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Table 3 Strategies recommended in clinical practice guidelines for the implementation of PA lifestyle advice for the primary prevention of CVD

From: Systematic review of international clinical guidelines for the promotion of physical activity for the primary prevention of cardiovascular diseases

Field Subfield Recommendation Details of recommendation Guideline reference number (see Table 1 for details)
Support & follow-up
Global CVD prevention—low to medium intensity
Patient be seen within one month of initiation of lifestyle therapy to determine adequacy of risk factor management, degree of patient adherence, presence of adverse effects Tailor the support and follow-up: Intensity & frequency based on individual need
Plan reviews: Before, during & after behavior change intervention to assess progress towards goals
Very brief intervention: (10–15 min) Target general public & focus on motivation & information
Brief intervention: (15–25 min) Target low SES people or people whose health/wellbeing could be at risk
Extended brief intervention: (30 min or more) Target people with high risk behavior; health problems; comorbidities; increased risk of harm; increased need for support to reach/maintain change
High intensity intervention: (over 30 min) Target people at high risk of causing harm to their health/wellbeing; who have not benefited lower-intensity interventions; who have medical condition that needs specialist advice/monitoring; overweight population who are aiming to lose weight
BP 1
Regular assessment and counselling on PA is recommended to promote the engagement and, if necessary, to support an increase in PA volume over time CVD 3
CVD 7
Adults at higher absolute risk of CVD should be given more frequent and sustained lifestyle advice, support and follow-up to achieve behavioral change CVD 1
Deliver very brief, brief, extended brief and high intensity behavior change interventions and programs LSt 3
Ensure behavior change is maintained for at least a year LSt 3
Once the patient's risk CVD factors are controlled, at least annually follow-up is suggested (more frequently as indicated), depending on patient preference BP 1
Weight management- high intensity For active weight management in adults, prescribe on-site, high-intensity interventions =  ≥ 14 sessions in 6 months with fortnightly review for the first 3 months, and at least 12 contacts within 12 months). Assess adherence to the weight loss program by measuring the patient’s weight and providing feedback and ongoing support Intensive: Multiple contacts over extended periods (5–26 contacts/9–12 months)
- Short-term: At least weekly
- Intermediate-term: At least weekly to monthly for another 6 months
- Long-term: After the first year, at least bimonthly
CVD 7
OW 2
OW 3
OW 4
Advise overweight and obese patients who have lost weight to participate long term (≥ 1 year) in a comprehensive weight loss maintenance program consisting of all behavioral components and ongoing support, with additional intervention as required Continued provision of comprehensive weight loss maintenance program, on-site or by telephone, for periods up to 2,5 years after initial weight loss CVD 7
OW 3
OW 4
Behavior change
Timing
For adults who are overweight or obese, discuss readiness to change lifestyle behaviors Awareness: Make people aware of their level of CVD risk in relation to lifestyle behavior
Timing of the intervention: Conform to current stage of motivation since people are most susceptible for lifestyle change interventions when exposed at a time when they are most open to change (e.g. following profiling results revealing elevated CVD risk)
OW 2
Counseling content Provide structured information and combined behavioral counseling regarding lifestyle behaviors (e.g. healthy diet & PA), in order to prevent CVD and to control CVD risk factors to patients with:
1. normal weight but positive for other CVD risk factors
2. overweight without obesity-associated conditions
Lifestyle: Based on long-standing behavioral patterns, maintained by social environment
Content: Focus on behavior change; didactic education & additional support; audit & feedback on progress; strategies for self-monitoring, plan for follow-up
Incorporate at least 2 behavior change strategies: Match with patient's needs; other evidence-based effective behavior change techniques; define rationale for techniques included; evaluate novel techniques (limited evidence)
Individualized counseling & care plan: patient-centered care as basis for motivation & commitment
OW 4
LSt 1
OW 1
OW 6
The use of established (proven) cognitive-behavioral strategies (e.g. motivational interviewing) to facilitate lifestyle change by evoking patient motivation to accept and participate in lifestyle treatments are recommended when designing interventions Goal setting: Specific, proximal, realistic, personal goals for behavior change/resulting outcomes to achieve/maintaining benefits. Moving forward in small, consecutive steps for changing long-term behavior). Consider achievement of outcomes & review further plans/goals
Action planning: Develop & prioritize actions, e.g. PA activity of choice & incorporated in daily life (developing routines & habits) for sustainability & acceptability
Problem solving: Well-rehearsed coping plans to prevent/manage relapse, e.g. stimulus control, changes in physical environment
Motivational interviewing: Encouraging, enabling, verbal persuasion, modelling exercising behavior, discussing positive effects
Other techniques: Self-efficacy (Empower patients by building confidence); Feedback & monitoring (Encourage self-monitoring of behavior/outcomes, provide feedback at regular intervals); Social support (Advise /arrange for social network -family, friends, peers- to provide practical help, emotional support, praise or reward); Cognitive behavioral strategies; Positive reinforcement; Cognitive restructuring; Shared decision-making (between HCP & pat/family)
CVD 3
CVD 5
LSt 3
LCh 4
OW 4
Provider
Team-based care
Team-based care with the involvement of multidisciplinary professionals is recommended Multifaceted approach, supporting: Clinical decision-making, collaboration among providers, patient and family member participation
Team composition: Trained professionals—dietician/nutritionist, physiotherapist/exercise professional, health educator, psychologist, GP, nurse, pharmacist, social worker, community health worker
Roles & responsibility: Limited evidence on organization of complementary competencies
Task shifting and sharing: Adding new staff or changing roles of existing staff, considering licensure and responsibilities. E.g. for delivery in primary health care: Brief lifestyle interventions delivered by PN are more cost-effective than delivered by GP
Initiation of treatment & follow-up by credentialed provider (e.g. exercise on GP prescription; further educative/follow-up counseling & progress/adherence assessments by other HCP than clinician (e.g. nurse-directed behavioral management)
Communication & coordination among various team members
BP 1
BP 2
CVD 3
CVD 5
CVD 7
Involve lay or peer workers to deliver interventions in high risk communities and ensure they are part of a wider team led by health care providers Involve peers/family in planning, design and delivery of credible appropriate messages and interventions (including helping people to develop practical skills to adopt healthy lifestyle). Management & supervision by professionals DM 2
Lay/peer workers & HCP should identify and encourage 'community champions' (e.g. religious and community leaders) to promote PA Encourage lay & peer workers to get other members of their community involved DM 2
Training Provide training for all professional practitioners and lay people who are responsible for and/or involved in helping to change people's behavior Competency & confidence/motivation in: Person-centered care; insight in factors affecting behavior change (incl. psychological, social, cultural & economic) & adverse behaviors; health inequalities; select & tailor appropriate evidence-based interventions; intervention mechanism of action; behavior change techniques; access & refer people to local support services
Training model: Focused/structured; based on evidence based content & training models; practice new skills in community/practice, share knowledge amongst peers; identify skills gaps
Tailored to: setting, participant's characteristics, focus/priority (integral to main role vs. additional task)
LSt 3
DM 2
BP 1
Monitor/assess behavior change practitioners, provide feedback and give time/support to develop and maintain competencies Monitoring & assessment: Competency frameworks & techniques (audio/video recording, observation tool) to monitor HCP’s knowledge & skills (personal development plans, annual reviews), keep up-to-date
Ongoing development: Regular evaluation of outcome & process (e.g. using participant feedback), supported by feedback (oral/written), refresher trainings and clear action plans & goal setting in acquiring the necessary competences
LSt 3
DM 2
Information & education
Communi-cation
Provide patient education and clearly communicate in order to encourage the person to participate in reducing their CVD risk Health education principles: Small, comprehensive amounts, didactic education and additional support, reinforced by resources (e.g. written, web-based, audiovisual materials)
Effective communication: Friendly & positive interaction; non-judgmental interaction (e.g. lower SES groups/minority groups), patient-centered; open-ended questions, reflective listening; show empathy
Content: Risk assessment; treatment; impact & benefits of behavior change; being more physically active and improving dietary habits; gradual improvements to PA; interventions/services available & how to use them
OW 7
BP 1
LCh 1
Exercise prescription by physicians (especially GPs), similar to drug prescription, should be considered for health promotion   CVD 3
Sensibili-zation Convey messages to the local population and use community resources to raise awareness and increase accessibility, such as short term community-based educational programs Lifestyle messages: consistent, clear, culturally appropriate, integrated within other local health promotion campaigns/interventions
Tailor messages to local community: Work with local practitioners, role models & peers; address misconceptions acting as a barrier; disseminate locally to groups at higher risk (e.g. low SES)
Channels of delivery: Involve local community (e.g. Community-wide campaigns, social media, local newspapers/radio channels/shops & businesses/events, social establishments, educational institutions, workplaces, places of worship, local health care establishments, community organizations)
CVD 3
DM 2
Patient-centered care Tailor interventions for specific groups and individuals in order to ensure interventions meet individual needs, preferences & circumstances and are culturally appropriate (especially in high-risk communities). Social determinants of health should inform optimal implementation of treatment recommendations Patient participation: At each step, beginning with assessment of ‘readiness to change’ & intention, capability, opportunity & motivation (e.g. if multiple behaviors need to be changed, assess which one the person is most motivated to tackle)
Socioeconomic inequalities: determinants for CVD risk. Tailor advice to SES
Individualized approach & communication: Assess & address previous experiences, beliefs on perceived ability to change, thoughts, worries, attitudes, knowledge, context (physical, economic & social environment), physical and psychological capacity, skills, obstacles, feelings, stage of motivation, skills, self-confidence, barriers to change, self-image, group norms and level of autonomy & tailor interventions and strategies to meet individual needs
CVD 7
LSt 3
LCh 4
DM 2
OW 7
Shared decision-making should guide discussions about the best strategies to reduce CVD risk Decisions should be collaborative between a clinician and a patient: Engage patients in discussions about personalized CVD risk estimates and their implications for the perceived benefits of preventive strategies (i.e. lifestyle habits & goals); hereby addressing potential barriers to treatment options CVD 7
Reach a shared understanding with overweight and obese patient about the risks of overweight and obesity and the benefits of weight management 1. Ask permission to discuss health risks & potential benefits/risks of interventions
2. Explore understanding, knowledge, beliefs, experience, values, family/social network
3. Share information about potential risks based on health status
4. Emphasize the need for ongoing commitment
5. Provide small amounts of information/advice, tailored to individual values/preferences & easy to understand
6. Use teach-back method to confirm shared understanding
OW 4
Self- management For adults who achieve initial weight loss, strongly recommend the adoption of specific strategies, appropriate to their individual situation, to minimize weight regain Strategies: Self-monitoring (e.g. regular self-weighing), tracking PA (mHealth/eHealth tools or noting activity in diary), relapse prevention & management (rehearsing action-plans e.g. contacting GP), development of routine, coping, self-care strategies OW 2
CVD 5
For adults, include a self-management and/or self-monitoring approach to monitor their weight, BP, or associated behaviors NOT stand-alone: Self-management approach as part of multicomponent intervention
Self-monitoring of chosen behavior or goal (diet/PA/body weight) at least weekly for therapy adherence
OW 2
OW 7
BP 1
Consider the use of a self-monitoring device/tracking system (e.g. pedometer, mobile apps) to increase adherence to PA Internet-based programs for goal-setting/reminders; lifestyle diaries BP 1
LCh 1
OW 7
Setting & referral
Primary health care
Managers and health professionals in all primary care settings should ensure that preventing and managing obesity is a priority at both strategic and delivery levels. Dedicated resources should be allocated for action Brief interventions in PHC OW 5
Community Use community links, outreach projects and lay or peer workers (from lower SES groups) to deliver interventions Community-based support: Community health workers assisting HCP & pat by serving as liaisons tot the HC system & lay educators DM 2
Commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed for weight loss, provided there is peer-reviewed published evidence of safety/efficacy Community schemes/facilities: Support & promote those that improve access to PA, combined with tailored information based on local needs OW 3
Navigation Work in partnership to develop cost-effective PA interventions Multifaceted approaches with linkage between PHC—community—public health & health policy interventions DM 2
Provide (written) information on local, affordable, practical and (culturally) acceptable opportunities for PA   DM 2
Recognize that people may need support to change their lifestyle. To help them do this, refer them to programs such as exercise referral schemes If no in-house program available or cost-effective option LCh 1
Delivery mode Offer comprehensive lifestyle interventions
1. face-to-face in either individual or group sessions
2. telephone based, either as an alternative or an adjunct to face-to-face intervention, provided it includes personalized feedback from trained practitioner
3. internet-based, either as an alternative or an adjunct to face-to-face intervention, provided it includes personalized feedback from trained practitioner
Providing interventions to groups: Group discussions, group tasks (promoting interaction/bonding), mutual support within the group
Remote intervention delivery: If there is evidence of efficacy (e.g. telephone, text messaging, apps, internet) for cost-effectiveness
OW 3
OW 4
LSt 1