Background
The number of obese adults in Sweden has doubled over a 20-year period, and about 10% of both women and men are estimated to be obese [
1]. Recent data show that the prevalence of obesity in a primary care setting is 20-24% [
2]. In Sweden, teams of general practitioners (GPs) and nurses, especially district nurses (DNs), are on the front line of the encounter between health care personnel and people with obesity or other lifestyle-related diseases [
3]. Consequently, these professional groups must, to a greater extent than before, assist patients with weight management. The trend in health care is towards a more patient-centred approach, empowering the patients themselves to take responsibility for their health [
4]. Accordingly, one of the tasks of GPs and DNs is to support patients in making healthy decisions about their daily living habits.
Primary health care is recognised as an important resource in co-ordinating the treatment of obese patients [
5]. Previous studies also reveal that GPs and nurses acknowledge that primary care has an important role in managing obesity [
6,
7]. Other studies, however, show that GPs do not regard obesity management as their responsibility, but rather that of the patient [
8].
A significant proportion of GPs and nurses in primary health care consider themselves insufficiently skilled or prepared to treat patients with obesity [
6,
7]. Both GPs and nurses regard themselves as ineffective in their work with obese patients [
7,
9], and a majority of GPs consider the possibility of a patient's succeeding with weight loss as limited [
6,
9]. Studies have also shown that medical staff attribute the failure to lose weight to personal, patient-related factors rather than to professional ones [
8,
10]. Several other studies support this notion, since they show that GPs and nurses perceive obese patients as having low motivation, lacking willpower, being unwilling to change lifestyle [
11,
12] and non-compliant to advice [
10]. However, there are studies supporting the presence of system-level barriers, such as lack of time during patient visits [
12], lack of places to which to refer patients, and lack of patient-oriented educational materials [
13].
The seemingly negative beliefs about obesity and obesity treatment which have been documented, especially in quantitative studies, might be over-simplified, and it is likely that GPs and nurses hold more complex views. Qualitative studies of GPs and nurses in primary health care support this idea to some extent [
8,
12,
14]. Nurses perceive weight as a sensitive issue to discuss with patients and therefore try to achieve a balance between factors involving personal responsibility and factors outside the individual's control [
14]. Mercer and Tessier found that GPs were negative about their role in obesity treatment, while practice nurses, although accepting it as part of their job, experienced that GPs "off-loaded" patients on to them [
12]. Epstein and Ogden found that GPs were sceptical about the success of available treatments, but still offered anti-obesity drugs and tried to listen to and understand the patient's problem [
8].
Reviewing the literature on existing qualitative studies, including those of nurses and GPs in primary health care, it becomes apparent that there is a need to know more about how they conceive their encounters with patients with obesity. Research has hitherto been limited in that no male nurses have been included, despite its having been demonstrated that gender might be important regarding attitudes and practices within obesity management [
9,
15]. This emphasises the need for further research. Against this background, the aim of the current study was to describe how GPs and DNs, both male and female, conceive their encounters with obesity in primary health care.
Methods
We used a phenomenographic approach to identify and describe the various ways in which a specific phenomenon is conceived [
16], in this case primary health care specialists' conceptions of obesity and obesity treatment. This qualitative approach has been used in health care research to study, for example, doctors' or nurses' conceptions of treatments for different diseases [
17]. The phenomenographic tradition acknowledges two research perspectives: there is a first-order perspective which concerns how the world actually is, and a second-order perspective which concerns how the world is experienced. In phenomenography, the second-order perspective is essential [
16]. The assumption is that there is only one world, but that it can be experienced in qualitatively different ways. The approach comes from educational research and entails adopting a content-related perspective to characterise, understand and describe the qualitatively different ways in which people make sense of the world around them. The conceptions are derived from individual interviews, but the analyses emanate in descriptive categories at a collective level [
16].
Participants
Eligible for participation in the study were staff from 57 primary health care centres in a well-defined area in Sweden. The criteria for inclusion were being a DN or GP with a specialist education, speaking Swedish fluently, and acceptance of tape-recording. A strategic selection of participants was made to obtain variety regarding age, gender and primary health care experience. This would provide a range of conceptions from DNs and GPs. The heads of the primary health care centre in question had to give their consent for staff to participate. Therefore we first contacted the heads by e-mail with an information letter, then by telephone approximately a week later. If the head gave permission, the informant in question was approached by either e-mail or telephone. We gave the informants the same information as their head.
We included 20 participants at 19 primary health care centres (Table
1). Two DNs came from the same centre. The participants' median age was 51 years, and their median professional experience 10.5 years. Of the 20 informants, 10 were recommended by their medical head, 3 were medical heads themselves, working as GPs, and 7 were contacted from staff lists. Four of the 10 DNs were specialists in diabetes or weight management. Among the GPs, 3 were involved in some kind of weight management strategies.
Table 1
Demographic characteristics of the primary health care professionals (n = 20).
Sex | | |
Female | 6 | 7 |
Male | 4 | 3 |
Age | | |
34-40 | 2 | 1 |
41-45 | 2 | 2 |
46-50 | 2 | 2 |
51-55 | 1 | 2 |
56-60 | 3 | 3 |
Years in profession | | |
1-5 | 4 | 2 |
6-10 | 2 | 2 |
11-15 | 2 | 2 |
16-25 | - | 2 |
26 or more | 2 | 2 |
Country of birth | | |
Sweden | 9 | 9 |
Other | 1 | 1 |
The medical heads at 16 primary health care centres refused to grant permission for participation, largely because of re-organisation, work overload or shortage of staff, although some were simply unwilling. We could not reach the medical heads at 10 centres. At 12 centres the medical head gave approval for the study but the DNs and GPs declined because of work overload, unwillingness or lack of financial compensation; some could not be reached. The Regional Ethical Review Board, Karolinska Institute, Stockholm, Sweden, approved the study (reference number 2006/7-31/1).
Data collection
Two of us (LMH, GA) developed an interview guide with open-ended questions. The main questions were: What are your experiences of meeting patients with obesity? How do you conceive the life situation of patients with obesity? How do you think care is working for patients with obesity? Individual interviews, which took the form of conversations, were performed by one of us (LMH). Follow-up questions were asked depending on how comprehensively the informant answered the main questions. Examples of follow-up questions were: "What do you mean?" "Can you explain?" "Can you tell me more?" "Is there anything you would like to add?" Participants chose where the interview should take place. Two of the 20 participants preferred to be interviewed at the interviewer's research department, while the remaining interviews were performed at the workplace. The tape-recorded interviews (30-80 minutes) were transcribed verbatim.
Data analysis
We carried out the analysis in four steps in accordance with the phenomenographic approach [
18,
19]. At the first step, the interviews were listened to again to verify that they had been transcribed correctly. The individual transcripts were then read through several times to get an overall impression, and thereafter statements relevant to the study were identified. At the second step, the aim was to identify distinct ways of conceiving obesity treatment, which involved constantly comparing and labelling the statements. The labelled statements were then treated as preliminary conceptions. At the third step the conceptions were compared with one another and grouped to obtain an overall picture of possible links between them. The grouped conceptions formed preliminary descriptive categories to which names were given. At the fourth step, the focus shifted from relations between conceptions to relations between the preliminary descriptive categories. Finally, the descriptive categories were critically investigated to ensure that they properly represented the conceptions.
Discussion
We found a wide variation in GPs' and DNs' conceptions of their encounters with obese patients in primary health care. Staff described the encounters from both an organisational/personnel perspective and a patient perspective. The need for primary care to have an adequate organisation for obesity treatment and competent staff for promoting lifestyle change was stressed. However, patients' adherence and attitudes to behaviour change were also looked upon as important. In addition to the findings on the collective level we found certain differences in the pattern of conceptions according to profession and gender. However, in view of the small number of male participants, especially in the DN group, these findings have to be interpreted cautiously.
The findings of the present study are to some extent in line with those of previous quantitative and qualitative investigations of attitudes and beliefs regarding obesity treatment in primary care. Examples of such beliefs are that primary care is not an entirely appropriate setting for obesity treatment (especially if no concomitant disease is present), that time is lacking for patient visits, that reimbursement systems are inappropriate, that distinct and evidence-based guidelines need to be improved, and that patient motivation to change is low [
7,
8,
12]. Male staff emphasised to a higher degree than female staff that there is a lack of guidelines and evidence. This may reflect that men to a higher degree explain lack of success in obesity treatment in terms of external (organisation) rather than internal (personal competence) causes. The conception that primary health care is not necessarily the best arena for the prevention and treatment of obesity was more evident among GPs than among DNs. This is in line with the finding of Mercer and Tessier [
12] to the effect that GPs were more negative as to their role in obesity treatment than were nurses.
Staff in this study (mainly female GPs) emphasised the need for respectful treatment and individual solutions, and showed an understanding of the difficulty of changing lifestyle. This replicates what has been found in previous qualitative studies. Brown and Thompson [
14] and Epstein and Ogden [
8] reported that staff perceived the patient-provider relationship to be central to the improvement of obesity treatment. Patients who are informed and involved in decision-making have been found to be more adherent [
20] and staff engaged in patient-centred care and make decisions together with their patients are in a better position to offer more individualised behavioural recommendations to their patients, resulting in better adherence [
21]. Patients themselves have also asked for a more personalised approach to weight management, and for specific advice rather than broad statements on how to lose weight [
22].
However, we also found that some staff experienced that, to motivate patients, they had to threaten them with a possibly fatal outcome, or at least inform them about the negative consequences of obesity. There is evidence in the literature that some patients view even mild warnings as scare tactics, with a negative impact on adherence [
23]; others, however, regard warnings as encouraging and motivating, even essential to change [
22]. It is important that GPs and DNs assess patient motivation and discuss what facilitates motivation individually. Previous studies have shown that patients report greater motivation and are more optimistic about weight loss than their GPs, but those who see obese patients more often are better at predicting patient motivation [
24].
The findings of the present study regarding the staff's perception that some patients exhibit evasive behaviour, are untrustworthy when it comes to revealing their lifestyles and off-load their problems on to staff, are in line with previous research [
8,
12]. These conceptions were more strongly expressed by DNs than GPs in our study. One reason for this difference could be that the sort of behaviour in question may not appear until after a couple of sessions, whereby DNs are more likely to encounter it in that they often spend more time with patients than do GPs. The problem with these attitudes on the part of staff is that they may manifest themselves in encounters with patients, and that patients might thereby sense that staff do not trust them [
25]. Previous studies have shown that patients' higher body mass index is associated with less respect from their doctors [
26] and higher reporting of perceived discrimination in a health care setting [
27]. Respect develops over time, therefore it would seem necessary that goals in obesity treatment should include continuity of care and long-term support, as indeed was emphasised by staff in our study.
The use of scare tactics and perceptions of patients as non-adherent might be due to staff's not being able fully to use or appreciate the strategies of motivational interviewing that are central to increasing patients' intrinsic willingness to change. Female GPs and DNs, and one male GP, were the only ones that considered that lack of self-confidence in changing lifestyle could be the reason for patients' not succeeding in losing weight. Patients' belief in their ability to make the necessary changes has been found to be important for behaviour change [
28], and an understanding of this on the part of the health care provider seems crucial. This finding may suggest that male GPs and DNs are too quick to jump to a conclusion about what underlies some of their patients' non-adherence.
Staff stressed the need for more knowledge and skills in counselling, such as motivational interviewing, and also in basic nutrition and appropriate dietary interventions. The question is whether staff are being trained in the most updated methods of obesity treatment. Staff might, for example, also need skills directed towards helping patients to cope with their situation, because of the limited chance of losing weight going together with the stigma related to obesity. Coping strategies to deal with stigma have important implications for emotional functioning, and health care staff could assist in finding methods to help improve patients' daily functioning.
There seems to be a need for evidence-based guidelines which are easy to use and regarded as effective by staff. The use of guidelines is intended to improve the quality of treatment, and it has been found that nurses with no specific preparation or guidelines regarding obesity treatment were the ones who experienced most awkward in meeting obese patients [
14]. However, a study of GPs found that awareness of the guidelines was associated with a more negative attitude towards obesity [
6]. These contradictory findings suggest that, even when guidelines are available, they might not be user-friendly, updated and/or integrated appropriately into primary care.
Staff in the present study emphasised the importance of having an active interest in obesity treatment. To further enhance work at primary care centres, it might be necessary for every unit to appoint specific staff to take responsibility for structuring activities and engaging others regarding obesity treatment, organised perhaps in the same way as for diabetic patients. Findings from the Counterweight Programme [
29] show, for example, that staff perceived that involvement and a sense of ownership, alongside a clear understanding of programme goals, are important factors in the effective implementation of weight management in primary health care.
Limitations and Strengths
There are certain limitations to consider when it comes to interpreting the findings of the present study. Firstly, there were quite a number of health care centres which refused participation, for which reason it is possible that the participants came from centres which had taken an active interest in weight management. The health care centres included, however, were situated in both affluent and poor areas of Stockholm, and were both large and small. The demographic characteristics of non-participants and participants are unfortunately not known. Secondly, the number of male participants was low (one third). However, owing to the limited number of males eligible from the nurse population and to the fact that previous research has not been able to recruit male nurses, this study makes an important contribution to the field. Thirdly, some of the participants were recommended by their medical head, and it is likely that those with a more positive attitude were chosen. However, the findings display very rich descriptions of conceptions; both negative and positive views were expressed, and participants were not afraid of raising difficult topics.
All participants were asked the same questions, and all interviews and analysis were performed by the first author (LMH), who is a nutritionist. However, the possibility cannot be excluded that the background of the interviewer prompted participants to focus more on issues related to healthy diet and physical activity. To attain greater rigour, the conceptions and descriptive categories derived were scrutinised at each step by the third author (GA), who is experienced in phenomenographic analysis. The findings were constantly discussed in depth during the analysis by two of us (LMH, GA) until agreement was reached.
Implications for Clinical Practice and Future Research
It is likely that low confidence of staff in treating obesity means that obesity in primary care has low priority, and their belief that patients are not motivated produces a moral dilemma for GPs and DNs. How should they prioritise their work? Is obesity the responsibility of the patient or of the health care system? Obesity treatment in primary health care, though, has the potential of being much more effective than it currently is, and the GPs and DNs in the present study touched upon many organisational aspects that need improvement. For example, obesity must be recognised as an important issue at all levels of the health care system. It also seems warranted to promote competence in motivational interviewing and evidence-based treatments, and also to increase awareness of staff's negative views on patient attitudes. Additional ways to enhance care might be to adopt a team-based approach within each unit, with resources to enable continuity in care, and also to promote co-operation with other stakeholders, such as social welfare authorities, commercial weight-loss organisations and specialist obesity units.
Finally, the gender- and profession-based differences which were found are somewhat difficult to interpret and therefore deserve further investigation in larger quantitative studies. For instance, to our knowledge no one has compared both profession and gender aspects in the same study. Moreover, research should investigate the association between staff's negative perceptions of patients with obesity and their actual practices, which, in the long run, might have additional harmful effects on obese patients' health.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
LMH, FR and GA all participated in the design of the study. LMH conducted all the interviews, made the initial analysis of the interview transcripts and drafted the manuscript. LMH and GA had discussions about the analysis and reporting. FR and GA offered comments on the draft of the manuscript. All authors read and approved the final manuscript.