Interventions targeted at primary care practitioners to improve the identification and referral of patients with co-morbid obesity: a realist review protocol

Abstract

BackgroundObesity is one of the most significant public health challenges in the developed world. Recent policy has suggested that more can be done in primary care to support adults with obesity. In particular, general practitioners (GPs) and practice nurses (PNs) could improve the identification and referral of adults with obesity to appropriate weight management services. Previous interventions targeted at primary care practitioners in this area have had mixed results, suggesting a more complex interplay between patients, practitioners, and systems. The objectives of this review are (i) to identify the underlying ‘programme theory’ of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity and (ii) to explore how and why GPs and PNs identify and refer individuals with obesity, particularly in the context of weight-related co-morbidity. This protocol will explain the rationale for using a realist review approach and outline the key steps in this process.MethodsRealist review is a theory-led approach to knowledge synthesis that provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, how, and why. In this review, scoping interviews with key stakeholders involved in the planning and delivery of adult weight management services in Scotland helped to inform the identification of formal theories - from psychology, sociology, and implementation science - that will be tested as the review progresses. A comprehensive search strategy is described, including scope for iterative searching. Data analysis is outlined in three stages (describing context-mechanism-outcome configurations, exploring patterns in these configurations, and developing and testing middle-range theories, informed by the formal theories previously identified), culminating in the production of explanatory programme theory that considers individual, interpersonal, and institutional/systems-level components.DiscussionThis is the first realist review that we are aware of looking at interventions targeted at primary care practitioners to improve the weight management of adults with obesity. Engagement with stakeholders at an early stage is a unique feature of realist review. This shapes the scope of the review, identification of candidate theories and dissemination strategies. The findings of this review will inform policy and future interventions.Systematic review registrationPROSPERO CRD42014009391Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-015-0046-y) contains supplementary material, which is available to authorized users.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review

“…The final stage of analysis involved configuring these CMO patterns into a coherent and plausible “refined” programme theory. As part of the process, several theoretical frameworks that could inform our data interpretation and synthesis were reviewed . From this, a “best fit” theory—candidacy theory—was identified and used to inform the final programme theory.…”

Impact of the 5As Team study on clinical practice in primary care obesity management: a qualitative study

“…4,22,23 The qualitative component of the 5As Team study is similarly unique compared to the existing qualitative literature on primary care providers and obesity management. Past studies focused on providers' self-reported barriers to obesity management, 3,24,25 assessment of providers' existing obesity management ability, 26,27 providers' views on the utility of obesity management interventions, 28 and providers' biases regarding weight and attitudes toward obesity management. 29 The current literature does not describe processes of provider change and development for supporting obesity management in response to an intervention.…”

Knowledge, attitudes and management skills of medical practitioners regarding weight management

“…18 The central role of the primary health care practitioners (general practitioners and practice nurses) has been acknowledged in the United Kingdom and Scotland, resulting in the formulation of guidelines on overweight/obesity prevention and management at primary care level. 19 The advantage of this strategy is the population coverage and continuity of care and trust built over a number of encounters, 20 and the practical application of the primary care principle that every patient encounter should be regarded as an opportunity for health promotion. 21 The Royal College of Physicians in the United Kingdom has issued a report on the training of general practitioners in weight management.…”

“…19 In a study comparing weight bias in 2001 versus 2013 in the management of overweight and obesity among weight management specialists, it was demonstrated that there has been a paradigm shift from implicit (unconsciously expressed) to explicit (consciously expressed) anti-fat bias. The biases were expressed by the medical practitioners as bad, lazy, stupid and worthless.…”

“…In addition, an overweight and obese patient may not take seriously advice from a practitioner of similar weight. 19 …”