Patient experiences of a lifestyle program for metabolic syndrome offered in family medicine clinics: a mixed methods study

Focus group participants consisted of individuals currently participating in the CHANGE study and were recruited through a mail-out to all participants, outlining the purpose of the study. In addition, flyers were posted in the clinic, inviting people to participate in the study. Potential participants were asked to contact the researcher either by phone or email. Focus groups took place in all three cities. An experienced qualitative researcher experienced in facilitating focus groups (JK) established a relationship at the beginning of the sessions outlining the purpose of the research, her role in the project and then moderated the English sessions. The focus group in French was led by a francophone researcher (AT) who established a relationship at the beginning of the sessions with participants, outlining the purpose of the research, his role in the project and then facilitated the discussion, with input from the original facilitator (JK) who is bilingual, but had French as a second language. Open-ended questions were used to explore participant perspectives. (See Additional file 2.) Focus groups lasted approximately 1 hour each and were conducted at the participants’ respective health care centre. Field notes were made after the focus groups.

The questionnaire is available in Additional file 1. Focus group questions are available in Additional file 2. Examples of themes and subthemes for focus group analysis are available in Additional file 3. Datasets used and analyzed during the current study are available from the corresponding author on request.

A total of 164 questionnaires were received (57 French, 107 English and 0 Russian) of 293 potential recipients (56% response rate); 76% as paper questionnaires and 24% online responses. Of the 164 responses to the survey, 27 (19.4%) respondents reversed their metabolic syndrome. This is consistent with the 19% reversal found in the entire study population (11). Therefore, the survey response reflects the population included in the larger study. Most questionnaire respondents (89%) had completed the one-year program; thus, results mostly reflect their perspectives. Numbers were inadequate to conduct subgroup analysis on the drop-outs.

There were 41 participants (15 females, 26 males) who participated in 6 focus groups across 3 clinics, each consisting of 6–10 participants. The focus group participants reflected the larger study population, including mean age of 60 (range 45–68 years), mean BMI 32, majority Caucasian along with some participants of Asian, Russian and Arabic ethnicity.

Published literature reports the most prevalent and important barriers to lifestyle change, from participants’ perspectives, are ‘lack of willpower’, self-discipline, and personal agency or self-efficacy, depending on the theoretical model being used [22, 23]. Lack of time (due to family, household and occupational responsibilities) is also a significant barrier that has been extensively discussed in the health behavior change literature [24‐26].

In the current study, changing habits was personally challenging, but participants shared that the program mitigated some of the challenges listed above. Comments on the individualized aspects of the program, the supportive and knowledgeable personalities of the providers and the social aspects were all seen as important to promote ongoing motivation and participation.

Results from both the questionnaire and focus groups reinforced the well-known challenges with maintaining changes, even after a one-year program. While over 60% were totally or very confident to maintain both diet and physical activity changes, there was a subgroup of about 10% who were less confident in maintaining physical activity changes and 4% for dietary changes. Optimal program length for the majority of people to maintain new lifestyle habits remains controversial and has implications for program delivery costs and sustainability.

Trust has been found to be an important element to consider in patient assessment of services [27]. Focus group results highlighted the importance of the family physician as motivating the participants to change, while also acknowledging the skills and knowledge of the other providers. The role of the family physician as a trusted mentor is likely critical to the success of the program.

While the family physician plays a key role as a coordinator and mentor, team functioning is also known to be very important in delivery of complex interventions [28]. This was not directly assessed, as patients might not know how teams work. It was indirectly assessed in the questionnaire by asking if patients received contradictory information on diet and exercise. Most felt that different providers did not tell them different information, an issue that has been identified in some team programs [29].

People enjoyed socializing with other participants during the program. While most health counselors are trained on motivational interviewing and other counseling techniques, they may not understand the importance of, nor have been formally trained on the social benefits of the program. Since, providers in this study usually counseled one-on-one, the social aspects of the program should be further enhanced. The importance of having significant others as part of the program was mentioned both in the questionnaire comments and in the focus groups. Greater appreciation for health behavior change influencing the whole household has implications for further development of the CHANGE program.

Mental health is a significant factor impacting behavior change programs [30]. In both the questionnaire and focus groups, participants reported that better mental health resources and supports were needed to provide increased success in the program. Feedback from participants highlights the importance of providing focused mental health related to low mood, fears, negative perceptions of health and life changes, and lack of motivation. Surprisingly, no studies were found that examined the impact of providing an experienced mental health worker in a similar lifestyle change program for MetS. However, the importance of providing psychological supports is reinforced in other studies [30‐33].

Several comments support a need to tailor the CHANGE program to various subgroups. Many middle-aged participants were still in the workforce, so time limitation was a key barrier. Offering more evenings and weekend programming would be beneficial for this group. At the organizational level, patients often advocate for increased flexibility regarding accessing services including increased flexible clinic hours. Through the development of primary care reform, clinics are starting to address this need by hosting clinics on evenings and weekends. However, allied health services need to be expanded as well. The older adult population had more flexibility in their time, but had higher levels of social disconnectedness and perceived isolation, which are independently associated with lower levels of self-rated physical health [34]. Seniors also encounter more barriers e.g., (transportation, increased physical activity limitations). Participants with lower socioeconomic status also need to be considered as they too have increased barriers (e.g., cost of parking, public transportation, child care costs, absence from work to attend appointments) as well as low participation rates in lifestyle change programs [35, 36]. Consideration of reimbursement for out-of-pocket expenses related to participating in the program could assist with attracting more participants from this subgroup. As some cultural minorities experience a high prevalence of MetS and engage in leisure time physical activities less frequently than do adults in the rest of the population [37], developing strategies to encourage this group to participate in CHANGE would also be important. For example, targeting the program toward participants with similar cultural and linguistic backgrounds, recruiting health professionals who speak the language, and weaving components of the culture such a traditional dance and ethnic diets into the program. Further development will need to address differing issues in differing locations.

Themes from the focus groups frequently complimented the questionnaire. There were no direct contradictions in comparing the results of questionnaire and focus groups; rather different aspects emerged as important. The key role of the family physician and importance of the social aspects emerged in the focus groups, while the questionnaire confirmed the trust they had in the team. Both methods revealed trust with their health professionals, along with an individualized realistic gradual approach led to the general support for such a lengthy and intensive program. Findings that a longer and more intensive program was preferred were unexpected and needs to be further explored.

Further validation of the questionnaire is needed including assessment of test-retest reliability and convergent and divergent validity. While we sent out the questionnaire to all participants in the study, the response rate of 56% is likely not representative. In addition, as the focus group consisted of participants self –selecting and were only offered in French or English, not Russian, there is potential for further bias. Extra concerted efforts would be needed to elicit perspectives from participants, who declined to participate in the questionnaire and focus groups, which was beyond study scope. We also have no knowledge of the needs of the wider group of people with MetS who did not agree to undertake the CHANGE intervention. Different approaches are needed to determine how to reach and promote lifestyle change among other subgroups in the population. Likely multiple strategies are needed, including web-based approaches, group programs, and programs with a stronger mental health focus. Further work is required to explore the 10% of participants who noted they were less confident in maintaining physical activity changes and 4% for dietary changes.

Implementing complex behavioral interventions such as lifestyle modification in primary care is challenging. Although intrapersonal issues (e.g., intention, self-efficacy, self-discipline) often dominate peoples’ perceptions of the success of such an intervention, modifying aspects at the interpersonal (e.g., trust, team functioning) and organizational level (e.g., mental health supports, flexible hours) can ultimately improve the effectiveness of a program. The positive participant experiences shown in our current work enhance the evidentiary basis of the CHANGE Program and supports the wide spread implementation of CHANGE in primary care. Multiple approaches may be needed to obtain future participant experiences to inform ongoing program improvements.