Factors that affect readiness to change lifestyle: A 22-country survey from primary care

Abstract

Background: The family physician's task in prevention is not only an assessment of patients’ health risks but also counselling individual patients.

Aim: Aim of this primary care based study was to find how patients’ characteristics relate to their readiness to change.

Methods: This multinational cross-sectional survey was conducted in primary care in 22 European countries, coordinated by EUROPREV. Consecutive attenders from randomly selected family practices answered a questionnaire about attitudes towards prevention and about lifestyle.

Results: The questionnaire was answered by 7947 patients in 224 primary care practices in 22 European countries. Smoking was reported by 828 women (23.2%) versus 1238 (32.57%) men, unhealthy diet by 637 (11.6%) women versus 830 men (17.62%), risky alcohol consumption by 348 women (8.19%) versus 1009 men (23.07%) and the lack of physical activity by 617 women (12.68%) versus 614 men (16.45%). The need for change was declared by 432 (31.8%) of 1357 risky drinkers, 612 (29.6%) of 2066 smokers, 1210 (82.4%) of 1467 patients with unhealthy diet and by 2456 (30.9%) of all participants, 1231 of them were not physically active at all. Among patients with unhealthy dietary habits, 681 (56.3%) were confident of successfully changing their behaviour, among physically inactive it was 1561 (63.6 %), among smokers 284 (46.4%), and among risky drinkers 214 (49.5%).

Conclusion: More likely to be ready to change unhealthy lifestyles are frequent attenders, European Union citizens, women and patients under 50 years of age.

Keywords::

• Health awareness
• lifestyle change
• family medicine
• prevention and health promotion

KEY MESSAGE:

Two variables are associated with the readiness to change health related behaviours:

• citizenship of European Union

• attending family practice more than twice in a year.

INTRODUCTION

Two-thirds of the population visit their family physician at least once a year and 90% consult at least once in five years (1). Therefore, primary health care is a suitable setting for the identification and reduction of behavioural risks, and for recommendation of preventive activities.

The study, performed by the European Network for Prevention and Health Promotion in Family Medicine and General Practice (EUROPREV) on the role of general practitioner/family physician (GP/FP) in prevention and health promotion, identified significant gaps between physicians’ knowledge and their everyday practice (2).

The FP's task in prevention is not only to make an assessment of patients’ health risks but also to intervene by counselling patients on how to change their lifestyle, adapting this counselling to the individual patient (3). It has been previously demonstrated that patients’ readiness to change lifestyle and their confidence in success depend on their risk factors (4,5). So far, several studies have addressed physicians’ professional advice and patients’ readiness to change, but few (5,15,18) dealt with the relationship between patients’ characteristics and their readiness to change lifestyle.

Previous research has found that strategies to incorporate preventive services into primary care settings have been under-utilized (18). After health risk assessment intervention, based on evidence, practice guidelines and protocols for determining preventive services should follow (3). An important step in this complex and difficult process is to determine who is eligible for what service, based on age, gender and clinical characteristics, and when, along with the patient's stage of readiness to change (19).

The aim of this study was to examine patients’ perspectives: specifically how patients’ characteristics, such as care utilization pattern, place of residence, gender and age relate to readiness to change risky behaviours.

METHODS

Study design

The study was conducted as a cross-sectional survey in primary care practices in 22 EUROPREV member European countries (3). The national ethics committees in all participating countries approved the study protocol.

Sample

Practices for each country were randomly selected from a list of centres or practices run by tutors, colleges or university departments. Each participating country randomized at least 10 practices, 50% from rural or semi-rural and 50% from urban settings.

Each practice invited 40 consecutive patients (20 men and 20 women), aged 30 to 70 years, to fill in a questionnaire, which was self administered. The only inclusion criterion was age. Age distribution was as follows: 10 men and 10 women were in the age group 30–49 years, and 10 men and 10 women in the age group 50–70 years. Patients’ who were not able to fill-in the questionnaire themselves were assisted by a practice nurse or a GP trainee (3).

Prior to distributing the questionnaires, the physician or the practice nurse had explained the study protocol and aims to patients and had obtained their informed consent (3,17).

As a previous study showed that the percentage of patients who did not receive reminders for preventive care attendance varied between 49% and 62% (21–23), we assumed that the estimated true proportion could be of 0.5. Therefore, taking an estimated proportion of patients who do not receive reminders (one of the most important objectives of the study) as 0.5, the maximum acceptable difference of 0.05, and an alpha error of 0.05, the required sample size calculated per country (assuming GPs take care of a population of 2000 patients on average) was 378 patients. Assuming a non-participation rate of 5% of selected patients, sample size was increased to compensate for anticipated loss. This was done by multiplying the sample size by the quantity 1/(1–d), where d is the anticipated loss, so the total sample size was approximately 9154 patients.

A custom-made web page was developed for the pupose of online data entry. Data was collected from October 2007 to May 2008 (3).

Questionnaire

For each participating country (except Ireland), the original questionnaire was translated from English to the national language and translated back to English using a standard procedure.

The structured questionnaire contained four sections:

1. Data on socio-demographic and clinical characteristics of participants;

2. Patients’ lifestyle (eating habits, physical activity, smoking and alcohol consumption);

3. Patients’ stage of change: their perceived importance and awareness of the need to change, their readiness and confidence to make changes in diet, physical activity, body weight, smoking and alcohol intake;

4. Care provided by participants’ family practice team;

Section 3 included questions on the perceived importance for patients of, need for, suitability of and confidence in being able to undergo blood pressure, blood glucose and serum cholesterol checks and flu vaccination plus cervical smear and mammography for women only. The patients’ views on the optimal interval for screening for risk factors and willingness to receive advice from their family physician were also assessed.

Patients were asked if their family practice team had ever initiated a discussion on disease prevention and if they would like to receive such advice and support.

Closed questions were used. For answers the Likert scale was used (yes/no/I don't know).

The presence of chronic illness was identified by the question ‘During the last 12 months have you been diagnosed with, or treated for, any of the following conditions: elevated blood pressure, elevated blood glucose, high cholesterol, heart disease, skeletal disorders, COPD or asthma, gastritis, anxiety, depression or cancer?’.

Risky drinking was assessed by the CAGE questionnaire, smoking by the WHO criteria (20,21).

Readiness to change was defined by the answers: ‘Planning to change (in the next month or in the next six months)’ and ‘Already changing’ to the questions:

(a) ’Do you plan to change your eating habits?’

(b) ’Do you plan to change your physical activity?’

(c) ’Do you plan to change your smoking habits?’

(d) ‘Do you plan to change your alcohol intake?’

Confidence to change was determined by the answer ‘Confident’ to the question ‘How confident are you of success in changing your diet, physical activity, smoking and drinking habits (3)?’

Statistical analysis

All analyses were performed taking into account the cluster design of the study; countries were considered as strata and practices as clusters. Mean and percentages were used to describe the continuous and categorical variables. In regard to the complex nature of the analysed data, all of them are followed by the 95% confidence intervals (3). Comparisons by sex were performed using the Student's t-test and the chi-square test. The statistical significance was set at 5%.

RESULTS

Participants

The relevant data on response rates was partially recorded only, with 11 countries providing data, where the mean response rate was 90.7%. Analysis excluded 60 participants, because of missing data for gender or because their age was outside the range.

The analysis was performed on the study population of 7947 participants (52.2% females and 47.8% males) in 22 European countries and 224 primary care practices. The respondents’ average age was 48.6 (95% CI: 48.32–49.07) years. 2945 (77.33%, 95% CI: 74.81–79.66) of men and 3065 (74.86%, 95% CI: 71.88–77.61) of women were married or living with a partner, 433 (13.48%, 95% CI: 11.61–15.60) men and 355 (9.93%, 95% CI: 8.13–12.07) women were single, 281 (7.00%, 95% CI: 5.70–8.57) men and 347 (8.21%, 95% CI: 6.77–9.92) women were divorced, 103 (2.19%, 95% CI: 1.53–3.14) men nd 339 (7.01%, 95% CI: 5.91–8.29) women were widowed.

Participants’ readiness and confidence to change lifestyle

Table 1 shows participants’ readiness to change health related lifestyles and their confidence of success:

• 1476 participants, 830 (17.6%, 95% CI: 15.77–19.64) men and 637 (11.6%, 95% CI: 9.94–13.50) women assessed their dietary habits as unhealthy (P < 0.05); 1210 (82.4%) were planning or already changing, 681 of them (56.3%) were confident of success;

• 1231 participants, 614 (16.45%, 95% CI: 14.29–18.87) men and 617 (12.68%, 95% CI: 10.51–15.23) of women were not regularly physically active (P = 0.0285); 2456 (30.9%) of all participants were planning or already increasing physical activity, 1561 (63.6%) were confident of success;

• 2066 participants, 1238 (32.57%, 95% CI: 29.45–35.85) men and 828 (23.20%, 95% CI: 20.99–25.56) women were smoking (P < 0.05); 612 (49.4%) were planning to or already changing, 972 (35%) were confident of success;

• 2066 participants, 1238 (32.57%, 95% CI: 29.45–35.85) men and 828 (23.20%, 95% CI: 20.99–25.56) women were smoking (P < 0.05); 612 (29.6%) were planning or already changing, 284 (46.4%) were confident of success;

• 1357 participants declared themselves as risky drinkers: 1009 men (23.07%, 95% CI: 20.58–25.76) and 348 women (8.19%, 95% CI: 6.95–9.62), (P < 0.05); 432 (31.8%) were planning or already changing, 214 (49.5%) were confident of success.

Table 1. Participants’ readiness and confidence to change their lifestyles (n = 7947).

	… eating habits?		… physical activity?		… smoking?		… drinking habits?
Do you plan to change your	No	%	No	%	No	%	No	%
No intention to change	1303	16.4	1330	16.7	905	11.4	916	11.5
I don't know	1006	12.7	972	12.2	559	7.0	465	5.8
Planning to change in next month	868	10.9	1067	13.4	422	5.3	194	2.4
Planning to change in next six months	410	5.2	592	7.4	170	2.1	71	0.9
Currently changing	1092	13.7	797	10.0	220	2.8	167	2.1
Not applicable (already controlling)	3059	38.5	2885	36.3	5299	66.7	5730	72.1
No answer	209	2.6	304	3.8	372	4.7	404	5.1
Confident of success in changing	960	79.3	1561	63.6	214	35.0	241	55.8

Associations between gender, age and readiness to change

Table 2 supplementary Tables 1–4 available online only, at http//www.informahealthcare.com/doi/abs/10.3109/13814788.2014.912269 examine the associations between gender, age, country of residence (EU or not-EU), number of patients’ visits to a practice in the last year, family physician's discussion on healthy lifestyle and patients’ readiness to change behavioural risk factors. Supplementary Tables 1–4 available online only, at http//www.informahealthcare.com/doi/abs/10.3109/13814788.2014.912269 provide detailed analyses (web only), whereas Table 2 provides a summary of the most important model.

Table 2. Model for lifestyle change. Wald test of parallel-lines assumption is violated in this model (P < 0.001).

No, I don't know, planning to change versus already changing OR (95%CI)		Eating habits n = 4233	Physical activity n = 4233	Smoking n = 4501	Risky drinking n = 2179
EU country		3.25 (2.18–4.83)	3.25 (2.18–4.83)	2.28 (1.46–3.56)	4.56 (2.11–9.84)
Gender, female^a		1.57 (1.27–1.93)	1.57 (1.27–1.93)	1.33 (1.08–1.63)	0.98 (0.69–1.41)^d
Age		0.982 (0.975–0.989)	0.982 (0.975–0.989)	0.984 (0.972–0.996)	1.01 (0.99–1.02)^d
Visits to GP during	3–4 times^b	1.29 (1.04–1.62)	1.29 (1.04–1.62)	1.08 (0.75–.55)^d	1.42 (1.02–1.99)
last year	5 or more times^b	1.10 (0.84–1.45)^d	1.10 (0.84–45)^d	0.93 (0.67-.30)^d	1.86 (1.29–2.67)
GP initiated a	I don't know^c	1.99 (1.30–3.05)	0.71 (0.36–39)^d	0.42 (0.15–1.22)^d	0.93 (0.33–2.64)^d
discussion about …	Yes^c	2.12 (1.72–2.61)	2.12 (1.72–2.61)	1.23 (0.71–2.16)^d	1.95 (1.35–2.80)

Number of strata = 22; number of PSUs = 224; F(20,183) = 14.83; P > F = 0.0000; Odds ratios (95% CI) from multivariate analysis for participants’ readiness to change.

^aReference category: male.

^bReference category: 1–2 times.

^cReference category: No.

^dNot statistically significant (OR includes 1).

EU countries’ citizens, participants in the age group 30–49 years, females, non-drinkers, patients feeling stressed, non-smokers, regularly physically active patients, participants, who had visited their practice three-to-four times in the last year and patients, whose family physician had ever initiated a discussion about diet, were more willing to change or were already changing their eating habits (Table 2; Supplementary Table 1 available online only, at http//www.informahealthcare.com/doi/abs/10.3109/13814788.2014.912269).

EU countries’ citizens, participants in the age group 30–49 years, females, patients feeling stressed, non-smokers and participants with healthy eating habits, participants, whose family physician had never initiated a discussion about physical activity and patients, who had visited their doctor more than three times in the last year, were more willing to change or were already changing their physical activity (Table 2; Supplementary Table 2 available online only, at http//www.informahealthcare.com/doi/abs/10.3109/13814788.2014.912269).

EU countries’ citizens were more willing to change or already their changing smoking habits as well as patients, who visited family practice more than twice during the last year, were smoking habits more often than non-EU citizens. Participants in the age group 30–49 years were dubious about changing smoking habits as well as patients, whose family physician had ever initiated a discussion about smoking and those who did not remember if he/she had ever touched the issue (Table 2; Supplementary Table 3 available online only, at http//www.informahealthcare.com/doi/abs/10.3109/13814788.2014.912269).

EU countries’ citizens, patients with healthy eating habits, participants, whose family physician had ever initiated a discussion about alcohol and patients, who had visited family practice more than twice in the last year were more willing to change their alcohol consumption (Table 2; Supplementary Table 4 available online only, at http//www.informahealthcare.com/doi/abs/10.3109/13814788.2014.912269).

DISCUSSION

Main findings

Aim of this study was to examine how patients’ characteristics, such as pattern of care utilization, country of residence, gender and age, relate to readiness to change risky behaviours. We show percentages of participants motivated to change their habits and of confident ones: proportions differ regarding lifestyle habits, ranging from 10–31% in willingness and from 13–60% in confidence respectively, changing drinking habits seems to be the most difficult task. This study identifies several variables associated with readiness to change. Two variables in particular were common to all lifestyle changes assessed—citizenship of EU and attending family practice more than twice in the last year, whilst some variables were lifestyle specific.

Strengths and limitations of the study

Strength of the study is the fact that we have managed to gather information from a wide variety of countries throughout Europe. This study also addressed readiness to change lifestyle in a variety of different behaviours, which is usually not done. Since this was a cross- sectional study, we cannot draw any causal conclusions, but we found some variables, associated with a patient's readiness to change.

The lifestyle habits were self-assessed by patients and this information was not cross-checked; therefore, it is possible that the reported lifestyle habits differ from actual ones. A further weakness is the lack of available data on response rates in 11 countrie, despite this being a mandatory item.

Interpretation of study results

We could not find any study on the influence of European Union citizenship or of family practice attendance rate on readiness to change lifetsyle.

There are many studies dealing with patients’ stage of change and cardiovascular risk (6–16), some of which also explored the influence of age, gender and marital status but only a few examine the relationship of these factors to patients’ readiness and confidence to change risky behaviours (3,6,15,17,18,20). Studies have all been performed in one country and are, therefore, prone to cultural bias and are difficult to generalize further.

DiClemente compared lifestyle changes in Texas and Rhode Island subjects, concluding, that there were no significant differences in gender distribution, education levels, mean age, and average income range (20).

Wallace et al. stated that the changes in alcohol consumption were not significantly affected by patients’ concern about their drinking, age or body mass index (21).

Padlina in a cross-sectional survey of the Swiss general population found no difference in stage of change distribution by gender or age, only in education level (9,21). We had different results—patients who were feeling stressed were more willing and determined to change their diet, physical activity and alcohol drinking habits, with some age and gender differences.

Carroll's adult weight management programme study showed that the improvement in readiness to change diet and physical activity habits significantly correlated with gender; male gender and readiness to change were significantly correlated (10).

Slovene authors found that nearly 20% of patients planned to change their eating habits, increase physical activity, and reach normal body weight (16,23). Approximately 30% of them wanted to receive advice on this issue from their FPs. Younger patients and patients with higher education were more confident that they could improve their lifestyle. Our findings were different, which probably reflects the country's specificity.

Sorensen's study investigated perceived barriers to engagement in physical activity and stages of change in relation to exercise behaviour and found significant age and gender differences in the perception of barriers at the various stages of change (18).

FPs have the unique opportunity to advise and advocate lifestyle change in patients at higher risk for development of chronic diseases, but EUROPREV studies show that significant gaps exist between physicians’ knowledge and their everyday performance, and that half the participants reported not having had any discussion on healthy lifestyles with their GP (2,3).

Implications for practice and research

The results of this cross-sectional survey study concern both primary care professionals and health policy makers, because the results show the readiness and confidence of patients attending family practices in Europe regarding changes in lifestyle. They could be useful in improving counselling strategy in family practice and may help practice teams to determine which patients are most likely to change their lifestyle.

FPs should pay more attention to men, patients over 50 years of age and rare attenders of family practices. They have less intention to change habits and lower confidence in success.

Special attention has to be paid also to discussion of unhealthy behaviours with patients as the first step of preventive intervention, especially in non-EU countries. The outcomes of this study should be valuable for designing and tailoring both motivational strategies and interventions to fit targeted groups.

We encourage researchers of preventive interventions to consider the influence of gender, age and marital status, as well as health related behaviours on outcomes; and also taking into account the health care system and organization of primary health care.

Conclusion

This study raises a number of health promotion and prevention issues of interest to family medicine teams, which should consider also patients’ characteristics when assessing health risks and advising lifestyle change.

Supplementary material available online

Supplementary Tables 1–4.

ACKNOWLEDGEMENTS

The authors express their gratitude to all the family doctors and trainees, participating in this survey, who made this study possible in spite of their workload. The authors thank all the participating patients who gave them the opportunity to explore their perspective and views.

Participating countries were: Austria, Belgium, Croatia, Cyprus, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Lithuania, Malta, The Netherlands, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, Georgia and Turkey.

The authors wish to thank the Europrev network for the study idea, protocol, data collection and especially to Mary Sheehan, MICGP, for language polishing.

The authors are very grateful to Irene Moral Peláez (semFYC) for statistical analysis and explanations.

FUNDING

This work was supported by a grant from the European Society of General Practice/Family Medicine and an educational grant from Unilever.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.