Evid Based Nurs 11:12 doi:10.1136/ebn.11.1.12
  • Treatment

Sequential counselling that targeted individual health behaviours did not differ from simultaneous counselling that targeted multiple behaviours

D J Hyman

Correspondence to: Dr D J Hyman, Baylor College of Medicine, Houston, TX, USA; dhyman{at}


In patients with multiple behavioural risk factors for cardiovascular disease, is sequential counselling (SQC) that targets 1 behaviour at a time more effective than simultaneous counselling (SMC) that targets multiple behaviours?



randomised controlled trial (RCT).





Follow-up period:

18 months.


2 primary care clinics in the southwestern US.


289 African-American patients 45–65 years of age (mean age 53 y, 67% women) who had hypertension, currently smoked (cotinine >40 ng/ml for 24 h urine sample or reported smoking ⩾5 cigarettes/d for the past wk), had a 24-hour urine sodium level >100 mEq/l per day, and did not exercise regularly (ie, ⩾3 times/wk for ⩾30 min, hard enough to work up a sweat). Exclusion criteria included systolic blood pressure (BP) >180 mm Hg or diastolic BP >110 mm Hg, type 1 diabetes mellitus, history of myocardial infarction, and inability to walk regularly at a moderate pace.


SQC (n = 96), in which the target behaviours (see Outcomes) were introduced 1 at a time (in random order) at 6 month intervals; SMC (n = 92), in which the 3 target behaviours were addressed at the same time; or usual care (n = 93), in which participants received a brief review of educational materials on the 3 target behaviours. Participants in the SQC and SMC groups received a brief in-clinic session with a health educator every 6 months, followed by seven 15-minute telephone counselling sessions and self-help materials.


adherence to >1 target behaviour (urine negative for cotinine, 24-h sodium level <100 mEq/l/d, and increase of 10 000 pedometer steps/wk in the previous wk). The study had 99% power to detect a 35% difference between SQC and usual care, 82% power to detect a 15% difference between SMC and usual care, and 70% power to detect a 20% difference between SQC and SMC (α = 0.05). Secondary outcomes included adherence to individual behaviours.

Patient follow-up:

79.6% were assessed at 18 months.


At 18 months, SQC, SMC, and usual care did not differ for adherence to >1 target behaviour (table) or adherence to individual behaviours (smoking cessation, n = 230, 17% v 20% v 10%; sodium reduction, n = 230, 13% v 9.5% v 18%; increased physical activity, n = 190, 27% v 33% v 23%).


In patients with multiple behavioural risk factors for cardiovascular disease, sequential counselling that targeted individual behaviours did not differ from simultaneous counselling that targeted several behaviours at the same time.

Sequential (SQC) v simultaneous counselling (SMC) v usual care in patients with behavioural risk factors for cardiovascular disease*


Hyman DJ, Pavlik VN, Taylor WC, et al. Simultaneous vs sequential counseling for multiple behavior change. Arch Intern Med 2007;167:1152–8.

Clinical impact ratings: Cardiology 7/7; Family/General practice 5/7; Health promotion 5/7; Patient education 7/7


  • Source of funding: National Heart, Lung, and Blood Institute.


Limited research is available on the differential benefits of SQC and SMC approaches to promoting multiple health risk behaviour change, and no outcome data are available to provide clear direction for optimal construction of health risk behaviour programmes. The study by Hyman et al is one of the few that compares the effectiveness of culturally tailored behavioural interventions delivered by telephone in primary care settings to improve adherence to lifestyle advice for cardiac risk factor modification. This well-designed study identified measurable behavioural outcomes and recruited African-American primary care patients, who have high cardiovascular risk and tend to be under-represented in RCTs. Because participants were recruited from a single geographical place, ethnic and age group findings may differ for other populations in the US and globally.

The primary hypothesis that SQC would lead to greater adoption of multiple risk reduction behaviours than SMC was not supported. Analysis of secondary outcomes showed that SMC was better than SQC for changing a single behaviour. The findings highlight the complexity of implementing effective behavioural change programmes in primary care. Such programmes are key to achieving successful risk reduction outcomes for major public health problems such as cardiovascular disease, especially in high-risk ethnic groups. While some practitioners may choose to focus on 1 behaviour at a time, there is no conclusive evidence that this is more effective than a SMC approach. For now, nurse practitioners, public health nurses, health educators, and others who focus on preventive behavioural change in primary care settings can consider the use of a SMC model for cardiovascular risk reduction involving several target behaviours. Providers and patients need to prioritise outcome targets since treatment success is likely to be limited to only one behaviour.

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