A number of risk factors are found with any chronic illness. Controlling these factors would help patients do a better job of managing their condition. Hyman and coworkers noted that many patients who receive treatment for cardiovascular disease in primary care present multiple behavioral risk factors. They suggested there was little information on the most effective ways to approach multiple behavior change counseling in clinical settings. To determine how this issue could be approached, they conducted a trial to test whether the one-by-one use of counseling to halt smoking, reduce salt intake, and increase activity would be more effective than counseling to change these behaviors all at once. African Americans with hypertension, aged 45 to 64 years, initially ineffective at changing their behavior, were randomized to the following conditions: (1) one in-clinic counseling session on all three behaviors every six months, supplemented by motivational interviewing by telephone for 18 months; (2) a similar protocol that addressed a new behavior every six months; or (3) one-time referral to existing group classes ("usual care"). The primary end point was the number in each arm that met at least two behavioral criteria after 18 months. A total of 289 individuals were randomized into the trial; 230 (79.6%) completed the study. At 18 months, only 6.5% in the simultaneous arm, 5.2% in the sequential arm, and 6.5% in the usual-care arm met the primary end point. However, results for single behavioral goals consistently favored the simultaneous group. At six months, 29.6% in the simultaneous, 16.5% in the sequential, and 13.4% in the usual-care arms had reached the urine sodium goal. At 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usual-care arms showed they had quit smoking.

COMMENTS: This study provides evidence that changing multiple behaviors one-by-one is not superior to, and may be inferior to, a simultaneous approach. These data are not all that surprising: in self-management studies, an aim is made to teach patients to alter several behaviors at once. These behaviors range from careful self-monitoring to taking action to relieve an acute episode of a condition. The current study reinforces the findings found in self-management studies.

D. J. Hyman et al. Simultaneous vs. Sequential Counseling for Multiple Behavior Change Archives of Internal Medicine, 2007;167:1152-1158.