.6 230 72 5.6 214 2690 265.6 102 0 17 88 0.5 78.5
1553 34 11 11 6 19 46 20 203 82 5.7 236 2766 290 112 25 27 106 6 80
1489 6 6.6 3.5 2.1 1.52 3.9 7.1 7.09 85,4 61.3 4.21 87.7 920 157.7 95.9 33.4 31.9 75.3 13.3 48.0
451 32 11 11 5 19 47 20 184 64 4.8 202 2572 273 98.5 18 17 87 0 89
1713 35 14 11 5 19 44 22 290 85 5.3 270 2849 284 105 26 36 103 6.4 84
1696 6.7 3.32 2.85 1.88 2.98 8.85 9 130.7 66.6 2.2 88.1 1035 170.4 131.2 35.98 45.9 68.5 16.1 51.9
531 34 13 11 5 20 42 22 257 65 5.2 253 2703 260 33 11 25 61 0.8 52
NS NS NS NS NS NS NS 0.020 NS NS NS 0.006 NS NS NS 0.041 NS NS NS NS
*Wilcoxon signed rank test.
Table 6. Adherence to lifestyle change (baseline, n=45; six months, n =24; 12 months, n=25). Average adherence per item
Adherence to instructions Voluntary nature of lifestyle change Significance of lifestyle change Desire to take care of oneself Responsibility for personal health Self-efficacy Readiness for change Open-mindedness about change Support of family and friends Expectations on leader’s support and motivation Expectations on group’s support and motivation Motivation for lifestyle change and self-treatment Concerned about the current ways of life
Baseline
Six months
12 months
(%)*
(%)*
(%)*
52 82 80 95 93 66 82 84 75 75 86 80 39
8 64 44 96 92 48 88 88 4 72 76 76 36
4 69 77 89 96 42 89 88 23 77 50 69 15
*At least 4 in scale 1–5.
be an overload if trying to implement several changes at the same time5,6 and, consequently, self-efficacy may be affected. From a methodological perspective, an interesting finding was that there was a discrepancy between the measured cardiovascular health and self-assessed health. There was also a discrepancy between diary and physical activity records and the self-assessed questionnaire answers.
Earlier studies have come up with the same finding.22 It has been suggested that overweight people tend to evaluate the level of physical activity as much higher and diet healthier than they actually are when recorded.23–26 This also reflects the situation in the current study. These conflicts raise questions about how to collect data in order to study lifestyle due to the possibility of under-reporting and over-reporting. However, self-assessment information is
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very important because it represents people’s own perspectives of their lifestyles. It is known that personal perspective underlies the choices that people make. Method-wise, another issue to take into account in intervention studies is the possible Hawthorne effect, which refers to the effect of being under observation.27 This may affect result interpretation and generalization. Some studies question the feasibility of having a large number of lifestyle changes implemented at the same time and during the same intervention.5,6 Generally, lifestyle change interventions focus on gradual step-by-step changes with a long follow-up time. In the present study, the follow-up time was 12 months. Several interventions and longer follow-up periods may be required in order to integrate lifestyle changes in everyday life. Between the baseline and the end of the intervention there were some statistically significant changes in the participants’ self-assessed lifestyles. However, these changes were not observed in the direct measurement parameters, such as weight or cholesterol level. Consequently, it is unknown whether the self-assessed changes can improve cardiovascular health over the long term. Alternatively, this may be an indication that people are able to implement gradual changes and progress step by step. Overall, one of the biggest challenges in intervention studies and the effectiveness of intervention as a method is how to motivate people with the highest health risk to participate and commit to lifestyle change. The intervention model used in the project and in this study has shown positive experiences and implementations in preventative health care in Finland. It has become a sustainable health care practice in several Finnish municipalities.
Strengths and limitations of the study One strength of the study was the multifaceted data collection approach, which provides a versatile view on lifestyle changes and effects of counselling intervention. The questionnaires had been used previously and were found to have high validity and reliability. The cardiovascular health parameters are also valid because they were measured and collected by dedicated health care professionals at official laboratories according with the Finnish health care standards. Overall, the project setup affected the study population due to the voluntary nature. First, lack of health care resources limited the number of participating municipalities. Second, people who took part in the initial screenings, in the intervention and in this study showed interest and motivation towards their health. This all may have an effect on the generalization of the results. Some of the participants did not join the six- and 12-month follow-ups but these participants were consistent in their absence from all follow-ups. These absent participants were mostly highrisk patients who were directed to special individual care.
Few participants dropped out of the follow-up meetings due to the scheduling of the meetings. However, the background information of the participants and the dropouts were compared and no significant differences were found. Consequently, the loss of participants during the study period did not have an effect on the interpretation of the results. Due to the type of study and the project setup, there was no intention to set up a control group. Indeed, the purpose was to evaluate the effect of counselling intervention on all volunteering participants with identified risk.
Ethical aspects Permission to conduct this study was given by the medical director of participating municipalities. The principles of the Declaration of Helsinki were followed. In the covering letter attached to the questionnaire it was emphasized that participation in the study was voluntary.
Conclusions We found that the intervention had significant effects on lifestyle changes with respect to eating snacks, using the plate model to create healthy meals and reading the product descriptions on grocery packages. Furthermore, some positive cardiovascular health improvements were detected between baseline and six months, but not as clearly between baseline and 12 months. Participants assessed that they had a healthier diet at 12 months than at baseline and that their motivation and self-efficacy were good, although there were only minor changes in diet. This indicates that eating behaviour and habits are likely to change gradually. Making lifestyle changes is a big challenge for individuals who consider that they do not have any health problems, which is possibly the biggest challenge in the effectiveness of counselling intervention. In order to achieve adherence to lifestyle change, people need both long-term support from family and friends and counselling from specialized health care professionals.
Implications for practice •• Current Internet technology provides effective means of counselling intervention, for example, Skype calls and Internet-based questionnaires can be used regardless of time or place. •• People at risk of cardiovascular disease benefit from counselling intervention, that is, the risk can be decreased and overall health improved. Conflict of interest The authors declare that there is no conflict of interest.
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Ylimäki et al. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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