Introduction
Adaptation of health systems to the efficient prevention and treatment of Non-Communicable Diseases (NCDs) is a priority in most all countries [
1‐
3]. The health systems of low and middle-income countries (LMICs), which are characterized by fragmented health-care services, are particularly challenged in treating people with NCDs and multi-morbidities [
4].
The burden of NCDs is attributabled substantially to behavioural risk factors such as physical inactivity, unhealthy diet, harmful use of alcohol and smoking. The behavioural risk factors are in principle cost-effective targets for NCD control [
5] and are included as primary targets in the World Health Organization’s (WHO) list of “best buys” for global NCD control. Yet, in LMICs, these interventions are not sufficiently implemented. This jeopardizes LMICs from their reaching the Sustainable Development Goal to reduce premature mortality from NCDs by one-third by 2030 [
2]. Considering that there is a lack of complementary services to manage risk factors for NCDs (such as smoking cessation, dietary counselling, and structured physical activity sessions), context-specific information is needed to guide LMICs in their specific NCD prevention approaches.
The Primary Health Care (PHC) setting is the most appropriate place to tackle modifiable health behaviour problems. PHC providers are most likely to see patients that present these issues before the onset of clinical disease [
3,
6,
7].
There is sufficient evidence showing that healthcare providers can play a vital role in helping and motivating patients to modify NCD risk behaviours. It has been reported that even during routine primary care consultations, patients welcome advice about behaviour change, and healthcare professionals are a trusted source of health behaviour change advice [
8]. In addition, a systematic review showed that in interventions, nurses were the most widely used health coaches [
9].
However, behaviour change is difficult and individual choices are greatly influenced by broader social, cultural and environmental factors [
10]. One of the behavioral change models named Transtheoretical model (TTM) shows that behavior change is a process and different people are in different stages of change and readiness. The results of several studies have shown the effectiveness of TTM when used, in interventions to prevent chronic conditions such as diabetes and different forms of cancers [
11].
An important component of effective behavioural counselling interventions is to engage patients actively in self-management practices that are needed to change and maintain healthy behaviours [
12]. Even though patients might have some knowledge about the importance of health behaviours such as healthy eating, smoking cessation, and physical activity, they may not fully understand how to convert this knowledge into an actual behaviour change [
13]. This may explain in part why many individuals do not get involved in these behaviours despite convincing evidence that engaging in the group of four health behaviours (physical activity, not smoking, eating a healthy diet, and drinking alcohol in moderation) leads to a delay of 11–14 years in all-cause mortality [
14].
Unhealthy behaviours are prevalent in Kosovo, a country with a comparatively low life expectancy in its regional context. Based on a recent WHO STEP wise approach to surveillance (STEPS) survey conducted among persons 25–64 years old, the prevalence of current smoking was 32% (higher in men: 42%) [
15]. In a population-based survey among older people, only 14% of the study population reported regular physical activities (20% in men; 9% in women) [
16]. An examination of anthropometric and physical fitness parameters in 14 to 15-year-old adolescents living in rural and urban areas, reported a high prevalence of overweight and obesity even in this young segment of the population [
17].
PHC and family medicine are “points of entry” to improve this situation as pointed out by a WHO-Rapid Assessment on PHC in Kosovo [
18] The Accessible Quality Healthcare Project (AQH) promotes and improves the quality of PHC in the public sector in Kosovo. Specifically, AQH implemented WHO ‘Packages of Essential Non-Communicable Disease (PEN) Protocols’ [
19] which were adapted to the Kosovo context by local experts. Therefore, Health Resource Centres delivering motivational counselling were embedded into local Main Family Medical Centres (MFMC) starting with 5 pilot municipalities. This approach of delivering motivational counselling sessions by PHC nurses based on motivational interviewing approach is a way of providing one-on-one sessions to patients through empathic listening, eliciting self-motivating statements, and responding to resistance [
20]. Motivational counselling based on motivational interviewing techniques for health behaviour change was shown to be effective in people with chronic conditions [
21]. Qualitative evidence supports the central role of nurse-driven health promotion [
10].
Implementation of WHO ‘Packages of Essential Non-Communicable Disease (PEN) Protocols’ through the AQH project started in 2018. It is timely to assess the uptake of motivational counselling sessions as well as understand patient experiences and needs during these sessions. In order to achieve safe, effective and person-centred care, it is important to pay attention and respond to patients’ feedback about their experiences of health care [
22,
23]. A patient experience is defined as a reflection of what occurred during the care process is defined as patient experiences. In this way patients can provide evidence about the healthcare workers performance [
24]. Furthermore, Patient Reported Outcomes (PROs) coming directly from individuals provide an understanding of how well health providers and treatments are meeting patient needs [
25]. PROs help find out why a program may or may not work. In this way, PROs empower the patient to actively participate in their healthcare management [
26]. Furthermore, scale-up of health interventions is facilitated by community participation [
27], and patient engagement can improve the quality of care in primary care [
28].
As Kosovo is lacking reliable health data, it is important to assess the health behaviour, the motivational stage for behaviour change and the patient’s view on motivational counselling in the early phase of motivational counselling. This will facilitate future assessment of the impact and it’s scaling up to improve effectiveness.
The objectives of this study, therefore, are:
1-
To quantitatively assess the uptake of motivational counselling sessions, as well as the distribution of health behaviours and participants’ stages of health behaviour change according to the intervention
2-
To qualitatively describe experiences and perceived benefits of PHC users towards motivational counselling.
Methods
Study setting
The AQH implementation project is a Swiss Agency for Development and Cooperation (SDC) project led by the Swiss Tropical and Public Health Institute (Swiss TPH). It was initiated in 2016 and has three goals: 1) to deliver quality services from PHC providers that respond better to communities’ needs, 2) to improve performance of health managers in guiding service delivery towards continuous quality improvement, and 3) to improve health literacy of the population and empower them to demand the right to quality services and better access to care.
Since May 2018, in 5 out of 12 AQH municipalities in Kosovo, specially trained nurses on ‘Motivational Interviewing’ provide one-to-one motivational counselling sessions. These counselling sessions are delivered to patients based on their needs at the Health Resource Centers. Initially there were only two trained nurses offering motivational counselling, but the AQH project is continuously training additional nurses in order to increase the capacity of human resources to benefit more patients through this intervention. The training was adapted for Kosovo according to ‘5 A’s Clinical Practice Guideline’ (Ask, Advise, Assess, Assist and Arrange), to facilitate behavior change in the domains of smoking, diet, alcohol use and physical inactivity for patients who are at risk of developing diabetes and/or hypertension, or those who have already been diagnosed. If a patient age 40 years or more seen in the MFMC is a smoker or is known to have one or more of the following conditions: hypertension, diabetes, history of hypertension and/or diabetes in the family (first-degree relatives), overweight or obesity, they are referred by the family doctor to the Health Resource Centre for nurse guided motivational counselling for behaviour changes.
This current study is part of the Kosovo Non-Communicable Disease Cohort (KOSCO) [
29] funded by SDC as part of the AQH implementation project. The quantitative methodology drew data from the KOSCO study to assess the uptake of motivational counselling, and to describe health behaviours, and stages of health behaviour change after delivery of motivational counselling. The qualitative methodology was used to describe the experiences and perceived benefit of motivational counselling in a randomly selected subset of KOSCO participants consenting to the qualitative interviews.
KOSCO is a prospective longitudinal study nested within the AQH project and has been described in detail according to the STROBE (The Strengthening the Reporting of Observational Studies in Epidemiology Statement) guidelines for reporting observational studies. For the inclusion into the cohort, adults aged 40 years or older were recruited consecutively among patients receiving medical services for various reasons at Main Family Medical Centres, at one of the 12 AQH study municipalities. Persons were excluded from KOSCO participation if (1) they had a terminal illness, (2) were not able to understand or respond to pre-screening questions, (3) did not live in one of the 12 study municipalities or (4) lived abroad for more than 6 months of the year. KOSCO participants are being followed-up every 6 months by trained study nurses, alternating between a structured telephone interview and an in-person interview with clinical measurements. Ethical approvals for the study were obtained from Ethics Committee Northwest and Central Switzerland (reference number 2018–00994) on 11 December 2018 and the Kosovo Doctors Chamber (reference number 11/2019) obtained on 30 January 2019. Before any data were collected, participants were asked for their verbal and written consent.
Study design
Qualitative methodology
Participants of the qualitative study module embraced participants of the KOSCO cohort having obtained at least one motivational counselling session from a trained nurse within the AQH project. The study participants were recruited through quota sampling [
35]. In order to achieve equal representation from each municipality, at least 5 Albanian speaking participants from each intervention municipality were selected from the database of the KOSCO study with the aim of interviewing up to 30 participants.
Discussion
To tackle unhealthy behaviours and improve motivation for health behaviour change, the AQH project developed and implemented a PHC intervention, where motivational counselling sessions are being delivered to patients by nurses in Main Family Medical Centres (MFMCs). Healthcare providers play a crucial health promotion role in older patients’ lives since patients have avery positive view about their providers [
38]. This is reflected in the feelings that participants expressed about the motivational counselling sessions for behaviour change which addressed their personal concerns and provided encouragement for lifestyle changes. The quantitative results of the current study point to the fact that motivational counselling uptake needs to be improved and reach all patients in need. The qualitative results of the study provide insight on improving the future effectiveness of the motivational counselling intervention. While participants have a high willingness to change behaviour, additional services to help them quit smoking as well as organizing group physical activity sessions would be needed. The quantitative study results show that there is an insufficient utilization of the intervention by the PHC users. Of 364 individuals living in one of the five intervention municipalities all fulfilled the eligibility criteria for motivational counselling, but only 22.0% of the eligible participants’ obtained at least one motivational counselling session. This low number of utilizing the health intervention is also supported by another study which showed that fewer patients use health interventions and not at regular intervals as recommended by clinical guidelines [
39].
There is descriptive, but not conclusive evidence that in the intervention municipalities, smoking is lower and fewer participants are in the precontemplation phase. With regards to fruit and vegetable consumption, considerably fewer participants in the intervention municipalities were in the precontemplation phase towards a healthier diet, yet a poor diet was still present in over 90% of participants. However, overall there was little difference between those having versus not having obtained motivational counselling and between intervention and non-intervention municipalities with regards to the distribution of unhealthy lifestyle behaviours. One of the reasons for not seeing a difference may be general barriers towards a healthier lifestyle, given the generally low household incomes in Kosovo. Another reason for not seeing a difference between these groups could be that for individuals to change their lifestyle behaviours, a longer period of time is required. This is also supported by another study which showed that changing lifestyle behaviours such as diet, smoking and exercise is difficult since it requires time, great effort as well as motivation [
39]. In addition, the participants who obtained motivational counselling were more likely to have a cardio-metabolic condition, which may add to the challenge of increasing physical activity. This may explain in part the higher observed rate of maintenance of improved physical activity behaviour among those who did not obtain motivational compared to those who did obtain motivational counselling in the intervention municipalities (23% vs. 10%). It has been reported that there is a risk associated with increased physical activity such as vigorous exercise in individuals with CVD, even though exercise is beneficial for those patients. Therefore, pre-participation assessment of risk should be given to individuals who might have a higher likelihood of CVD, since CVD may be unrecognized and subclinical [
40]. Furthermore, the lack of lifestyle difference between those who did versus did not actually obtain motivational counselling in the intervention municipalities could be due to the fact that nurses in the intervention municipalities were generally more alert in their everyday counselling to the issues of prevention with all patients. Preventive knowhow may also spread in the social networks and through media coverage in the intervention municipalities, given that they have a healthier average lifestyle in several domains compared to non-intervention municipalities. In regards to alcohol consumption, the overall very low prevalence of alcohol consumers in this setting does not provide a sufficient sample size for observing a change in the relation to motivational counselling for future analysis.
Regarding qualitative study results, participants that obtained motivational counselling sessions described positive experiences and perceptions towards the PHC intervention and willingness to start to change their health behaviours. This could be due to the fact that the nurses provided motivational counselling based on the ‘motivational interviewing’ approach, which differs from other approaches since it is directive and patient-centred and it focuses on what the patient thinks, wants and feels [
39]. Main findings regarding health behaviours showed that participants were more motivated to start to change behaviours related to nutrition and physical activity compared to smoking. Furthermore, participants described their main needs for health behaviour change, such as services to help them quit smoking as well group physical activity sessions.
One of the main strengths of this study is that it provides insights into health behaviours among PHC users in Kosovo based on their experiences and perceptions. When interpreting the results the following study limitations need to be considered. There are three limitations in regards to the quantitative part of the study. The first limitation is that the analyses are descriptive and not analytic in nature. The short follow-up time does not yet allow for the observation of the impact of the intervention. Some of the study participants obtaining motivational counselling have only obtained one session which is not sufficient to infuse behaviour change in a person presenting any risk behaviour. In the absence of information on the exact date of motivational counselling obtained as result of time constraints in the interview, it is not possible to know the prevalence of unhealthy behaviours before and after motivational counselling. This is also the reason why relapse was not considered as motivational state of behavioural change, because a relapse may in fact have been a particularly strong reason for participating or not participating in motivational counselling. Continuing the assessments in the KOSCO cohort will help address some of these issues in the future. Fully adjusted modelling is foreseen in a separate paper planned after a longer follow-up time with a clearer timing of events. The current descriptive analysis of the subpopulations sets the stage for these future analyses and points to, but does not consider confounders and effect modifiers. We observed differences between those who did versus did not receive motivational counselling with a higher rate of retired and obese persons in the former demonstrating that motivational counselling is targeting in part those in most need. We also observed noticeable differences in behaviours and motivational stages between intervention and non-intervention municipalities irrespective of whether motivational counselling was obtained, which may reflect a potential spill-over effect within the intervention municipality to general counselling of all patients or to social and community networks. The second quantitative limitation entails the following: while consecutive sampling of study participants into the KOSCO cohort regardless of the reason for their doctor’s visit, aimed at improving the representativeness of the population aged 40 years and older suffering from health problems, it could at the same time have introduced selection bias as compared to an alternative approach of random sampling from the public PHC users in the respective municipalities. The third quantitative limitation: including only participants with complete data in the quantitative analysis lowered the sample size and may have introduced selection bias. If data completeness differed by the main endpoint and, in particular, if this incompleteness additionally differed by municipality and having or not having obtained motivational counselling.
Limitations with regards to the qualitative methodology include
first, that in-depth interviews were conducted through telephone instead of in-person due to the coronavirus pandemic. Therefore, during telephone interviews body language and other non-verbal cues could not be observed from study participants. In this way, there could be some potential loss of contextual data, and potential probing from in-depth interviews could have been missed. On the other hand, evidence shows that telephone interviews are a good medium for data collection [
41].
Second, participants were selected from five intervention municipalities through quota sampling, which is a non-random sampling strategy. Therefore, our sample for qualitative methodology was less representative and the perspective on generalizability could be limited. While an overall sample size of 30 participants for the qualitative study is reasonable and in line with the available funds, a higher sample size would have allowed to better represent the 5 intervention municipalities.
Suggestions to improve services
The results of the quantitative study describe early differences between intervention and non-intervention municipalities and between those who did versus did not obtain motivational counselling to guide future analyses on the longer-term impact of motivational counselling. The quantitative results demonstrate that there are still potential biases whom the motivational counselling should reach and actually does reach. The results of the qualitative study contribute to strengthening the PHC intervention based on patients’ views and identified potential barriers for its impact.
To improve the health behaviour of PHC users, and by taking into consideration their experiences and needs towards this intervention the following tailored approaches are suggested: a) strengthened referral mechanism within PHCs from family doctors to nurses b) specialized services for smoking cessation and c) delivery of group physical activity sessions for PHC users.
Strengthen the referral mechanism within the facility
Our quantitative study results show that from five intervention municipalities only 22.0% obtained at least one motivational counselling session. Even though the uptake of motivational counselling sessions was low, qualitative findings show that participants who attended the motivational counselling sessions mainly reported positive experiences towards the sessions and were more motivated to start to change their health behaviours. Therefore, it is recommended to increase the uptake of motivational counselling sessions offered by MFMCs. In order to increase the flow of patients to receive preventive services, the referral mechanism within the facility from the family doctor to the nurse needs to be strengthened. Previous research on physical activity counselling in primary healthcare suggests an interdisciplinary model where primary care physicians refer their patients to allied health professionals for physical activity behaviour change [
42].
Specialized services for smoking cessation
Quantitative as well as qualitative findings show that participants that are currently smoking require additional approaches for quitting smoking such as professional support from nurses or the primary healthcare system. One of the approaches would be to offer specialized services within PHC where nurses receive additional training on smoking cessation and integrate this additional service into motivational counselling sessions. Evidence shows that patients who obtained an intervention led by a nurse had a higher smoking cessation rate compared to those who obtained usual care [
43]. In addition, behavioural therapy and smoking cessation aids are needed for patients that have difficulty quitting smoking [
44].
Group physical activity sessions for PHC users
Based on qualitative findings it was evident that besides motivational counselling sessions, PHC users identified the need to have physical activity sessions in a group. The quantitative findings showed that there was low adherence to WHO recommendations for physical activity. Therefore, organizing structured group physical activity sessions for PHC users would increase adherence to WHO physical activity recommendations. Furthermore, study participants noted that group physical activity sessions would enable them to have more social support and create new friendships. Evidence on the relationship between social support and physical activity in older adults showed that people with greater social support were more likely to do leisure-time physical activity. Therefore, interventions for older adults should take into consideration the promotion of the social benefits of physical activity participation [
45].
Acknowledgments
The authors thank the study participants that are continuing to participate in the KOSCO study and are sharing their experiences for our collective learning. We are grateful for the contributions of AQH project team, specifically the members of logistics and administration for their continuous involvement during the implementation of the KOSCO study. Study nurses: Tevide Bllaca, Arizona Igrishta, Selvete Zyberaj, Alma Stojanovic for the great job during data collection. Finally, the KOSCO study cannot be possible without close collaboration of directors and healthcare staff from participating Main Family Medicine Centres of the following Municipalities: Drenas, Fushe Kosova, Gjakova, Gracanica, Junik, Lipjan, Malisheva, Mitrovica, Obiliq, Rahovec, Skenderaj, Vushtrri. The authors thank Dr. Aurelio Di Pasquale for his support and insight into data collection by ODK.
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