Simultaneous vs sequential counseling for multiple behavior change

Arch Intern Med. 2007 Jun 11;167(11):1152-8. doi: 10.1001/archinte.167.11.1152.


Background: Many patients in primary care settings present with multiple behavioral risk factors for cardiovascular disease. Research has provided little information on the most effective ways to approach multiple behavior change counseling in clinical settings.

Methods: We implemented a randomized trial in a publicly funded primary care setting to test whether a sequential presentation of stage of change-based counseling to stop smoking, reduce dietary sodium level to less than 100 mEq/L per day, and increase physical activity by at least 10,000 pedometer steps per week would be more effective than simultaneous counseling. African Americans with hypertension, aged 45 to 64 years, initially nonadherent to the 3 behavioral goals, were randomized to the following conditions: (1) 1 in-clinic counseling session on all 3 behaviors every 6 months, supplemented by motivational interviewing by telephone for 18 months; (2) a similar protocol that addressed a new behavior every 6 months; or (3) 1-time referral to existing group classes ("usual care"). The primary end point was the proportion in each arm that met at least 2 behavioral criteria after 18 months.

Results: A total of 289 individuals (67.3% female) were randomized, and 230 (79.6%) completed the study. At 18 months, only 6.5% in the simultaneous arm, 5.2% in the sequential arm, and 6.5% in the usual-care arm met the primary end point. However, results for single behavioral goals consistently favored the simultaneous group. At 6 months, 29.6% in the simultaneous, 16.5% in the sequential, and 13.4% in the usual-care arms had reached the urine sodium goal (P = .01). At 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usual-care arms were urine cotinine negative (P = .08).

Conclusions: Long-term multiple behavior change is difficult in primary care. This study provides strong evidence that addressing multiple behaviors sequentially is not superior to, and may be inferior to, a simultaneous approach.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Ambulatory Care Facilities
  • Blacks
  • Cardiovascular Diseases / prevention & control*
  • Cotinine / urine
  • Counseling / methods*
  • Diet, Reducing
  • Female
  • Group Processes
  • Health Behavior*
  • Humans
  • Hypertension / epidemiology
  • Interviews as Topic
  • Male
  • Middle Aged
  • Motivation
  • Motor Activity
  • Patient Compliance
  • Primary Health Care
  • Prospective Studies
  • Risk Factors
  • Smoking Cessation
  • Sodium / urine
  • Sodium, Dietary / administration & dosage
  • Treatment Outcome


  • Sodium, Dietary
  • Sodium
  • Cotinine