Review question and objectives

This research aims to identify, describe, classify and analyse the range of models developed to date for delivering health-related lifestyle advice (HRLA), or training, for effectiveness, mechanism of effect, cost-effectiveness, equity and acceptability in improving the health and well-being of individuals and communities, with particular reference to the reduction of inequalities in the UK.

Typical of the complexity of public health issues, the question addressed in this review is broad and multifaceted. The overall question was therefore broken down and grouped under two broad groupings:

1. What are the component intervention techniques of lifestyle advisors (LAs) in the UK and similar contexts?
2. What are the outcomes of HRLA interventions?

Methods

Results

In total, 269 studies that evaluated HRLA were identified but 243 were excluded owing to a range of methodological factors that made them unsuitable for inclusion in a systematic review. The 26 included studies addressing chronic care, mental health, breastfeeding, smoking, diet and physical activity, screening and human immunodeficiency virus (HIV) infection prevention.

Overall, the evidence was not sufficient to support or refute the use of LAs to promote health and improve quality of life (QoL). Although there is likely to be considerable uncertainty about statements of interventions' cost-effectiveness because of the sparse evidence base for effectiveness, lessons can be drawn from the realist analysis of the included studies.

• LA interventions in chronic care are cost-effective. The success of interventions to improve the management of chronic conditions is linked to their largely already engaged target group and to their aim, which differs from that of some of the other HRLA, in that they help people live with a condition rather than necessarily aiming at behaviour change.
• LA interventions for smoking cessation are cost-effective because of the important health gains that derive from cessation. The economic analysis excluded studies when effectiveness did not reach statistical significance. However, the buddy schemes explored in these studies have much to offer to an analysis of intervention components and may still offer potential as a practice model.
• From the evidence that could be accessed, the cost-effectiveness of LA interventions for breastfeeding is inconclusive. Intervention mechanisms details suggest that these interventions tended to use peers with common experience, and aimed at enhancing, rather than changing, behaviour.
• Included studies did not allow the production of a conclusive cost-effectiveness estimate for LA interventions for mental health. This intervention presented a mechanism in common with the smoking cessation 'buddy' system, in that it paired people with a similar experience (that of being the parent of a child with a chronic condition). LA interventions for screening uptake are not cost-effective. These interventions did reach, however, a large number of people, they presented, on the whole, high degrees of acceptability, and targeted population groups, which tended to be disengaged from mainstream service provision.
• LA interventions for diet and physical activity are not cost-effective. Highlighted by the realist analysis was an alternative intervention mechanism, in that one study targeted whole family groupings rather than individuals. This was a unique intervention characteristic within this review.
• LA interventions for HIV infection prevention were cost-effective, but not in a UK context. Realist analysis highlights that they did succeed, however, in reaching hard-to-reach communities and build on social capital – two aims of the health trainer scheme in the UK.

Conclusions

The wide variety of LA models, delivery settings and target populations prevented the reviewers from establishing firm causal relationships between intervention mode and study outcomes. Evidence is variable and can only give limited support to LAs having a positive impact on health knowledge, behaviours and outcomes. Levels of acceptability appear to be high. LAs acted as translational agents, sometimes removing barriers to prescribed behaviour or helping to create facilitative social environments. Reporting of processes of accessing or capitalising on indigenous knowledge (IK) is limited. Ambiguity continues with respect to the role and impact of lay and peer characteristics of the interventions.

Recommendations for practice

• Interventions that are low cost and have some effect are recommended.
• Further recognition of the IK base of the LA may be required.
• Training of LAs may be worthy of particular attention, as a balance needs to be reached between provider and LA-identified learning needs.
• The process of message tailoring and the effectiveness of inclusion of different aspects of community allegiance and IK require further exploration.
• There is a need for clearer definitions of target groups, their characteristics and particular needs.
• Intervention approaches need to be made more explicit.
• Peership and layness need to be considered and defined for particular settings.
• Short-, medium- and long-term intervention outcomes need to be clearly identified and measured.

Recommendations for a future programme of research

The following recommendations carry particular relevance to the UK context, but may also be of international relevance. They are designed to form a programme of research on HRLA, around the identification of needs, the broadening of population focus and intervention aims, the measurement of outcomes and the reviewing of evidence.

• Identifying need:
  • A concept mapping approach may be an appropriate strategy to use in order to identify what people believe helps them adhere to healthy lifestyle advice, and to triangulate this to views of public health professionals and community leaders.
• Target groups:
  • Interventions in groups not addressed in the review (men, transient populations, homeless people, etc.), broader interventions in groups with specific issues (e.g. physical health in mental health population groups), and prevention in general health promotion (such as stop smoking plus diet, exercise and screening) need further development.
  • Research on alternative target groups that may be of broader focus than health related, such as, for example, faith groups, youth groups, community centres, gangs, playschemes, etc.; within each group, existing leaders could be identified and collaborative relationships nurtured to identify, assess and address local needs. Such schemes are likely to lead to community development activities but would require longitudinal funding schemes.
• Intervention aim:
  • Research is needed on the building of social capital or community development through LA schemes. This would entail a focus on social and structural, rather than individual, determinants of health inequalities.
  • A development of research led by, or conducted in collaboration with, community guides would help to develop ways for health-care providers to maximise the potential of pre-existing 'unofficial' health improvement activities.
• Outcome identification and measurement:
  • This review endorses the need for a strategic movement along the Medical Research Council continuum of evidence so that research evolves from scoping practice to evaluating outcomes.
  • HRLA schemes would benefit from a development of current methodological advancements to help identify and assess short-, medium- and long-term intervention outcomes. In the long term, this would encourage the publication of promising outcomes and thus strengthen the HRLA evidence base.
  • There is a need to establish equity of outcomes between groups of different socioeconomic profiles.
  • There is a need to identify what enables long-term effects, i.e. regular low-cost 'top-up' interventions or multidimensional interventions with changes in approach over time.
• Systematic reviewing in public health:
  • A greater engagement with realistic review or synthesis principles would allow exposure of contexts and mechanism components that influence a range of outcomes in HRLA interventions.
  • This review supports previously published commentaries on the necessity for the development of quality assessment tools that could allow increased methodological flexibility.

Funding

This study was funded by the Health Technology Assessment programme of the National Institute for Health Research.

Publication

• Carr SM, Lhussier M, Forster N, Geddes L, Deane K, Pennington M, et al. An evidence synthesis of qualitative and quantitative research on component intervention techniques, effectiveness, cost-effectiveness, equity and acceptability of different versions of health-related lifestyle advisor role in improving health.. Health Technol Assess 2011;15(9). [PMC free article: PMC4781312] [PubMed: 21329611]

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