Effectiveness of the nurse-led Activate intervention in patients at risk of cardiovascular disease in primary care: a cluster-randomised controlled trial

Effectiveness of nurse-led interventions versus usual care to manage hypertension and lifestyle behaviour: a systematic review and meta-analysis

AIMS

This review aimed to investigate the effectiveness of nurse-led interventions vs. usual care on hypertension management, lifestyle behaviour, and patients' knowledge of hypertension and associated risk factors.

METHODS

A systematic review with meta-analysis was conducted following Joanna Briggs Institute (JBI) guidelines. MEDLINE (Ovid), EmCare (Ovid), CINAHL (EBSCO), Cochrane library, and ProQuest (Ovid) were searched from inception to 15 February 2022. Randomized controlled trials (RCTs) examining the effect of nurse-led interventions on hypertension management were identified. Title and abstract, full text screening, assessment of methodological quality, and data extraction were conducted by two independent reviewers using JBI tools. A statistical meta-analysis was conducted using STATA version 17.0.

RESULTS

A total of 37 RCTs and 9731 participants were included. The overall pooled data demonstrated that nurse-led interventions may reduce systolic blood pressure (mean difference -4.66; 95% CI -6.69, -2.64; I2 = 83.32; 31 RCTs; low certainty evidence) and diastolic blood pressure (mean difference -1.91; 95% CI -3.06, -0.76; I2 = 79.35; 29 RCTs; low certainty evidence) compared with usual care. The duration of interventions contributed to the magnitude of blood pressure reduction. Nurse-led interventions had a positive impact on lifestyle behaviour and effectively modified diet and physical activity, but the effect on smoking and alcohol consumption was inconsistent.

CONCLUSION

This review revealed the beneficial effects of nurse-led interventions in hypertension management compared with usual care. Integration of nurse-led interventions in routine hypertension treatment and prevention services could play an important role in alleviating the rising global burden of hypertension.

REGISTRATION

PROSPERO: CRD42021274900.

A codesigned integrated kidney and diabetes model of care improves patient activation among patients from culturally and linguistically diverse backgrounds

BACKGROUND

Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD.

METHODS

This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non-CALD backgrounds spoke English only as their primary language. Paired t-tests compared baseline and 12-month patient activation scores by CALD status.

RESULTS

Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non-CALD backgrounds (58.5 ± 14.6) at baseline. Within-group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow-up (52.1 ± 17.6-59.4 ± 14.7), and no significant change was observed for those from non-CALD backgrounds (58.5 ± 14.6-58.8 ± 13.6).

CONCLUSIONS

Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi-structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses.

Spin in the abstracts of randomized controlled trials of nurse-led care: A cross-sectional study

BACKGROUND

Nurse-led models of care had been reported as effective intervention approaches for improving health management and reducing hospitalizations of target patients in a number of studies. However, the reporting quality of studies in the field varied and there was a lack of literature evaluation.

OBJECTIVE

The objective of the study was to assess the reporting quality and spin of abstracts of published randomized controlled trials which had statistically not significant primary outcomes. Moreover, potential factors associated with the presence of spin were also assessed.

METHODS

Studies on nurse-led care were retrieved from PubMed from January 1st, 2017, to December 31st, 2021. Only randomized controlled trials with statistically not significant primary outcomes were included. Study screening and data extraction were carried out by two reviewers independently. The reporting quality of each abstract was evaluated by the Consolidated Standards of Reporting Trials statement, and spin strategies were analyzed using a pre-designed assessment form. Potential predictors for the presence of spin were analyzed by multivariate logistic regressions.

RESULTS

The overall reporting quality of the included 75 randomized controlled trial abstracts was not satisfying, with a median score of 16-item Consolidated Standards of Reporting Trials statement at 6 (IQR 5, 8). Forty abstracts used at least one spin strategy in abstracts. Among them, 18 (45.0 %) used spin strategies in the result section and 39 (97.5 %) had spin in the conclusion section. The most common spin strategy identified in abstracts was focusing on statistically significant secondary outcomes (12/40, 30.0 %) in the result section and claiming benefit with no consideration of statistically not significant results for the primary outcomes (32/40, 80.0 %) in the conclusion section. Based on the definition, 29 (72.5 %) abstracts were assessed to have high level of spin in the conclusions of abstracts. By multivariate logistic regression analyses, it was found that only geographic origin (reference: studies from Asian countries, OR = 0.118, 95 % CI 0.027 to 0.511, P = 0.004) and the Consolidated Standards of Reporting Trials statement score (reference: lower score, OR = 0.625, 95 % CI 0.470 to 0.829, P = 0.001) were significantly associated with the presence of spin in abstracts.

CONCLUSION

Among the randomized controlled trials with statistically not significant primary outcomes in the field of nurse-led care, the reporting quality of abstracts needs to be improved. Trials from Asian countries and with lower Consolidated Standards of Reporting Trials statement scores are more likely to present spin in abstracts. Findings reported in the result and conclusion sections of these abstracts need to be interpreted with caution.

Promoting nurse-led behaviour change interventions to prevent cardiovascular disease in disadvantaged communities: A scoping review

Cardiovascular diseases (CVD) are the leading cause of death worldwide and they disproportionally affect people living in disadvantaged communities. Nurse-led behaviour change interventions have shown great promise in preventing CVD. However, knowledge regarding the impact and nature of such interventions in disadvantaged communities is limited. This review aimed to address this knowledge gap. A six-stage scoping review framework developed by Arksey and O'Malley, with revisions by Levac et al., was used. The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews (PRISMA-ScR). Three electronic databases were searched (PUBMED/MEDLINE, CINAHL Plus, and Cochrane CENTRAL), and included studies were analysed using Braun and Clarke's 'Thematic Analysis' approach. Initial searches yielded 952 papers and 30 studies were included in the review following duplicate, title/abstract, and full-text screening. The included studies indicate that nurse-led behaviour change primary prevention interventions in disadvantaged areas are largely effective; albeit the considerable variety of intervention approaches, study populations and outcome measures used to date make it difficult to ascertain this. Other identified key areas in the promotion of nurse-led behaviour change included tailoring interventions to specific populations, providing adequate training for nurses, overcoming patient access difficulties and encouraging patient engagement. Overall, the findings indicate that nurse-led behaviour change interventions for high-risk CVD patients in disadvantaged areas show much promise, although there is considerable variety in the interventions employed and studied to date. Further research is needed to examine the unique barriers and facilitators of interventions for specific disadvantaged groups.

Theory-Informed Design of a Tailored Strategy for Implementing Household TB Contact Investigation in Uganda

Since 2012, the World Health Organization has recommended household contact investigation as an evidence-based intervention to find and treat individuals with active tuberculosis (TB), the most common infectious cause of death worldwide after COVID-19. Unfortunately, uptake of this recommendation has been suboptimal in low- and middle-income countries, where the majority of affected individuals reside, and little is known about how to effectively deliver this service. Therefore, we undertook a systematic process to design a novel, theory-informed implementation strategy to promote uptake of contact investigation in Uganda, using the COM-B (Capability-Opportunity-Motivation-Behavior) model and the Behavior Change Wheel (BCW) framework. We systematically engaged national, clinic-, and community-based stakeholders and collectively re-examined the results of our own formative, parallel mixed-methods studies. We identified three core behaviors within contact investigation that we wished to change, and multiple antecedents (i.e., barriers and facilitators) of those behaviors. The BCW framework helped identify multiple intervention functions targeted to these antecedents, as well as several policies that could potentially enhance the effectiveness of those interventions. Finally, we identified multiple behavior change techniques and policies that we incorporated into a multi-component implementation strategy, which we compared to usual care in a household cluster-randomized trial. We introduced some components in both arms, including those designed to facilitate initial uptake of contact investigation, with improvement relative to historical controls. Other components that we introduced to facilitate completion of TB evaluation—home-based TB-HIV evaluation and follow-up text messaging—returned negative results due to implementation failures. In summary, the Behavior Change Wheel framework provided a feasible and transparent approach to designing a theory-informed implementation strategy. Future studies should explore the use of experimental methods such as micro-randomized trials to identify the most active components of implementation strategies, as well as more creative and entrepreneurial methods such as human-centered design to better adapt the forms and fit of implementation strategies to end users.

Effectiveness of physical activity interventions delivered or prompted by health professionals in primary care settings: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To examine the effectiveness of physical activity interventions delivered or prompted by primary care health professionals for increasing moderate to vigorous intensity physical activity (MVPA) in adult patients.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Databases (Medline and Medline in progress, Embase, PsycINFO, CINAHL, SPORTDiscus, Sports Medicine and Education Index, ASSIA, PEDro, Bibliomap, Science Citation Index, Conference Proceedings Citation Index), trial registries (Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, TRoPHI), and grey literature (OpenGrey) sources were searched (from inception to September 2020).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials of aerobic based physical activity interventions delivered or prompted by health professionals in primary care with a usual care control group or another control group that did not involve physical activity.

STUDY SELECTION AND ANALYSIS

Two independent reviewers screened the search results, extracted data from eligible trials and assessed the risk of bias using the Cochrane risk of bias tool (version 2). Inverse variance meta-analyses using random effects models examined the primary outcome of difference between the groups in MVPA (min/week) from baseline to final follow-up. The odds of meeting the guidelines for MVPA at follow-up were also analysed.

RESULTS

14 566 unique reports were identified and 46 randomised controlled trials with a range of follow-ups (3-60 months) were included in the meta-analysis (n=16 198 participants). Physical activity interventions delivered or prompted by health professionals in primary care increased MVPA by 14 min/week (95% confidence interval 4.2 to 24.6, P=0.006). Heterogeneity was substantial (I2=91%, P<0.001). Limiting analyses to trials that used a device to measure physical activity showed no significant group difference in MVPA (mean difference 4.1 min/week, 95% confidence interval -1.7 to 9.9, P=0.17; I2=56%, P=0.008). Trials that used self-report measures showed that intervention participants achieved 24 min/week more MVPA than controls (95% confidence interval 6.3 to 41.8, P=0.008; I2=72%, P<0.001). Additionally, interventions increased the odds of patients meeting guidelines for MVPA by 33% (95% confidence interval 1.17 to 1.50, P<0.001; I2=25%, P=0.11) versus controls. 14 of 46 studies were at high risk of bias but sensitivity analyses excluding these studies did not alter the results.

CONCLUSIONS

Physical activity interventions delivered or prompted by health professionals in primary care appear effective at increasing participation in self-reported MVPA. Such interventions should be considered for routine implementation to increase levels of physical activity and improve health outcomes in the population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021209484.

Effectiveness of health literacy- and patient activation-targeted interventions on chronic disease self-management outcomes in outpatient settings: a systematic review

Chronic diseases are the leading causes of morbidity and mortality and account for approximately 60% of all deaths worldwide. Self-management is a key strategy to manage chronic diseases, and there is emerging evidence recommending targeting both health literacy (HL) and patient activation (PA) to improve chronic disease self-management outcomes. The aim of this systematic review is to summarise the current evidence on the impact of HL- and PA-led interventions on self-management outcomes using randomised control trials (RCTs). Six well known databases (MEDLINE, Web of Science, Scopus, Science Citation Index, EMBASE and Academic Search Complete) were searched for RCTs of chronic disease self-management interventions targeting both HL and PA and published between 2004 and June 2021. The search terms included chronic disease, self-management, patient activation/engagement and health literacy/education. Ten studies were eligible for inclusion. We found that patients with low HL and PA levels are most likely to benefit from the interventions. The moderate improvements in PA and HL in the reviewed studies were translated into some improvements in physical activity and mental health outcomes but failed to improve patients' quality of life and healthcare utilisation outcomes. Patients with low HL were more likely to have higher PA levels after the interventions. This review suggests that both HL and PA are essential pillars for improving chronic disease self-management outcomes. However, more studies are needed to explore the long-term impacts of a combination of HL and PA on chronic disease self-management outcomes.

Promoting physical activity in primary care: a systematic review and meta-analysis

Background

Promoting physical activity is an important part of patient care in primary care and has been investigated in many studies with a wide range of intervention characteristics, often including external support. It is unclear, however, if promoting physical activity is effective.

Aim

To investigate the effectiveness of behaviour change interventions to promote physical activity in primary care.

Design and setting

This is a systematic review and meta-analysis to evaluate physical activity promotion in a primary care setting.

Method

EMBASE, MEDLINE, PsycInfo, and the Joanna Briggs Institute Database were searched for ‘physical activity’, ‘interview’, ‘motivation’, ‘primary care’, and equivalent words to identify randomised controlled trials with physical activity as the outcome at patient level.

Results

The review identified 25 eligible studies. The quality appraisal showed that most studies reported insufficient details regarding randomisation, group allocation, blinding, and fidelity of intervention delivery. The included studies reported a wide range of interventions with varying numbers of follow-up visits or phone calls. The overall effect size for interventions with a 6-month follow-up interval was 0.04 (95% confidence interval [CI] = −0.06 to 0.14), and for interventions with a 12-month follow-up interval it was 0.19 (95% CI = 0.03 to 0.36). Only one intervention based on three motivational interviewing sessions achieved a moderate effect.

Conclusion

Counselling to promote physical activity in primary care has a limited effect on patients’ behaviour and it might not, on its own, be enough to change physical activity behaviour.

Fidelity of primary care nurses' delivery of a behavioural change intervention enhancing physical activity in patients at risk of cardiovascular disease: an observational study

OBJECTIVE

To evaluate the fidelity of delivery of a nurse-led intervention to enhance physical activity in patients at risk for cardiovascular diseases, the Activate intervention, by assessing: (1) self-reported fidelity of delivery; (2) observed fidelity of delivery; (3) quality of delivery of the Activate intervention and (4) nurses' beliefs about their capability, motivation, confidence and effectiveness towards delivering the Activate intervention, including behavioural change techniques.

DESIGN

An observational study.

SETTING

General practices in the Netherlands.

PARTICIPANTS

Primary care nurses (n=20) from 16 general practices.

PRIMARY AND SECONDARY OUTCOME MEASURES

Nurses' self-reported fidelity was evaluated using checklists (n=282), and the observed fidelity and quality of delivery were examined using audiorecordings of consultations of the delivery of the Activate intervention (n=42). Nurses' beliefs towards delivering the intervention were assessed using questionnaires (n=72).

RESULTS

The self-reported fidelity was 88.1% and observed fidelity was 85.4%, representing high fidelity. The observed fidelity of applied behavioural change techniques was moderate (75.0%). The observed quality of delivery was sufficient and varied among nurses (mean 2.9; SD 4.4; range 0-4). Nurses' beliefs about their capability, motivation, confidence and effectiveness towards delivering the intervention increased over time.

CONCLUSIONS

Nurses delivered most intervention components as intended with sufficient quality. Nurses believed they were capable, motivated and confident to deliver the intervention. They believed the intervention was effective to increase patients' physical activity level. Despite the high fidelity and moderate fidelity of applied behavioural change techniques, the varying quality of delivery within and across nurses might have diluted the effectiveness of the Activate intervention.

TRIAL REGISTRATION NUMBER

NCT02725203.