Adherence to healthy ways of life through counselling by health care professionals

OBJECTIVE: To estimate the prevalence of factors associated with adherence to healthy ways of life. METHODS: This is a cross-sectional study carried out with users aged over 19 from a primary health care unit in Belo Horizonte, MG, Southeastern Brazil, from 2009 to 2010. The sample was selected to estimate the proportion of people who adhere to healthy ways of life (healthy eating and physical activity) through counseling conducted by health care professionals, and associated socio-demographic, dietary and health factors. Additionally, the perceived benefi ts from the adherence to healthy ways of life and their possible barriers were verifi ed. Descriptive analysis, univariate (Chi-square Test or Fisher’s Exact) and multivariate by Poisson Regression were performed. RESULTS: Of the 417 users selected for the survey, only 40.8% received counseling, of which 50.9% demonstrated adherence. In multivariate Poisson regression, adherence was associated with the perception of food being healthy (PR = 1.67, 95%CI 1.15;2.43) and participation in the public service health campaigns(PR = 1.55, 95%CI 1.18;2.03). The main reported benefi ts of adherence were greater willingness and weight loss and, the most commonly reported barriers were diffi culty of changing habits and lack of time. CONCLUSIONS: Adopting healthier lifestyles requires the proposing of strategies that promote adherence, as well as the participation of professionals in implementing counseling as a health promoting action that generates greater autonomy and quality of life among those involved, supported by policies and programs promoting health. DESCRIPTORS: Patient Compliance. Health Behavior. Life Style. Health Promotion. DOI: 10.1590/S0034-8910.2013047003936 2 Adherence to healthy ways of life Toledo MTT et al In Brazil, the current health care situation is characterized by the increase in chronic non-communicable diseases (NCD) as a consequence in the increasing adoption of unhealthy lifestyles, especially in the areas of poor nutrition and being physically inactive, due to the processes of industrialization and globalization.a Even though the benefi ts of a healthy diet, rich in fruit, vegetables, whole grains and fi ber and doing regular exercise on promoting health and controlling chronic NCD are currently recognized,17 many Braziliansb have diffi culties in following healthy lifestyles with regards to these areas.19 Mean adherence to long term treatment for chronic NCD in developing countries is below 50%, which is considered low, according to the World Health Organization (WHO).21 According to a study carried out on patients’ adherence to healthy lifestyles and the social and psychological processes which pervade the doctor-patient relationship, only 25% of patients seen follow doctor’s advice with regards lifestyle changes, such as dietary restrictions and stopping smoking, among others.10 Moreover, the study by Duran et al11 revealed an adequate intake of macronutrients in around 60% of individuals who did physical exercise. Behavior related to adherence is a complex phenomenon with multiple determinants, there being no gold-standard in estimating it.21 Despite the different strategies for measuring adherence reported in the literature, in observational studies, patient self-reporting through structured interviews is the most frequently used option due to their ease of use, low cost and reliable predictions.16 Many patients have diffi culty adopting the guidance received in the counseling conducted by health professionals aimed at promoting health and preventing and controlling NCD, mainly because they require changes in behavior and lifestyle.21 Factors affecting adherence include demographic, psychological and social factors, those related to the patient-health care professional relationship, as well as those related to treatment and to the health care system. Thus, understanding the obstacles to and opportunities for adherence to healthy ways of living in different socio-cultural contexts constitutes a useful strategy form increasing the benefi ts from actions promoting health and controlling chronic NCD.9 INTRODUCTION The aim of this study was to estimate the prevalence of adherence to healthy ways of living and associated factors.

In Brazil, the current health care situation is characterized by the increase in chronic non-communicable diseases (NCD) as a consequence in the increasing adoption of unhealthy lifestyles, especially in the areas of poor nutrition and being physically inactive, due to the processes of industrialization and globalization.a Even though the benefi ts of a healthy diet, rich in fruit, vegetables, whole grains and fi ber and doing regular exercise on promoting health and controlling chronic NCD are currently recognized, 17 many Brazilians b have diffi culties in following healthy lifestyles with regards to these areas. 19an adherence to long term treatment for chronic NCD in developing countries is below 50%, which is considered low, according to the World Health Organization (WHO). 21cording to a study carried out on patients' adherence to healthy lifestyles and the social and psychological processes which pervade the doctor-patient relationship, only 25% of patients seen follow doctor's advice with regards lifestyle changes, such as dietary restrictions and stopping smoking, among others. 10Moreover, the study by Duran et al 11 revealed an adequate intake of macronutrients in around 60% of individuals who did physical exercise.
Behavior related to adherence is a complex phenomenon with multiple determinants, there being no gold-standard in estimating it. 21Despite the different strategies for measuring adherence reported in the literature, in observational studies, patient self-reporting through structured interviews is the most frequently used option due to their ease of use, low cost and reliable predictions. 16ny patients have diffi culty adopting the guidance received in the counseling conducted by health professionals aimed at promoting health and preventing and controlling NCD, mainly because they require changes in behavior and lifestyle. 21Factors affecting adherence include demographic, psychological and social factors, those related to the patient-health care professional relationship, as well as those related to treatment and to the health care system.Thus, understanding the obstacles to and opportunities for adherence to healthy ways of living in different socio-cultural contexts constitutes a useful strategy form increasing the benefi ts from actions promoting health and controlling chronic NCD. 9

INTRODUCTION
The aim of this study was to estimate the prevalence of adherence to healthy ways of living and associated factors.

METHODS
Cross-sectional study of service users of a basic health care unit (UBS) in Belo Horizonte, MG, Southeastern Brazil, from 2009 to 2010.Primary health care (PHC) in the municipality is structured into nine regions and 147 UBS.Family health strategy (ESF) teams work within these unit, supported by health care professionals from the family health care support services, such as social assistants, homeopaths, nutritionists and psychologists, among others.Each ESF team is responsible for the health of around a thousand families, corresponding to a mean of 3,450 to 4,500 people.
The UBS in question is located in a regions of the city which is extremely socially vulnerable, with high prevalence of chronic NCD, such as high blood pressure (49.5%), diabetes mellitus (36.0%) and dyslipidemia (15.7%).c The strong link between these morbidities and unhealthy ways of life, such as being sedentary and an unhealthy diet, added to the pattern of vulnerability and the presence of health promoting activities in the UBS's catchment area were factors which determined the inclusion of this UBS in the investigation.
The study's sample size was defi ned as 206 participants, based on the criteria of 95% confi dence intervals, statistical power of 80% and 9.4% expected adherence in the group which did not receive counselling. 10,11dividuals aged over 19 who were waiting to be seen in the UBS were eligible for the study.The interviews, carried out by previously trained interviewers, were scheduled in the morning and afternoon between October 2009 and January 2010.Pregnant women and seriously ill patients were excluded from the study.
The data were collected by academics from courses in the health care area, members of the Education Program for Working for Health (PET-Saúde) of the Universidade Federal de Minas Gerais (UFMG), the Belo Horizonte Municipal Health Department, the Ministry of Health and the Ministry of Education.
A pre-tested structured questionnaire, developed based on the instrument proposed by Lopes et al 15  Socio-demographic (age, sex, schooling and income), dietary intake (salt, sugar, oil, lean meat, skinless chicken, fruit and vegetables), reported morbidity (high blood pressure, diabetes mellitus, hypercholesterolemia, hypertriglyceridemia and coronary disease), taking medication and doing exercise.Participation in health care services aimed at promoting healthier ways of life was also investigated, such as the Community Leisure Center, located in the area in UBS and offering regular practice of physical exercise and nutritional counseling, as well as nutritional counseling developed in their own individual UBS.
To evaluate dietary intake, questions were included on the frequency and quantity of foodstuffs consumed in the preceding six months. 15When the frequency was "rarely" or "never", the item was deemed not to be consumed.Frequency of consumption was compared based on the Food Guide for the Brazilian Population.d To measure the service users' level of physical activity, the International Physical Activity Questionnaire (IPAQ), 13 revised version, was used.This instrument allows the time spent in moderate and strenuous physical activities (work, household chores, transport and leisure) to be estimated, based on recalled physical activity for the last seven days.From the score obtained, the service users were classifi ed as sedentary, irregularly active, regularly active or active.
The anthropometric evaluation consisted of measuring weight, height, waist (WC) and hip (HC) circumference, according to WHO recommendations.e Based on height, weight, WC and HC measurements, body mass index (BMI) and waist/hip ratio (WHR), respectively, were calculated.To classify the WC, WHR and BMI of adults, the references proposed by the WHO were used f and for BMI in the elderly the classifi cation proposed by the Nutrition Screening Initiative was used.f With regards WC, men with WC CC ≥ 94 cm to 101.9 cm and women with WC 80 cm to 87.9 cm were classifi ed as at high risk of metabolic complications associated with obesity and as very high risk those men with WC ≥ 102 cm and women with WC ≥ 88 cm.For WHR, men whose ratio was > 1.00 and women with values > 0.85 were classifi ed as at risk of developing cardiovascular disease.g To defi ne the variable excess weight the following BMI values were used: adults (IMC ≥ 25.0 kg/m²) and the elderly (IMC ≥ 27.0 kg/m²).
The outcome variable -service users' adherence to healthy ways of life -was defi ned as following advice given verbally by a health care professional, measured by self-reporting. 16,23Based on the responses obtained, two categories were created: individuals who adhered and individuals who did not adhere to the advice.In the adherence group were included those service users who reported following all the guidelines received from health care professional at any time, or for a time, or those who followed just some of the guidelines proposed.Those who reported attempting to follow the guidance, but not managing to, and those who did not try to follow and guidelines were included in in non-adherence group.
The categorical variables analyzed were: sex (female/ male); reported diagnosis of disease and health problems (diabetes mellitus, high blood pressure, coronary disease, hypercholesterolemia and hypertriglyceridemia); on medication (yes/no) and type of medication taken (antihypertensive, insulin, oral hypoglycemic, antidepressant or other); smoker (yes/no); familiar with the Community Leisure Center (yes/no)' eating chicken skin and fat on meat (yes/no); consider their diet to be healthy (yes/no); attempted to lose weight in the last six months (yes/no); received advice on healthy ways of living (yes/no); level of adherence to guidance (followed all received, followed all for a time and then abandoned them, followed some, tried to follow them but did not manage to, did not try to follow any guidance given); perception of benefi ts after adhering to advice (higher motivation, weight loss, improved health, others); obstacles to adhesion (diffi culty changing habits, lack of time, fi nancial diffi culties, lack of family support and others); participation in community nutrition activities (yes/no); level of physical activity according to the International Physical Activity Questionnaire -IPAQ) active, regularly active, irregularly active or sedentary); body mass index classifi cation (underweight, normal weight, overweight, obese); classification of waist circumference (no risk, high risk or very high risk of metabolic complications associated with obesity); classifi cation of waist/hip ratio (not at risk or at risk of developing diseases associated with obesity).
The quantitative variables analyzed were: age (years); household income; per capita income (household income divided by number members); years schooling; daily per capita salt, sugar and oil intake (monthly consumption/number of individuals who eat lunch and dinner at home); portions of fruit, vegetables and legumes consumed (frequency and quantity consumed transformed into portions/day); time spent in moderate physical activities per week (minutes); time spent in strenuous physical activities per week (minutes); weight (kg); height (meters); waist circumference (centimeters) and waist/hip ratio.
In the descriptive analysis the distribution of the frequency of the categorical variables and measures of central tendency and dispersion for numeric variables were calculated.Their distribution was evaluated using the Kolmogorov-Smirnov test.All had an asymmetrical distribution, being described by mean and median and minimum and maximum values.
To verify the link between the response variable and the explanatory variables Pearson's Chi-squared test or Fisher's exact test for small sample sizes were used.The values of the prevalence ratios, with their respective 95% confi dence intervals were estimated.In this analysis, all of the quantitative variables were categorized.
Variables which had a p value below 0.20 in the univariate analysis were included in the multivariate Poisson regression model with robust variance, and the fi t was achieved by individually eliminating the variables.Signifi cant variables with a 5% level of signifi cant were maintained as part of the fi nal model.
The statistical analyses were carried out using the Stata program, version 9.2.
There were 432 service users interviewed, with a loss of 3.5% (15), due to not completing the questionnaire (11), interviews with pregnant women (2) and with individuals aged under 20 (2).Therefore, 417 individuals participated in the study, the majority being female (78.9%).The median per capita income was US$ 158.23

RESULTS
With regards prevalence of disease, it was observed that 33.3% of the interviewees reported having been diagnosed with high blood pressure, 17.3% with hypercholesterolemia and 10.1% with diabetes mellitus.In addition, 54.7% reported taking some kind of medication, the most common being anti-hypertensive (27.6%) (Table 1).
Regarding nutrition, 58.9% of the individuals were overweight, 53.6% at risk of metabolic complications associated with obesity, according to WC, and 25.2% at risk of developing disease according to the WHR (Table 1).
For participation in health care service activities aimed at promoting healthier lifestyles, only 8.6% reported taking part in physical activity and nutritional guidance in the Community Leisure Center, and 2.9% reported individual nutrition monitoring in the UBS (Table 2).
Moreover, in spite of 56.8% considering their diet to be healthy, less than half of the service users (48.4%) ate lean meat, only 5.5% had an adequate intake of fruit and vegetables, 5.5% of vegetable oil and 19.7% of salt (Table 2).Of the service users interviewed, 170 (40.8%) reported having received advice from their UBS at some point, of which two individuals did not respond about their adherence, totaling 168 individuals.Of these, 50.9% (n = 86) reported total or partial adherence to the guidelines proposed (Table 3).
From adhering to healthy ways of living, 90.7% (n = 78) reported feeling some health benefi t.The main benefi ts related by the service users were better motivation (66.7%), weight loss (47.4%) and improved health (25.6%).Benefi ts such as reduced anxiety, improved self-esteem and reasoning ability and muscular hypertrophy, among others, were also reported.
Among those who did not adhere to advice received (n = 82%), the most commonly reported obstacle to adherence was diffi culty in changing habits (36.2%), followed by lack of time (25.4%) and fi nancial diffi culties (8.5%).Other obstacles cited were family problems, forgetfulness, lack of patience and distance from the Community Leisure Center.
Table 4 shows the variables signifi cantly associated with adherence (p < 0.05) in the uni-variate analysis.
With regards the socio-demographic variables, greater reported adherence to advice received was observed in those aged 60 and over compared with those aged between 20 and 39 (PR = 1.59; 95%CI 1,13;2.24).Service users with hypercholesterolemia also had better rates of adherence (PR = 1.48; 95%CI 1.10;1.99),as did those who reported participating in activities in the Community Leisure Center and individual nutrition monitoring in the UBS, those who considered their diet to be healthy and those who had tried to lose weight in the preceding six months (p < 0.05).

DISCUSSION
Although there are no specifi c parameters for evaluating adherence, d the results of this study show that around half of service users reported some degree of adherence to advice received, a higher percentage than that estimated by the WHO for developing countries d and those verifi ed in other studies on the same subject. 10,12,18lthough the degree of adherence refl ects positive health results for the individuals, as reported, signifi cant barriers to its increasing were detected, indicating the possibility for expansion through appropriate actions.
The reported health benefits of adopting healthier habits were having better motivation, losing weight and health improvements.Similarly, a study carried out with elderly obese women who adhered to a nutrition intervention program associated with physical activity indicated improved health and motivation in daily activities as well as in the context of some chronic diseases and self-esteem. 8Thus, the importance of adopting healthy ways of living through counselling as a way of helping individuals seeking to improve their health and quality of life is shown.
Among those who did not follow the guidance, obstacles cited included diffi culties in changing habits, lack of time and fi nancial conditions, as had also been found in other studies. 1,20e socio-demographic context of low income and education contribute to the perception of the existence of obstacles to adherence, given that these factors are hindering the adoption of healthier habits. 3,19Population studies on the individual factors associated with the use of medical consultations by adults show similar results to those found in this study, with greater participation of females, individuals from lower income backgrounds, with a mean age of 43 and a mean eight years of schooling. 6It stands out, then, that these characteristics are not uncommon among service users in primary health care and should be taken into consideration when developing health care activities aiming to improve service users' adherence to the proposed strategies.
On verifying the factors associated with adherence, the following variables were kept in the fi nal multivariate model: considering diet to be healthy and participating in Community Leisure Center activities.Considering diet to be healthy was probably a perception obtained from adopting healthier eating habits.However, this perception could be infl uenced by various factors, meaning the concept of healthy eating changes according to the social construct.Even with the variations, there was a noticeable trend to consider as healthy a diet which included low-calorie 'light' and 'diet' foods, low in animal fat and protein and in salt and sugar and rich in fruit, vegetables and fi ber and micronutrients. 5e link between participating in Community Leisure Center activities and adherence to healthy ways of living suggests that individuals who participate in this program may have better motivation, social support and However, participating in Community Leisure Center activities was not limited to physical exercise, as the space is also aimed at providing the opportunity to give advice on nutrition and social engagement, which could result in greater autonomy and quality of life for those involved.Thus, participating in the program is linked to adherence to both doing physical activity and to healthier eating habits. 14rroborating these fi ndings, in the Brazilian literature Araújo et al 4 identifi ed actions promoting health which contributed to improving the quality of life in the elderly, as they stimulated participation, interaction and empowerment in individuals.Moreover, various programs promoting health showed health benefi ts in the elderly, as well as in the general population. 4spite the benefits related to programs like the Community Leisure Center, it was found that the service users had insufficient awareness of this program, suggesting its limited divulgation within the community.Thus, widening the divulgation of the program constitutes an important strategy in reinforcing adherence to advice given to service users on healthy ways of living.
When considering the important of adherence to healthier ways of living faced with the service users' health profi les, it becomes indispensable to create strategies which aim to have more participation on the part of the health care professionals in implementing them and to incentivize these professionals to take practical qualifi cations in health care counselling.Therefore, it is necessary to consider both the obstacles to adherence reported by service users and the diffi culties experienced by health professionals in their implementation in daily work and life.Very often, such diffi culties are related to lack of time, motivation theoretical-practical knowledge of the subject, the diffi culty inherent in adopting healthier ways of living and to the patients' perception on adhering to the advice. 2,22 spite of the fi ndings, the cross-sectional design of the study made it impossible to establish temporal cause-effect relationships between adherence to healthy ways of living and service users' socio-demographic, nutritional and health characteristics.Moreover, other factors, such as availability of health promoting services, in addition to the Community Leisure Center, access to healthy food in the area, he time for diagnosing diseases and use of medicines, that were not analyzed, could be associated with adherence, constituting possible residual effects.
It also needs to be considered that, as the sample process was carried out in only one UBS, the results found cannot be extrapolated to the general population; however, they can contribute to greater knowledge of the subject.
Another limitation of the study is the lack of specifi c parameters in the literature for evaluating adherence to healthy ways of living, factors which may compromise the conclusions drawn.However, in order to estimate patterns of adherence in observational studies, patient self-reporting cased on structured interviews is currently the most commonly used option. 16 conclude, the fi ndings of this study reinforce the need for actions in the area of primary health care which encourage the practice and adherence to advice on healthy ways of living through policies and programs promoting health.

d
Ministério da Saúde, Secretaria de Atenção à Saúde, Coordenação-Geral de Política de Alimentação e Nutrição.Guia alimentar para população brasileira.Brasília (DF); 2006.e World Health Organization.Physical status: the use and interpretation of anthropometry: report of a WHO Expert Committee.Geneva; 1995.(Technical Report Series, 854).f Nutrition Screening Initiative.Nutrition interventions manual for professionals caring for older Americans: project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging.Washington (DC); 1992.

Table 2 .
Prevalence UBS: Basic Health Care Unit; IPAQ: International Physical Activity Questionnaire

Table 4 .
Variables associated with adherence to healthy ways of living through counselling by health care professionals.Belo Horizonte, MG, Southeastern Brazil, 2009-2010.(N = 168)

Table 5 .
7inal support of health care professionals in adopting these habits.Accordingly, it was found in a study in Campinas, SP, Southeastern Brazil, that attending a recreation center, like Community Leisure Center, increased the chance of doing moderate or strenuous physical exercise by 11.4 times among the women interviewed.7 PR: prevalence ratio Test goodness of fi t: p = 0.99 the