Interventions based on a single health behaviour change theory:

• Motivational Interviewing 
• The Flinders ProgramTM

Some health behaviour change interventions have no evidence of a theoretical framework and have been developed in response to an identified gap such as action plans and pulmonary rehabilitation.

The majority of chronic conditions are managed in primary care by general practitioners (GPs). The management of such patients is complex and often requires both clinical and self-directed input. Due to the number of available interventions, it is important that GPs are aware of which health behaviour change interventions (which encompass self-management) are most effective when making referral decisions for a patient with COPD.

The evidence

• Randomised controlled trial and systematic review evidence published between 2005 and 2011 
• Eleven electronic databases, including Medline, Embase, and the Cochrane Library
• Intervention - health behaviour change interventions for people with COPD 
• Comparison - usual care or patient education alone
• Primary outcome - increased physical activity

Fifteen eligible randomised controlled trials (16 papers) and 4 systematic reviews were identified, summarised and critically appraised. Participants were mostly elderly (mean reported age ranged from 62 to 74 years) and the majority were male.

Which health behaviour change interventions were most effective?
An intervention based on a single health behaviour change theory (Cognitive Behavioural Theory/Therapy) was no more effective than a control intervention in an 8 week treatment using the standardised 6 minute walking test (Kunik, 2008).2

One trial and one systematic review were identified that were considered to be programmes or models based on health behaviour change theory/ies. Targeted exercise therapy in addition to a counselling strategy (Motivational Interviewing) significantly increased the mean number of steps per day (+11%) compared with usual care (-18%), p=0.01.3 However, the sample size in this study is small (n=39) and as a result the study is likely to be underpowered to detect any significant differences. A systematic review of interventions within the Chronic Care Model reported on significantly increased exercise capacity in the intervention groups.4

The remaining studies had no evidence of a theoretical framework. Action plans were found to be no more effective at increasing physical activity than education alone.5 There was no evidence of a significant difference for physical activity level, physical function or exercise capacity in a combined self-management, exercise and education programme compared with an exercise and education programme.6 Pulmonary rehabilitation (including behavioural change strategies) increased exercise capacity at 8 and 12 weeks (p<0.05) compared with a control group.7 However, there was a deterioration in exercise capacity over time suggesting that reinforcement may be required to maintain benefits. In another rehabilitation intervention, at 20 weeks the 6 minute walk test was significantly different between groups in favour of the pulmonary rehabilitation group (p=0.02). However, these differences were no longer evident at one year.8 A 3-armed trial compared exercise training and behavioural training with exercise and didactic education, or education alone. Exercise tolerance improved in all groups and there were no between-group differences.9

Four systematic reviews were identified. One reported significantly increased exercise capacity in the intervention groups.10 Another reported a significant benefit for pulmonary rehabilitation in high risk COPD patients (those recently hospitalised for acute exacerbations) compared with usual care (p<0.02).11 However, high levels of heterogeneity suggest that the trials included in the systematic review may have differed from each other (eg, disease severity or study design). In contrast the remaining systematic reviews identified no significant differences between intervention and control groups.12,13

What were the effective components of the health behaviour change interventions?
There was no indication of which components were essential and which were extraneous. However, a number of recurring components were identified:

• problem solving/goal setting
• lifestyle modifications
• disease specific information
• medication
• relaxation and stress management.

The relative importance of each component could not be determined. It is probable that the success of a health behaviour change intervention is its multi-component nature.

Conclusion
For patients with COPD the emphasis of the interventions seemed to be on dealing with an irreversible chronic disease and early identification and treatment of exacerbations. 

The overall effectiveness of self-management interventions on physical activity outcomes for people with COPD is difficult to determine due to the diverse outcome measures reported. The evidence suggests there is a benefit for improving physical activity outcomes in people with COPD following interventions based on health behaviour change theories. Even in the absence of a theoretical framework some interventions appear to be effective in increasing exercise capacity and walking distance. Pulmonary rehabilitation appears to improve exercise capacity in the short term, although it is not clear whether the beneficial effects are maintained. 

The following health behaviour change interventions were identified as being useful in increasing physical activity in patients with COPD:

• Motivational Interviewing
• Chronic Care Model
• Pulmonary Rehabilitation

For relevant Cochrane reviews on changing behaviour in COPD, click here.

1. Ministry of Health. A Portrait of Health- Key results from the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health2008.
2. Kunik ME, Veazey C, Cully JA, Souchek J, Graham DP, Hopko D, et al. COPD education and cognitive behavioral therapy group treatment for clinically significant symptoms of depression and anxiety in COPD patients: a randomized controlled trial. Psychological Medicine. 2008 Mar;38(3):385-96.
3. Hospes G, Bossenbroek L, ten Hacken NHT, van Hengel P, de Greef MHG. Enhancement of daily physical activity increases physical fitness of outclinic COPD patients: Results of an exercise counseling program. Patient Education and Counseling. 2009 May;75 (2):274-8.
4. Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of Chronic Obstructive Pulmonary Disease-Management Programs: Systematic Review and Meta-Analysis. American Journal of Medicine. 2008 May;121 (5):433-43.e4.
5. Wood-Baker R, McGlone S, Venn A, Walters EH. Written action plans in chronic obstructive pulmonary disease increase appropriate treatment for acute exacerbations. Respirology. 2006 Sep;11(5):619-26.
6. Berry MJ, Rejeski WJ, Miller ME, Adair NE, Lang W, Foy CG, et al. A lifestyle activity intervention in patients with chronic obstructive pulmonary disease. Respiratory Medicine. 2010 June;104 (6):829-39.
7. Karapolat H, Atasever A, Atamaz F, Kirazli Y, Elmas F, Erdinc E. Do the benefits gained using a short-term pulmonary rehabilitation program remain in COPD patients after participation? Lung. 2007 Jul-Aug;185(4):221-5.
8. Steele BG, Belza B, Cain KC, Coppersmith J, Lakshminarayan S, Howard J, et al. A Randomized Clinical Trial of an Activity and Exercise Adherence Intervention in Chronic Pulmonary Disease. Archives of Physical Medicine and Rehabilitation. 2008 Mar;89 (3):404-12.
9. Norweg AM, Whiteson J, Malgady R, Mola A, Rey M. The effectiveness of different combinations of pulmonary rehabilitation program components: A randomized controlled trial. Chest. 2005 Aug;128 (2):663-72.
10. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease [Systematic Review]. Cochrane Database of Systematic Reviews. 2009;1:1.
11. Puhan MA, GimenoSantos E, Scharplatz M, Troosters T, Walters HE, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease [Systematic Review]. Cochrane Database of Systematic Reviews. 2011;1:1.
12. Effing T, Monninkhof EM, van der Valk PD, van der Palen J, van Herwaarden CL, Partidge MR, et al. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane database of systematic reviews (Online). 2007;(4):CD002990.
13. Blackstock F, Webster K. Disease-specific health education for COPD: a systematic review of changes in health outcomes. Health Education Research. 2007 Oct;22(5):703-17.