Brief training in patient-centered counseling for healthy weight management increases counseling self-efficacy and goal setting among pediatric primary care providers: results of a pilot program

Physical Activity Counseling and Documentation by Pediatric Residents in Primary Care: Before and After Introduction of the FITT Principle

Physician training on physical activity (PA) counseling in patient care is highly variable. The objective of this study was to improve PA counseling by pediatric residents through introduction of the four components of PA, called the FITT principle (frequency, intensity, time, type). Pediatric residents (n=30) received lectures, curriculum content, and an electronic smart-phrase addressing PA in obesity, including the FITT principle. Surveys assessed resident attitudes, and chart reviews (n = 423 over 16 months) identified evidence of PA counseling including FITT principle components preintervention and postintervention. Survey results showed positive attitudes and confidence regarding primary care provider roles in counseling on PA, with no differences postintervention. Chart reviews demonstrated increased documentation on PA frequency postintervention (pre 31.9% vs post 50.9%, P=.00006), but no significant changes in intensity, time or type. In conclusion, a focused PA curriculum promoted PA counseling by pediatric residents, with increased documentation of one component of the FITT principle.

Impact of a brief training on motivational interviewing and the 5A's approach on weight-related counseling practices of pediatricians

Background

Pediatric primary healthcare providers are well-positioned to provide healthy lifestyle and weight management related counseling but many lack training in evidence-based messages and methods.

Objectives

We assessed the impact of a brief, easy-to-access training for pediatric healthcare providers, (the Strong4Life Provider Training), designed to introduce/review current evidence-based messages and methods and improve healthy weight-related assessment and counseling practices.

Methods

Following their well-child visit, a convenience sample of children 12-17 years and parents of children 6-11 years (N = 121) of randomly selected Strong4Life trained (N = 15) and untrained (N = 15) pediatricians were administered a survey designed to assess the frequency, content, and patient satisfaction with weight management-related counseling provided. Results from parents and patients of trained pediatricians (N = 62) compared to those from parents and patients of untrained pediatricians (n = 59) were compared using chi-square tests. Generalized estimating equations were used to account for lack of independence among respondents from the same practice. P-values less than 0.05 were considered to be statistically significant.

Results

Parents/patients of trained pediatricians were more likely than those of an untrained pediatrician to report having been asked about child's consumption of fruit/vegetables, 57 (92%) versus 44 (75%), p = 0.04 and sugary drinks, 50 (81%) versus 29 (49%), p = 0.005, and their readiness for behavior change, 47 (76%) versus 29 (49%), p = 0.005, and to set a behavior change goal, 36 (59%) versus. 23 (40%), p = 0.005. Regardless of training status, physical activity, screen time, and weight status were assessed for most patients, and most were satisfied with the discussion. Few (21%) were asked about barriers to behavior change.

Hospital Culture and Healthcare Workers' Provision of Patient-Centered Care: A Moderated Mediation Analysis

Background

Patient-centered care (PCC) is globally recognized as a high-quality and high-value healthcare service. It emphasizes the broad participation of patients and families in health-related decision-making and the provision of healthcare services that cater to patients' needs, preferences, and values. However, the mechanisms driving healthcare workers' provision of PCC are yet to be fully uncovered.

Methods

Using stratified random sampling, we recruited 1,612 healthcare workers from different levels of public hospitals in Hangzhou. We conducted survey interviews using questionnaires based on psychometrically sound scales. Structural equation modeling was used to analyze the effects of hospital culture, self-efficacy, and achievement motivation on the perceived provision of PCC by healthcare workers and to explore the mechanisms underlying their relationships.

Results

Self-efficacy had a positive mediating effect in the relationship between hospital culture and healthcare workers' perceived provision of PCC (β = 0.424, p < 0.001). Furthermore, the pursuit of success positively moderated the mediating role of self-efficacy (β = 0.128, p < 0.001), whereas, the avoidance of failure negatively moderated the mediating role of self-efficacy (β = -0.017, p < 0.001).

Conclusion

The findings suggest that hospitals should foster patient-centered and innovative cultures and develop strategies focusing on both internal motivation (self-efficacy and achievement motivation) and external environments (hospital culture) to help and encourage healthcare workers to implement PCC. For example, hospitals could further communication skills training, enhance leadership, build team spirit, and promote collaboration among healthcare workers.

U.S. medical students personal health behaviors, attitudes and perceived skills towards weight management counseling

Physicians' abilities to address obesity in routine care may be affected by their own health behaviors, skills in and attitudes toward weight management counseling (WMC). Gender differences have been noted amongst these factors as well. We examined gender differences in personal health behaviors and predictors of perceived WMC skills and attitudes of medical students enrolled in a WMC trial. Enrollment took place in 2020 and consisted of students from eight U.S. medical schools. Baseline measures included demographics, exercise, and weight management behaviors, WMC attitudes and perceived skills. Descriptive statistics were calculated, and linear mixed models used to assess the effect of personal health behaviors on outcomes of WMC attitudes and perceived skills. Complete data were available for 1145 medical students. More males reported exercising 4 or more days/week (58.6% v. 41.4%), being more likely to monitor their weight (75.6% v. 70.3%) and less likely to intentionally attempt weight loss in the past (50.3% v. 65.3%) compared to females (all p's < 0.05). Exercising 4 or more days per week was positively associated with perceived WMC skills in the adjusted model (β = 0.10, CI 0.06 to 0.14, p < 0.01). Exercise frequency was positively associated with perceived WMC skills, regardless of gender. WMC curriculum may consider focusing on personal health behaviors such as exercise to increase perceived WMC skills.

Social Context, Self-Efficacy, and Patient-Centered Service Behavior of Medical Professionals: The Moderating Role of Achievement Motivation

Patient-centered services are high-value, high-quality medical services that can improve patient satisfaction and safety. However, little is known about their driving mechanisms. This study examined whether external (social context) and internal (self-efficacy) motivation affects medical professionals' patient-centered service behavior, and explored the moderating role of medical professionals' achievement motivation. A cross-sectional survey was conducted with medical professionals at public hospitals in Hangzhou. Descriptive statistics, hierarchical linear regression analysis, and structural equation modeling were used to analyze the data. The final analysis included 1,612 medical professionals. Results indicated that perceived social context and self-efficacy had direct and positive effects (β = 0.578, β = 0.269) on medical professionals' patient-centered service behavior. Social context also indirectly influenced medical professionals' patient-centered service behavior mediated by self-efficacy (β = 0.149). Additionally, achievement motivation played a moderating role (β = -0.037) between the social context and self-efficacy. From the results it can be deduced that an excellent social environment and strong self-efficacy can promote the patient-centered service motivation of medical professionals. This promoting effect is even more significant under the moderating effect of high achievement motivation. Governments, health administrative departments, and hospital management should use internal and external motivation factors to promote medical professionals' patient-centered service behavior. Along with formulating relevant laws and regulations, efforts should also be made to guide medical professionals to improve their self-efficacy and achievement motivation, thereby encouraging patient-centered medical service behavior.

Improvement in Primary Care Provider Self-Efficacy and Use of Patient-Centered Counseling To Address Child Overweight and Obesity after Practice-Based Changes: Texas Childhood Obesity Research Demonstration Study

BACKGROUND

The Texas Childhood Obesity Research Demonstration project, a multicenter, multisystem approach to childhood overweight and obesity (OW/OB), included training and materials to support primary care clinics (PCCs) in addressing child OW/OB in the office. This study evaluated the impact over 24 months of brief training and practice-based support on primary care providers' (PCPs) perceived self-efficacy and practice behaviors.

METHODS

The PCPs at five Houston and seven Austin PCCs completed questionnaires at baseline (2012, n = 36), 12 months (2013, n = 30), and 24 months (2014, n = 34) follow-up. Mixed-effects linear regression models were used to compare changes in self-efficacy (15 items, responses 1-4: not at all confident to very confident) and practice behaviors (30 items, responses 0-4: never to always) in obesity-related screening and counseling, and to assess association between prior training and these outcomes.

RESULTS

Self-efficacy items for identification of (2.9 [0.1] vs. 3.3 [0.1]) and counseling about (2.8 [0.1] vs. 3.4 [0.1]) OW/OB-related parenting practices, and setting behavioral goals (2.9 [0.2] vs. 3.3 [0.2]) improved significantly (p < 0.05) between baseline and 24-month follow-up. Self-efficacy items with "confident" mean baseline scores that further improved included determining child OW/OB (3.6 [0.1] vs. 3.9 [0.1]) and interpreting BMI (3.6 [0.1] vs. 3.9 [0.1]). At all measurements, PCPs reported frequently addressing medical problems and lifestyle behaviors. Use of patient-centered counseling techniques, which was low at baseline, increased significantly, including asking permission before discussing lifestyle (1.5 [0.3] vs. 2.4 [0.3]). Prior training was associated with improved self-efficacy.

CONCLUSIONS

The improvement in PCPs' self-efficacy and patient-centered counseling to address childhood OW/OB supports implementation of brief training and practice support in clinics that serve Medicaid-eligible children.

Prevention and Management of Obesity in Children with Autism Spectrum Disorder Among Primary Care Pediatricians

Children with autism spectrum disorder (ASD) are at high risk for being overweight and obese. Little is known about how obesity in children with ASD is being addressed in primary care. This article reports findings from a survey completed by 327 general pediatricians, which included a fictional clinical vignette and Likert-scales assessing attitudes, practices, self-efficacy, and barriers to obesity management. Although the majority of respondents agreed pediatricians should be the main providers to manage obesity in children with ASD, few reported receiving adequate training to do so. Pediatricians were more likely to refer to developmental-behavioral pediatricians and dietitians for a child with ASD compared to a child without ASD. Higher self-efficacy was associated with increased weight-related counseling frequency by pediatricians.

A call to action to inform patient-centred approaches to obesity management: Development of a disease-illness model

Patient-centred care is an essential component of high-quality health care, shown to improve clinical outcomes and patient satisfaction, and reduce costs. While there are several authoritative models of obesity pathophysiology and treatment algorithms, a truly patient-centred model is lacking. We describe the development of a patient-centric obesity model. A disease-illness framework was selected because it emphasizes each patient's unique experience while capturing biomedical aspects of the disease. Model input was obtained from an accumulation of research including contributions from experts in obesity and patient-reported outcomes, qualitative research with adults living in the United States, and two targeted literature searches. The model places the patient with obesity at its core and links pathologic imbalances of energy intake and expenditure to environmental, sociodemographic, psychological, behavioural, physiological and medical health determinants. It highlights relationships between obesity signs and symptoms, comorbid conditions, impacts on health-related quality of life, and some barriers to obesity management that must be considered to attain better outcomes. Providers need to evaluate patients holistically, understand what changes each patient is motivated to make, and recognize what challenges might impede weight reduction, improvements in comorbid conditions, signs and symptoms, and health-related quality of life before pursuing individualized treatment goals. Patients living with obesity who do lose weight perceive benefits beyond weight loss. Ideally, this model will increase awareness of the complex, heterogeneous impacts of obesity on patients' well-being and recognition of obesity as a chronic disease, and prompt a call to action among stakeholders to improve quality of care.

Impact of an American board of pediatrics maintenance of certification (MOC) on weight-related counseling at well-child check-ups

OBJECTIVE

The Healthy Weight Counseling Maintenance of Certification (MOC) program integrates pediatrician training and clinic changes to promote use of evidence-based, diet and physical activity (PA) health messages and counseling strategies. This interrupted time series study assessed the impact of this MOC program on provision of weight-related counseling.

METHODS

We randomly selected 10-15 well-child visit charts at three time points before and three time points after 102 Georgia pediatricians began the MOC in 2012-2015. Linear binomial regression compared the frequency of behavior-change goal setting and health messaging documentation (fruit/vegetable consumption, sugar-sweetened beverage consumption, out-of-home food consumption, PA, and screen time) before and after MOC participation.

RESULTS

At baseline, pediatricians documented behavior-change goals with 44% of patients, with an additional 49% of patients having documented goals after their pediatrician started the MOC (99.5% confidence interval [CI]: 21-77%). Similarly, absolute increases in the proportion of patients with documentation for sugar-sweetened beverage consumption (adjusted prevalence difference [aPD]: 37%; 99.5% CI: 13-62%) and out-of-home eating were observed (aPD: 38%; 99.5% CI: 12-64%).

CONCLUSION

The Healthy Weight Counseling MOC is associated with increased and sustained use of evidence-based health messages and counseling strategies.

PRACTICE IMPLICATIONS

Continuing education and facilitation of system changes help improve physicians' weight-related counseling.

Internet-based self-monitoring interventions for overweight and obese adolescents: A systematic review and meta-analysis

BACKGROUND

Internet-based self-monitoring intervention offers accessibleand convenient weight management. This review aimed to systematically review the evidence on the effectiveness of internet-based self-monitoring intervention for overweight and obese adolescents.

METHOD

PubMed, CINAHL, Cochrane Library, EMBASE, ProQuest, PsycINFO and SCOPUS were systematically searched for randomised controlled trials (RCTs) from inception until December 13, 2017. The risk of bias and strength of evidence was assessed using the Cochrane Collaboration Risk of Bias Tool and the Grading of Recommendations, Assessment, Development and Evaluations criteria. Meta-analysis was performed on the RevMan software using a random effects model. The overall effect was assessed using effect size (Cohen'sd)and heterogeneity was evaluated using Cochrane Q and I2 values. PROSPERO database #CRD42016050089.

RESULTS

A total of 6841 records were identified. Six RCTs in 10 articles were selected amongst 505 adolescents across three countries who were overweight and obese. The meta-analysis revealed a small effect on the reduction of body mass index (BMI) and BMI z-scores (d = 0.30, 95% CI: -0.48 to -0.12). Subgroup analyses suggest the use of daily multicomponent self-monitoring, specified goal setting, face-to-face counselling and parental involvement. The overall quality of evidence was low due to the risk of bias and imprecision.

CONCLUSION

Internet-based self-monitoring intervention is a possible approach for overweight and obese adolescents to reduce their BMI. Further well-designed RCTs with follow-up data and large sample sizes are needed to ensure the robustness of the evidence.

Evaluating the Impact of Training in Obesity Prevention Methods on the Counseling, Knowledge, and Skills of WIC Nutritionists in Georgia, 2014-2015

OBJECTIVES

Motivational interviewing, a client-centered intervention method focused on enhancing intrinsic motivation for behavior change, shows a positive impact on children's weight status (ie, stabilizing or slowing down weight gain as a child grows). We evaluated the impact of a training program on knowledge and adoption of evidence-based obesity prevention counseling strategies among counselors from Georgia's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

METHODS

Between July 2014 and September 2015, Children's Healthcare of Atlanta's Strong4Life program provided 388 WIC counselors in Georgia with a 2-hour training session on motivational interviewing, patient-centered counseling, and goal setting for obesity prevention. We evaluated the training using (1) self-administered pre- and post-training surveys that assessed knowledge of counseling strategies, (2) post-training observation of counseling interactions, and (3) a review of behavior change goal quality pre- and post-training in a random sample of 200 WIC client charts.

RESULTS

In a comparison of pre-training knowledge with immediate post-training knowledge among 388 counselors, 81% vs 91% ( P < .001) knew that, to be effective, goals must be important to clients, and 66% vs 94% ( P < .001) knew the 5 A's (assess, advise, agree, assist, arrange) of counseling. Knowledge improvements were sustained at 3 months post-training. We observed no improvements in the quality of chart-documented behavior goals.

CONCLUSIONS

WIC nutrition counselors in Georgia were aware of evidence-based counseling strategies but did not consistently apply them. The training program was helpful, but time and additional support are needed to adopt new practices.

Missing an opportunity: the embedded nature of weight management in primary care

The 5As Team study was designed to create, implement and evaluate a flexible intervention to improve the quality and quantity of weight management visits in primary care. The objective of this portion of the study was to explore how primary care providers incorporate weight management in their practice. 5AsT is a randomized controlled trial (RCT) on the implementation of a 6-month 5 As Team (5AsT) intervention designed to operationalize the 5As of obesity management in primary care. Data for the qualitative portion of the study presented here included semi-structured interviews with 29 multidisciplinary team providers and field notes of intervention sessions. Thematic analysis was undertaken. A key pattern that emerged from the data was that healthcare providers usually do not address obesity as a primary focus for a visit. Rather, obesity is embedded in a wide range of primary care encounters for other conditions. Implications were it can take extra time to discuss weight, it can be inappropriate to bring up weight as a topic, and treating risk factors and root causes of obesity have indirect benefits to patient weight management. Our findings have implications for obesity treatment approaches and tools that assume a discreet weight management visit. The embedded nature of obesity management in primary care can be harnessed to leverage multiple opportunities for asking and assessing root causes of obesity, and working longitudinally towards individual health goals.