Brief Advice

The inclusion criteria for patients to be enrolled in the SBIR intervention were: a) patients aged 18 or older; b) resident of Alberta; c) cognitively and emotionally able to participate as assessed by the healthcare provider; and d) patients’ willingness to participate. Clinical providers were asked to routinely screen eligible patients for these four modifiable risk factors using standardized screening questions (Screening) [24 (link), 26 (link)–31 (link)] and discuss the screening results with the patients. Patients who screened low risk on these factors were provided positive reinforcement. Patients who screened medium or high risk on these factors were offered brief, tailored advice and resources to encourage health behavior modification (Brief Intervention). Lastly, providers were required to offer referral(s) to health promotion programs (e.g., the AlbertaQuits smoking cessation program) in the community or within the hospital for high-risk patients (or upon patient request) who could benefit from more intensive behavior change support outside the scope of brief intervention (Referral). Paper-based SBIR pathways and form were designed to guide providers in the implementation process and the documentation of screening, brief intervention, referral aspects of the intervention received by each patient (Figure 1; Supplementary Material). Not all eligible patients cared for in the participating units were invited by healthcare providers to participate in the intervention. The providers were given latitude to suspend implementation periodically based on their judgement of feasibility within their clinical workflow.

For those patients who participated in screening for four risk factors at baseline (i.e., SBIR intervention phase), data on screening results (or risk stratification) and brief advice and referral support received status were collected using the SBIR form. At follow-up, CATI was conducted with the patients who received SBIR intervention, upon their consent, to measure the acceptability and effectiveness of SBIR. The interviews were conducted using structured questionnaires administered by the Alberta Health Services Cancer Epidemiology and Prevention Research Team, who were contracted by the HPHS innovation team to conduct the follow-up interviews. For those who did not respond to the first call, up to 6 additional calls were made, twice per day in weekdays and up to 3 messages to call back were left. Of the 543 patients screened, 307 agreed to participate and we were able to complete follow-up interviews with 108 patients (study participants, n = 108) (Figure 2). The median time from baseline to follow-up interview was 16 weeks (interquartile range = 12 weeks, 21 weeks). The reasons for non-participation at follow-up were: a) the follow-up calls were made during the office days/hours only, which limited the response from those who did not want to pick up the phone during that time; b) follow-up calls were put on hold during the early stages of the COVID-19 pandemic as research team members were deployed to respond to the pandemic; and c) in some cases incorrect or out-of-service phone numbers had been recorded on the study form. Additionally, a considerable number of patients did not agree to be interviewed during the calls, particularly after the start of the COVID-19 pandemic.
The study variables were [1 (link)]: patients’ acceptability of being asked, in the context of their hospital visit, about their health behaviors in relation to the risk factors, and [2 (link)] the effectiveness of the SBIR intervention in terms of (a) whether patients recalled the risk factor conversation with healthcare providers; (b) whether they perceived improvement in their knowledge of the link between the risk factors and chronic disease; and (c) patient behavior change in relation to the risk factor(s). To collect the data on acceptability, patients were asked “were you ok with being asked about whether you were a tobacco user at the hospital/clinic?” The same question was asked in relation to the other three risk factors.
SBIR effectiveness was measured by asking whether the patient (a) recalled having a conversation with the healthcare provider regarding the risk factors; (b) perceived that their knowledge of the link between the risk factors and chronic disease improved after they received the SBIR intervention. During the follow-up call, patients were also ask about their current behaviors on the risk factors and whether they had made any changes in their behavior on the risk factors since they had received the SBIR intervention in hospital. Patients’ behavior change in relation to the risk factors (i.e., reduced risk-level) in the time since they received SBIR intervention was identified based on changes between their baseline screening results during the SBIR intervention and the follow-up assessment on the risk factors. That included quitting tobacco use at least for the past 30 days, reducing the levels of alcohol use to low risk (risk score of ≤3 for women or ≤4 for men on the AUDIT-C screening tool); increasing physical activity levels to adequate levels (≥150 min of moderate-strenuous physical activity in a week); increasing vegetable and fruit consumption to sufficient levels (i.e., ≥5 servings of vegetable and fruit intake per day).

Using data from the SBIR form, we calculated the proportion of patients who screened medium or high risk on modifiable risk factors; who screened medium or high risk on modifiable risk factors, the proportion of total patients at medium or high risk who received brief advice, and the proportion of patients found to be high risk at screening who then received referral support. The sociodemographic characteristics of study participants, such as age, gender, and education status, which were collected at follow-up, were analyzed using descriptive statistics as appropriate to the data type (mean and standard deviation for continuous data; frequency and proportion for categorical data).
The proportion (and 95% confidence intervals (CI)) of the study participants who either agreed or strongly agreed that they were “ok with being asked,” during their hospital visit, about their behavior with respect to the risk factors was estimated to assess the acceptability outcome. The data collected on the various effectiveness outcomes were analyzed: the proportion (95% CI) of study participants were calculated for each effectiveness outcome. A chi-squared test was used to assess whether the proportion of participants with medium or high risk on at least one risk factor was statistically different (α < 0.05) between the baseline and the follow-up. Data were analyzed using SPSS version 25.0.