Implementing a dietary intervention in primary care practice: a process evaluation

The Incomplete Medicalization of Obesity: Physician Office Visits, Diagnoses, and Treatments, 1996-2014

OBJECTIVES

Despite increased awareness of obesity-related health risks and myriad treatment options, obesity still affects more than one-third of persons in the United States and is a substantial public health problem. Studies show that physicians play a key role in obesity prevention and treatment. The objective of this study was to examine the extent to which obesity is diagnosed and treated at the level of patient-physician interaction.

METHODS

We used data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative data set of US physician office visits. We estimated the number of obesity diagnoses and prescriptions of weight-loss management solutions (exercise counseling, diet counseling, or weight-loss drugs) in clinical practice from 1996 through 2014. We also calculated rates of obesity diagnosis and compared these rates with national rates of obesity based on body mass index data from the Behavioral Risk Factor Surveillance System (BRFSS) for the same period.

RESULTS

The estimated number of weight gain-related physician office visits increased from 2.3 million in 1996 to a peak of 7.6 million in 2012, and then fell to 4.5 million in 2014. National estimates of obesity diagnoses resulting from physician office visits ranged from 7.1 million in 1996 to 12.7 million in 2014 and substantially outnumbered the estimates for weight gain-related physician office visits throughout the study period. Estimates of exercise counseling and diet counseling and weight-loss medication prescriptions resulting from physician office visits fluctuated over time but never exceeded obesity diagnoses. When compared with national rates of obesity from the BRFSS, rates of obesity diagnoses resulting from physician office visits were substantially lower in the NAMCS (17%-30% vs 1%). National trends for weight-loss medication prescriptions closely mirrored those of weight gain-related physician office visits, even though fluctuations were substantial.

CONCLUSIONS

Our results suggest that obesity is largely underdiagnosed and undertreated in clinical encounters. Future studies should investigate the structural changes needed to better engage physicians in obesity prevention and care. Practitioners should also reflect on their biases in treating obesity as a chronic disease.

Measures of fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions: A systematic review of measure quality

PURPOSE

Understanding the effectiveness of complex, face-to-face health behaviour change interventions requires high-quality measures to assess fidelity of delivery and engagement. This systematic review aimed to (1) identify the types of measures used to monitor fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions and (2) describe the reporting of psychometric and implementation qualities.

METHODS

Electronic databases were searched, systematic reviews and reference lists were hand-searched, and 21 experts were contacted to identify articles. Studies that quantitatively measured fidelity of delivery of, and/or engagement with, a complex, face-to-face health behaviour change intervention for adults were included. Data on interventions, measures, and psychometric and implementation qualities were extracted and synthesized using narrative analysis.

RESULTS

Sixty-six studies were included: 24 measured both fidelity of delivery and engagement, 20 measured fidelity of delivery, and 22 measured engagement. Measures of fidelity of delivery included observation (n = 17; 38.6%), self-report (n = 15; 34%), quantitatively rated qualitative interviews (n = 1; 2.3%), or multiple measures (n = 11; 25%). Measures of engagement included self-report (n = 18; 39.1%), intervention records (n = 11; 24%), or multiple measures (n = 17; 37%). Fifty-one studies (77%) reported at least one psychometric or implementation quality; 49 studies (74.2%) reported at least one psychometric quality, and 17 studies (25.8%) reported at least one implementation quality.

CONCLUSION

Fewer than half of the reviewed studies measured both fidelity of delivery of, and engagement with complex, face-to-face health behaviour change interventions. More studies reported psychometric qualities than implementation qualities. Interpretation of intervention outcomes from fidelity of delivery and engagement measurements may be limited due to a lack of reporting of psychometric and implementation qualities. Statement of contribution What is already known on this subject? Evidence of fidelity and engagement is needed to understand effectiveness of complex interventions Evidence of fidelity and engagement are rarely reported High-quality measures are needed to measure fidelity and engagement What does this study add? Evidence that indicators of quality of measures are reported in some studies Evidence that psychometric qualities are reported more frequently than implementation qualities A recommendation for intervention evaluations to report indicators of quality of fidelity and engagement measures.

Results from the dissemination of an evidence-based telephone-delivered intervention for healthy lifestyle and weight loss: the Optimal Health Program

Despite proven efficacy, there are few published evaluations of telephone-delivered interventions targeting physical activity, healthy eating, and weight loss in community dissemination contexts. This study aims to evaluate participant and program outcomes from the Optimal Health Program, a telephone-delivered healthy lifestyle and weight loss program provided by a primary health care organization. Dissemination study used a single-group, repeated measures design; outcomes were assessed at 6-month (mid-program; n = 166) and 12-month (end of program; n = 88) using paired analyses. The program reached a representative sample of at-risk, primary care patients, with 56 % withdrawing before program completion. Among completers, a statistically significant improvement between baseline and end of program was observed for weight [mean change (SE) -5.4 (7.0) kg] and waist circumference [-4.8 (9.7) cm], underpinned by significant physical activity and dietary change. Findings suggest that telephone-delivered weight loss and healthy lifestyle programs can provide an effective model for use in primary care settings, but participant retention remains a challenge.

They think they know but do they? Misalignment of perceptions of lifestyle modification knowledge among health professionals

OBJECTIVE

The present study aimed to evaluate the knowledge and practices of public-sector primary-care health professionals and final-year students regarding the role of nutrition, physical activity and smoking cessation (lifestyle modification) in the management of chronic diseases of lifestyle within the public health-care sector.

DESIGN

A comparative cross-sectional descriptive quantitative study was conducted in thirty primary health-care facilities and four tertiary institutions offering medical and/or nursing programmes in Cape Town in the Western Cape Metropole. Stratified random sampling, based on geographical location, was used to select the health facilities while convenience sampling was used to select students at the tertiary institutions. A validated self-administered knowledge test was used to obtain data from the health professionals.

RESULTS

Differential lifestyle modification knowledge exists among both health professionals and students, with less than 10 % achieving the desired scores of 80 % or higher. The majority of health professionals seem to be promoting the theoretical concepts of lifestyle modification but experience difficulty in providing practical advice to patients. Of the health professionals evaluated, doctors appeared to have the best knowledge of lifestyle modification. Lack of time, lack of patient adherence and language barriers were given as the main barriers to providing lifestyle counselling.

CONCLUSIONS

The undergraduate curricula of medical and nursing students should include sufficient training on lifestyle modification, particularly practical advice on diet, physical activity and smoking cessation. Health professionals working at primary health-care facilities should be updated by providing lifestyle modification education as part of continuing medical education.

Treatment of obesity in the primary care setting: are we there yet?

Obesity is a significant public health issue in the US constituting an independent risk factor for morbidity and mortality as well as complicating the management of other medical conditions. Yet, traditionally most physicians receive little training in evidence-based obesity interventions. Previous literature suggests many physicians believe they do not have effective tools to address obesity and/or that obesity management is not within their scope of practice. Given the new emphasis from NIH and AAFP urging physicians to conceptualize and treat obesity as a chronic medical condition, we examined obesity-related knowledge and practices among military and civilian primary care physicians. Results were similar across these two physician groups in suggesting many physicians still may be ill-prepared to manage obesity in the primary care setting. Implications for patient care and future research are discussed.

Lifestyle counseling in type 2 diabetes prevention: a case study of a nurse's communication activity to produce change talk

As a case study, this article describes a nurse's communication activity, focusing on change talk during lifestyle counseling in primary healthcare. All videotaped counseling sessions with a single patient within a period of two years were transcribed verbatim. In the analysis, an emphasis was placed on the nurse's communication activity that produced change talk, how the nurse initiated change talk, and how the patient received it. The observations provide evidence that the dilemma of simultaneously maintaining professional authority and patient perspective leads to sensitivity in lifestyle counseling. Three categories of change talk were identified: rejected, restrictive, and expansive change talk. Producing change talk is a very demanding task for counselors. It is best produced when the nurse stays within the patient's frame of reference with a combination of reflective, change-inducing questions, encouraging assessments and conversational space. On the basis of our results, we suggest that nurses need training to identify and to encourage patients' change talk and to communicate flexibly according to patients' values during lifestyle counseling. In addition, in order to insist on change talk, we need to demonstrate how change talk could be carried out so that nurses could orient to it.

The effectiveness of nutrition counselling by Australian General Practitioners

OBJECTIVE

To determine whether General Practitioners (GPs) consider or provide nutrition counselling for hypertension, diabetes, lipid disorders, ischaemic heart disease (IHD), overweight or obesity, and whether GPs include assessment of the patient's usual diet, assessment of the patient's readiness to change their diet, provision and discussion of nutrition leaflets when counselling.

DESIGN

A self-completed questionnaire.

SETTING

New South Wales, Australia.

SUBJECTS

A total of 399 GPs were surveyed using a division mailing list.

METHODS

Questionnaires were distributed in May 2004 with two reminders provided at four-weekly intervals.

RESULTS

Of the 399 GPs, 28 no longer practiced at the address while nine were on extended leave. Of the remaining 362, 50% responded, 5% declining to participate, while 163 (45%) completed the questionnaire. GPs were less likely to strongly agree to consider nutrition for hypertension (37%), IHD (61%) and overweight (68%), than diabetes (86%), lipid disorders (82%) and obesity (83%). They were also less likely to strongly agree to provide nutrition for hypertension (22%), IHD (46%) and overweight (45%), than diabetes (79%), lipid disorders (71%) and obesity (68%). In total, 97% of GPs provided some nutrition counselling, with 66% 'often' assessing the patients diet and 59% 'often' assessing the patient's readiness to change their diet. In total, 45% were unaware of stage of change behaviour theory. A total of 85% used nutrition leaflets and 59% 'often' discussed these with their patients.

CONCLUSIONS

Determining what are the barriers to nutrition counselling for hypertension, IHD and overweight is urgently needed. Educating GPs on stage of change behaviour theory could increase the efficacy of the counselling provided.

Advice-giving styles by finnish nurses in dietary counseling concerning type 2 diabetes care

Dietary advice-giving is an important part of dietary counseling in diabetes care and prevention. The strategies of advice-giving, however, have not been explicated and the qualitative characteristics of conversations in diabetes counseling have remained mainly unstudied. This article describes the styles in which nurses responsible for diabetes counseling in Finnish primary care practices offer dietary advice for patients with recently diagnosed type 2 diabetes or impaired glucose tolerance. The data consisted of 55 videotaped naturally occurring counseling sessions between 18 patients and five nurses and were analyzed using typology as an analyzing method. Four different styles of dietary advice-giving were recognized from the speech episodes concerning dietary behavior: recommending, persuasive, supportive, and permitting styles. Recommending style of advice-giving is recognized to be the dominant style that has arisen from the data and, actually, it seems to be the starting point in advice-giving practices. The other styles were used rarely, which suggest that the nurses rely upon quite a narrow selection of communication strategies that helps them to control the topics and the situation, although patient-centered counseling is strongly demanded nowadays. On the basis of our results we suggest that health professionals may need to become more aware of their advice-giving practices in routine situations through conscious effort of self-evaluation. A more detailed analysis of interpersonal conversations during counseling sessions is also needed as it may offer valuable information to promote patients' self-management skills by facilitating observation of conversational elements recognized to be successful in diabetes counseling.

Implementation of a cancer prevention program for working class, multiethnic populations

BACKGROUND

This paper describes the implementation of the Healthy Directions-Health Centers intervention and examines the characteristics of participants associated with completion of intervention activities. Healthy Directions-Health Centers was designed to address social contextual factors relevant to cancer prevention interventions for working class, multi-ethnic populations.

METHODS

Ten community health centers were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief study endorsement from a clinician; (2) an in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; and (4) multiple distributions of tailored materials.

RESULTS

Among the 1,088 intervention group participants, 978 participants (90%) completed at least five out of six intervention activities. Participants who missed clinical appointments were less likely to complete all components of the intervention. Participant characteristics that predicted receipt of clinician endorsement differed from characteristics that predicted completion of health advisor activities. Low acculturation did not present a barrier to delivery of the intervention once the participant was enrolled.

CONCLUSIONS

Collection and reporting on process evaluation results can help explain variations in program implementation.

Negotiation in type 2 diabetes counseling: from problem recognition to mutual acceptance during lifestyle counseling

Negotiation, an essential communication activity in lifestyle counseling, has rarely been studied at the micro level of interaction. Furthermore, the evidence for interpersonal negotiation to occur in counseling practice is inconclusive. In this study, the authors describe how negotiation focused on lifestyle changes was produced in nurse-patient interaction. The research data, 73 videotaped diabetes counseling situations, were analyzed using conversation analysis. The process of negotiation consisted of recognizing the problems in the patients' health behavior, offering proposals as solutions to the problems, and reaching an agreement on them. Negotiation had characteristics similar to those mentioned in the literature, but there were also prominent inadequacies. The authors suggest that nurses might need to become more aware of their counseling practices in routine situations through conscious effort for self-evaluation. In addition, further research would be required to demonstrate the effectiveness of negotiation for facilitating changes in patients' health behavior.

Behavior change intervention research in healthcare settings: a review of recent reports with emphasis on external validity

BACKGROUND

Information to judge both the internal and external validity of health behavior research conducted in healthcare settings is vital to translate research findings to practice. This paper reviews the extent to which this research has reported on elements of internal and external validity, with emphasis on the extent to which research has been conducted in representative settings with representative populations.

METHODS

A comprehensive review was conducted of controlled interventions for dietary change, physical activity, or smoking cessation conducted in healthcare settings and published in 12 leading health behavior journals between 1996 and 2000. Using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, the characteristics and results of these studies were summarized to document the extent to which intervention reach, adoption, implementation, and maintenance were reported and what has been learned about each of these dimensions.

RESULTS

A total of 36 studies qualified for review. Participation rates among eligible patients were reported in 69% of studies and were generally quite high; in contrast, only 30% of studies reported on participation rates among either healthcare settings or providers. Implementation data were reported in 77% of the studies and these rates were generally high, with the caveat that intervention was often delivered by paid research staff. Long-term maintenance results were reported very consistently at the individual level, but program continuation was almost never reported at the setting level.

CONCLUSIONS

We conclude that a much stronger emphasis needs to be placed on the representativeness of providers and settings that are studied. Examples of how this can be done and recommendations for future research are provided.