A Scoping Review of Positive Lifestyle and Wellness Interventions to Inform the Development of a Comprehensive Health Promotion Program: “HealthPro.” A Commentary to Schuette and Colleagues (2018)

‘With the growing morbidity associated with chronic disease in both developed and developing countries, evaluating new and effective health promotion programs is a critical component of public health and health care.’

Health promotion—providing individuals and communities the knowledge, skills, and abilities to improve their health—has become a primary focus on a worldwide scale.¹ With the growing morbidity associated with chronic disease in both developed and developing countries, evaluating new and effective health promotion programs is a critical component of public health and health care. Schuette et al² recently performed a scoping review of healthy lifestyle promotion programs that focused on multiple behavioral changes in healthy individuals. They used this scoping review as the basis for the development of a comprehensive healthy lifestyle program specifically targeting healthy individuals across a broad age range.

Activities that reduce the emergence of increased risk for disease in healthy populations, what has been termed primordial prevention, has garnered growing interest over the past 2 decades.³ To distinguish between primordial and primary prevention strategies, Lancarotte and Nobre⁴ identify primordial prevention as aiming “to prevent the development of risk factors” and primary prevention as aiming to modify “existing risk factors to prevent the development of disease.” As suggested by the American Heart Association,⁵ primordial prevention is based on the fundamental principles of (1) focus on changing foundational behaviors to enhance overall health rather than activities addressing disease-specific risks, (2) prevention activities located in the community setting, and (3) the interventions requiring access to public services such as parks for recreation, healthy food outlets, and smoke-free environments.

Schuette et al² used a relatively unique approach to develop a comprehensive health promotion program. Rather than designing an intervention based on a specific behavior change theory or model, the authors based their curriculum on findings from a scoping review of randomized controlled trials of health promotion interventions published over a recent 10-year period. The authors’ initial literature search was based on a number of criteria. Most significantly, the intervention included only healthy adults and was group based, with the intervention administered in person. Each of the studies included in the review focused on more than one behavioral outcome, including combinations of weight reduction, stress reduction, increased physical activity, and improved eating behaviors. Of particular significance, the authors only included studies that showed positive results in at least one of the outcomes of interest regardless of the behavior change theory or model. The authors did not indicate what constituted a positive result, nor did they evaluate the combination of positive results by type of intervention strategy or theory.

The initial results of the literature search included 7439 articles, with a culling of nonrelevant articles resulting in 689 publications. A final selection process by the lead authors produced a final group of 58 articles that were included in the review. The review of these articles illustrates the very broad range of intervention strategies and variety of theoretical foundation, length of program participation, duration of individual session, group facilitator, group activity, and target population. A total of 52 of the publications (89%) focused on behavioral change strategies for increased physical activity and/or improved eating behavior. In addition, several studies incorporated social support and developing coping skills. Of particular importance, the review was not restricted by age, demographic category, or level of health (beyond not diagnosed with a chronic disease). Therefore, the final group of articles included in the review were studies targeting the elderly and socioeconomically disadvantaged populations, pregnant women, and participants who were at high risk for chronic disease.

The authors used the results of the scoping review as a mechanism to create a comprehensive health promotion intervention for primarily healthy individuals with or without established risk factors for chronic diseases. The resulting 9-week curriculum addresses physical, mental, emotional, and social health challenges and draws on multiple behavioral theories, including social cognitive theory, transtheoretical model of change, and motivational interviewing. The intervention is designed to use the most common delivery methods found among the studies that were included in the scoping review. These methods focused generally on group-level activities and included lecture, group member interaction techniques, some mild stretching exercises, and self-monitoring and awareness building.

A number of large, comprehensive, community-based studies have been performed to test the effectiveness of interventions that address change to multiple health behaviors.^6-9 The impetus for this broad approach arises from research indicating that individuals tend to engage in multiple unhealthy behaviors simultaneously.¹⁰ These behaviors, such as physical inactivity, poor diet, and smoking, appear to be interrelated. Previous efforts at multibehavioral interventions have been complex multilevel approaches that address personal, social, and environmental factors. Typically administered by professional practitioners, follow-up analyses in these studies have shown relatively small changes to behavioral outcomes—emphasizing the immense challenge of sustainability of lifestyle change.¹¹ The scoping review by Schuette et al² and subsequent development of a multibehavioral intervention undertakes a practical approach—combining what has worked previously—rather than a theory-based approach. Because the curriculum can be administered by a broad range of individuals, including peer leaders, and at community-based meeting sites, the program is designed to minimize cost.

A primary limitation of the process is that the structure of interventions that target changes to multiple health-related behaviors cannot provide an in-depth understanding of the association between any one successful change and the theoretical mechanism for that change.^12,13 As important, the intervention addressing multiple behaviors is unlikely to fill the void of knowledge concerning the theoretical basis of successful long-term behavioral change. These limitations were identified by the authors, along with the limitation created by defining healthy individual simply as an individual not diagnosed with diabetes, cancer, heart disease, or other major medical condition. However, the curriculum as designed should be appropriate for addressing a wide range of specific unhealthy behaviors among various demographic groups, and the design of the intervention for administration in a community setting will enhance access by underserved populations.

A second limitation of the review—and subsequently the construction of the intervention—is that the authors did not provide any disconfirming research. In other words, the reviewers did not evaluate the use of these behavioral change methodologies among studies that were not successful in changing behavioral outcomes. Therefore, it is not clear if the methodologies found among the articles that were included in the review explained the effectiveness of the interventions or how the interventions may have been administered differently than in unsuccessful trials. And because articles were included in the review that had multiple targeted behaviors with only a requirement of 1 successful behavior change, the methodologies clearly did not work in all cases. It would be important to identify which methods had a higher probability of success across multiple behaviors, particularly among the specific healthy demographics.

The authors have presented a comprehensive behavioral change intervention that addresses a wide range of fundamental unhealthy behaviors. Their pragmatic approach to development of the intervention’s curriculum is focused on previous success rather than theoretical basis for the behavior change strategy. This approach is in contrast to the strong movement in behavioral science toward theory- or model-based curriculum development. As the new curriculum, “HealthPro,” is currently being tested its effectiveness remains to be determined.