A Case Study of Change: Obesity

Obesity in primary care has become an increasingly common problem. Like any other medical condition overweight and obese patients should have access to appropriate treatment and care using a delicate, understanding and non-judgemental approach. Weight loss in primary care is of interest for the purposes of improving a person’s quality of life. During the study the author will explore the prevalence of obesity using the geographical trust region with a population of 158,000 (Office of National Statistics (ONS) 2007) in comparison with the town centre based practice where the author works as a trainee nurse practitioner. The practice has a mixed socioeconomic, predominately (95.53%) White British population of 15, 186 (Annual Public Health Report 2008). Local authority with in which the author works has been ranked as 49th most deprived out of the 354 local authorities in England in 2007 in the Index of Multiple Deprivation 2007 (IMD 2007). Although obesity is increasing at the same rate in all social classes, the prevalence of obesity is higher in lower socio-economic groups, particularly in women (Henderson and Gregory 2002).

The National Institute for Health and Clinical Excellence (NICE) developed guidelines on identifying and treating obesity in 2006 following on from the Scottish Intercollegiate Guidelines Network (SIGN 1996), this in turn along with Primary care service Framework 2007 has lead to Health Care Professionals looking at ways to gain the background knowledge, provide and implement a service to deliver integrated obesity management enabling patients to change their eating and activity habits and motivate obese individuals to lose weight, maintain weight lose and increase fitness in accordance with the White paper (2004). It is also thought that additional training in behavioural counselling maybe vital when assessing a patient’s readiness to accept change (Drummond 2000). Individuals who are not emotionally ready to tackle the issue of lifestyle changes are more likely to fail.

Dealing with obesity in the practice setting can be achieved by setting up specific lifestyle clinics dedicated to offering support and advice to patients who wish to lose weight or maintain a healthier lifestyle looking specifically at behaviour change. This clinic can run alongside or in conjunction with existing chronic disease and routine Health check clinics with self referral or healthcare professional referal. By helping the patient look at how unhealthy behaviours can be an element of their lifestyle and daily choices (see table 1) it is possible to suggest ways in which to change in a mutually agreed plan of care.

Awareness and knowledge of what change is required and why, are fundamental first steps in enabling change to occur. Motivation is an essential part of nearly everything we do. Regular reviews can provide motivation and change behaviour through incentives and penalties. Personal factors, such as individuals’ self motivation, drive and desire to improve their appearance and health are also important. Target and objectives can influence how much people want to change but their priorities and commitments may also obstruct their ability to change.

Change to clinical practice can only be successful if the reasons for introducing the change are clear, compatible with current practice and ideas and the process is planned carefully in advance (Davis1999). Change theories share common factors. To ascertain behavioural change, according to these theories, patients need the desire to make a change, have the ability to make the change, believe that they will have a better quality of life if they make the change, believe that the change is “right for them,” and discover how and when to make changes.

Obesity management needs an integrated approach involving a multi-disciplinary team of Healthcare Professionals. General Practice is an ideal starting point to influence and initiate management strategies. Healthcare professionals need better training and access to management programmes that include dietary advice, physical activity and behavioural change if they are to initiate the policy effectively. For the programme to succeed the patient needs to be the central component. Obesity does not lend itself to the classical medical model where the condition is diagnosed, treatment prescribed and then the professional responsible for the outcome. It is ultimately the patient who is in control over their decision to proceed and succeed. Weight lose/maintenance is not easy for obese/overweight patients, many of whom have already tried and failed in controlling their weight. It is the role of the primary care team to support and encourage weight management and lifestyle change. In an attempt to achieve these changes in behaviour management are vital.

Eating and physical activity are human behaviours which can be modified even though they are predisposed by a complicated set of factors. If in practice the overweight/obese patient was identified and advised of the fact, they simply wouldn’t care. Consultation with the patient and establishing if they recognise they have a weight problem using a sensitive and respectful manner is the first essential step to change. It is then possible to produce a plan of action involving providing information and eliciting the patient’s views about their weight as well as details about their weight history and any previous attempts at weight loss. The early stages of consultation are about building a rapport with the patient through active listening. Communications skills are essential to implement a behavioural approach effectively (NICE 2007). Professionals should also have the ability to express consideration, build self-belief and provide clear, structured and relevant information.

Raising the issue of lifestyle changes can be extremely difficult to talk about as the patient may feel uncomfortable and they may feel responsible. This could have a negative effect on the patient-professional relationship (Drummond 2000). As a professional it can be maintained that we have a duty of care to discuss the importance of a behavioural approach in managing obesity and its practical application in helping overweight patients achieve and maintain behavioural changes. Pearson 2003 suggests that ‘linking weight to a current health concern is often an appropriate way to introduce weight management issues’. Advice should be individualised to condition and patient.

By providing the patient with the appropriate information to help them make informed decisions about their health behaviour is part of the professional role. By individualising programmes to assist/support patients in changing their lifestyle for good can give them the incentive to lose some weight or prevent further weight gain. There is always the risk at this point that the patient will abandon the change process altogether.

Behaviour change theory examines the difference between models of behaviour and theories of change (Darnton 2008). Models of behaviour identify us with specific behaviours, by pointing out the underlying factors which influence them. By contrast, theories of change illustrate behaviour change over time. The theories are complementary to each other; understanding both is essential in order to improve successful advances in behaviour change.

Numerous models can be incorporated together to assist in understanding the reasons for our behaviour and how they interrelate but also help us work out the relationships between the reasons to allow us to envisage the behavioural outcomes. Tim Jackson writes ‘models reveal factors where policy can work’ (Jackson 2005).

Models essentially recommend a feature menu for policy makers to choose from making no one model the perfect model but giving the policy maker choice and flexibility to use several different models.

Social-psychologist Kurt Lewin’s Change Theory (1951) involves group work to change habitual behaviours, using an unfreezing, restructure, refreezing guide in which habitual behaviours (attitudes, values and behaviours) are studied by the group and reorganised, before being reintegrated back into everyday routines (Coghlan and Brannick, 2003; Coghlan and Claus, 2005; Lewin, 1951). Lewin’s work on change has provided the basis for many later advances in change theories (Lewin 1951). Lewin’s change theory will be the basic model for the proposed change in practice.

Lewin’s early research entailed changing the patterns of diet in America and is therefore particularly relevant to issues, such as obesity, that we face today. Lewin concluded ‘that we are likely to modify our own behaviour when we participate in problem analysis and solution and more likely to carry out decisions we helped to make’ (Lewin 1951).

Unfreezing is a reflective process that involves unlearning without removing own uniqueness and difficult relearning and restructuring of thoughts, awareness, beliefs and way of thinking. In the planning process of change this critical starting point for change can be overlooked. Three pre-conditions simultaneously need to be satisfied for current patterns of behaviour to unfreeze. Firstly ‘disconfirming information’ which involves disproving a theory. Secondly Lewin (1951) suggested creating ‘guilt or survival anxiety’, getting patients to accept behaviour is incorrect but this destructs self-esteem and identity. The third pre-condition was that disconfirming information could also create what he termed ‘learning anxiety’. This creates a sense of weakness, a feeling that change can’t be initiated due to being unable to learn quickly enough to enable a move into a new situation and adapting inadequately often looks more acceptable than risking failure in the learning process. Overcoming learning anxiety is probably the hardest and most critical element in unfreezing.

Unfreezing is the most significant and complicated part of any change process, and also the most difficult to achieve as self-esteem and identity securely control people. Yet achieving this is not the end but a gateway to the next level

Lewin’s (1951) next stage, ‘restructuring’, also had three elements beginning with reorganising thinking. He called this ‘cognitive redefinition’ and it is at the heart of much of today’s ‘systemic thinking’ (Senge 1990).

Albert Einstein quoted ‘the significant problems we have cannot be solved at the same level of thinking with which we created them’. It is therefore essential to meet and communicate with others to look at the same problem in different ways. Lewin (1951) then suggested ‘managed learning’. ‘Imitation or identification’ is the simplest way of learning in this situation. Learning by copying those we respect and trust. This process is very evident today in standard setting and peer-based learning. Lewin (1951) suggested learning in this way to be shallow and superficial; seen as an easy alternative in a difficult situation as it is a case of doing what has been advised without really understanding the implications of why it is being done. Kurt Lewin (1951) therefore favoured a different means of learning that he called ‘scanning’. This meant seeking alternative sources of information including reading, travel and conversation with people from different backgrounds in order to obtain an accurate understanding of your own situation and adapt accordingly. The problem he saw with peer approaches was that if nobody had research a subject in detail data was incomplete. And if the new behaviour isn’t correct for the behaviour and understanding of the learner then it becomes ‘disconfirming’.

The final element of Lewin’s model (1951) is ‘refreezing’: making things stick. What he found was that working with ‘gatekeepers’, collectively, through ‘scanning’ rather than ‘identification’ creates change that sticks and becomes eventually refrozen into the new norm. Lewin offers a basis for change within an ever changing environment.

Health Belief Model Janz and Becker 1984 was influenced by Kurt Lewin’s theories (1951) which state that perceptions of reality, rather than objective reality, influence behaviour. For an obese patient to perceive the effects their weight has on their lifestyle they need to be able to admit they have a weight problem.

The stages of change model Prochaska and Diclemente 1984 describes change as a process, broken down into a series of stages through which individual’s progress, dependent on the degree of interest in the desired outcome of the individual. The concept of change is that the patient considers the consequences of actions for changing behaviour, what their desired outcome is and which results in a contract to make change. Changing habits happens gradually and often people will need to go through stages of the cycle many times before they achieve lasting change. Gottlieb 2004 suggested that the stages of change model conceived that everyone is on a journey of change, beginning with limited knowledge and progressing through numerous stages to achieve change.

‘Societal’ models are also important to those developing policies and change as often it is necessary to work on the background factors limiting behavioural options directly. Enabling change is not just about changing a person’s perception of these material factors (e.g. cost). The Main Determinants of Health model (Dahlgren and Whitehead 1991) needs to be incorporated into obesity management and is a good ‘Societal’ model. The model shows the individual’s behaviour as one element, beneath four other ‘tiers’ of influencing factors including social and economic factors, cultural factors, environmental factors and also the services that are available locally.

Since Lewin’s field theory (1951), theoretical approaches to change have recommended developing theory through practice. Piloting and evaluation, followed by figuring learning back in, are the final stages in a process of intervention development which can be characterised as learning through doing. Guidance on policy development needs to be clear; however, it must also be flexible to different frameworks.

Evaluation of any policy is undoubtedly important. Obesity as we have seen is measured in many different ways. Evaluations should measure change in the intended behaviour among the consultation group, as well as the effect on the key influencing factors. Process evaluation concentrates on how a program is put into practice rather than the outcome. It asks how services are delivered, differences between the intended population and the population served, how programmes are accessed and managed. It aims to provide an explanation of how or why proposed outcomes of the project were (or were not) met. Information from process evaluations can be used to decide future action, looking at whether a program should be abandon and a new plan of action devised , revise the current program (or components of it) to improve delivery, or how best to deliver it. This type of evaluation may also provide understanding about a programme’s cultural, socio-political, legal and economic contexts that affect implementation

Impact evaluation measures overall achievements; it is interested with the direct result of a program when it is finished. It should include a way of measuring unintended effects of a program, as well as the individuals targeted by the programme.

Outcome Evaluation measures program goals and is concerned with longer term benefits of the program among the targeted population, and by how much. Monitoring of outcome is useful and necessary to determine whether outcomes were achieved within a specified timescale (Health Promotion, 2002), whereas evaluation attributes the changes observed to the intervention tested

The models and theories used to underpin the intervention may then be reassessed in the framework of the target behaviour, and understanding of the behaviour itself assist in progression to the closing phase of the cycle in which learning from the evaluation is fed back into the policy process. As part of the evaluation process, the appropriateness of the behavioural models used in the intervention should be assessed. Evaluation findings should update the development of the intervention itself and future interventions in similar policy areas.

Audit is a technique that can be used to monitor then maintain or improve the quality of care and services provided. It is the method used ‘to assess, evaluate and improve the care of patients in a systematic way, to enhance their health and quality of life’ (Irvine 1991)

Structural audits are undertaken in relation to what resources there are available, suitability and access to the clinics, access to continued support either 1:1, self-help, buddying up with others, web based support or group and also the staff available to run the clinic looking at skill mix.

Process audits focus on what was done to a patient, where clinical protocols and guidelines followed and did they work in practice. The audit may look at how an individual or the team operate, looking at waiting times from referral, patient recall for review, management plans, record keeping, communication between the patient and staff.

Outcome audits relate to the impact of the team or services provided on the patient. This could be achieved through patient satisfaction questionnaires provided at the start of the intervention, part way through and on reaching target. Has there been an impact on their lifestyle and if so was this a positive experience or has it had a negative effect on their lives.

Clinical audit gives valuable insight into how effective a service is being provided by systematically collecting and analysing data on current practice. This allows the lifestyle team to become involved in assessing the effectiveness of their interventions. Clinical audit can help identify areas of behaviour and management which meet required standards, identify area which could be improved, promote changes in problem areas, improve quality of patient care, develop Healthcare Professional skills, give direction for the most effective use of resources and evaluating how successfully changes have been implemented.

Audit is also an important part of clinical governance, there to encourage the continual monitoring and improvement of healthcare services. When designing an audit many factors need to be considered (see table 2)

A fixed date of 6 months would be agreed from the start for the collection of data and interpretation of the results initially but then audit would continue as long as needed to provide information to continue improving the service.

Cost effectiveness also needs to be evaluated. Cost-effective analysis compares the cost-benefit ratio for one intervention against an alternative intervention. Benefits maybe expressed as patient-orientated health outcomes such as quality of life.

The economic impact of lifestyle change maybe assessed in terms of direct costs, indirect costs and intangible costs. Direct costs arise from the use of health care resources and if the direct cost of providing treatment is lower than the direct cost of illness, the treatment is cost-saving for the health care system.

Indirect costs look at the cost of illness to the economy. The broader costs to society and the economy from weight problems already cost the wider economy in the region of £16 billion, and is set to rise to £50 billion per year by 2050 if left unchecked (Department of Health 2009).

Intangible costs are monetary values attached to the physical or psychological effects of illness, such as joint and back pain, breathlessness, varicose veins and gallbladder problems. Obesity is estimated to cost the National Health Service approximately £4.2 billion (Department of Health 2009). Simple activities like getting around can be problematic for an obese individual (Drummond 2000). Quality of life for an obese person is thought to be less than optimal and this can lead to psychological problems. Intangible costs of illness maybe compared with the intangible costs of treatment, such as surgery.