Health care providers' perspectives on challenges and opportunities of intercultural health care in diabetes and obesity management: a qualitative study.

BACKGROUND: Migrants often face worse health outcomes in countries of transit and destination because of challenges such as financial constraints, employment problems, lack of a network of social support, language and cultural differences, and difficulties accessing health services. As understanding how the migrant context affects patient-provider engagement is critical to the provision of contextually appropriate care, this study aimed at understanding primary health care provider perspectives on challenges and opportunities of the intercultural care process for migrant patients with diabetes and obesity. METHODS: This qualitative study within a multimethod, participatory research project involved primary care providers in clinics and primary care networks in Edmonton, Alberta, between September 2019 and February 2020. We explored health care providers' approaches to diabetes and obesity management, and experiences of and challenges with intercultural care. We conducted a thematic analysis using an interpretive qualitative approach. RESULTS: We conducted 9 interviews and 4 focus groups and identified 3 themes: a shift from traditional weight loss-centred approaches; relationships and navigating cultural distance; and importance of and limitations in identifying and addressing root causes and barriers. Health care providers encounter considerable nonmedical challenges when supporting immigrant patients, such as navigating cultural distance and working with patients' financial constraints. INTERPRETATION: The nonmedical challenges we identified can hinder the process of chronic disease management. Thus, in addition to educational programs and trainings to enhance the cultural competency of health care providers, incorporating avenues for cultural brokering in health care can provide invaluable support in patient-provider engagements to mitigate these challenges.

Contextually Appropriate Tools and Solutions to Facilitate Healthy Eating Identified by People with Type 2 Diabetes.

Type 2 diabetes (T2D) is a complex, multifaceted disease and its treatment involves lifestyle intervention (LI) programs that participants may find difficult to adopt and maintain. The objective of this study is to understand the lived experiences of participants with T2D regarding healthy eating behavior change, in order to identify and incorporate relevant information, skills, and educational approaches into LI programs. An explorative qualitative study was undertaken. Purposeful sampling was used to recruit 15 participants. One-on-one, semi-structured, open-ended, and in-depth interviews were conducted. An essentialist paradigm was adopted to accurately report the experiences, meaning, and reality of participants. An inductive approach was used to analyze the data. Participants reported that being diagnosed and living with T2D could be overwhelming, and their ability to manage was influenced by health care providers (HCP), family, and individual context. Many experienced a loop of "good-bad" eating behaviors. Participants expressed desires for future diabetes management that would include program content (nutrition, physical activity, mental health, foot care, and consequences of T2D), program features (understand context, explicit information, individualized, hands-on learning, applicable, realistic, incremental, and practical), program components (access to multidisciplinary team, set goals, track progress and be held accountable, one-on-one sessions, group support, maintenance/follow-up), and policy change. In conclusion, the results of this study indicate that T2D management requires more extensive, comprehensive, and ongoing support, guided by the individual participant.

Improving obesity management training in family medicine: multi-methods evaluation of the 5AsT-MD pilot course.

BACKGROUND: Quality, evidence-based obesity management training for family medicine residents is needed to better support patients. To address this gap, we developed a comprehensive course based on the 5As of Obesity Management™ (ASK, ASSESS, ADVISE, AGREE, ASSIST), a framework and suite of resources to improve residents' knowledge and confidence in obesity counselling. This study assessed the course's impact on residents' attitudes, beliefs, and confidence with obesity counselling. METHODS: The course combines lectures with a bariatric empathy suit experience, standardized and in-clinic patient practice, and narrative reflections. Using a multi-methods design we measured changes in 42 residents' attitudes, beliefs, and self-confidence and thematically analyzed the narrative reflections to understand residents' experience with the course content and pedagogy. RESULTS: Following the course, residents reported improved attitudes towards people living with obesity and improved confidence for obesity counselling. Pre/post improvement in BAOP scores (n = 32) were significant (p < .001)., ATOP scores did not change significantly. Residents showed improvement in assessing root causes of weight gain (p < .01), advising patients on treatment options (p < .05), agreeing with patients on health outcomes (p < .05), assisting patients in addressing their barriers (p < .05), counseling patients on weight gain during pregnancy, (p < .05), counseling patients on depression and anxiety (p < .01), counseling patients on iatrogenic causes of weight gain (p < .01), counseling patients who have children with obesity (p < .05), and referring patients to interdisciplinary providers for care (p < .05). Qualitative analysis of narrative reflections illustrates that experiential learning was crucial in increasing residents' ability to empathically engage with patients and to critically reflect on implications for their practice. CONCLUSION: The 5AsT-MD course has the potential to increase residents' confidence and competency in obesity prevention and management. Findings reflect the utility of the 5As to improve residents' confidence and competency in obesity management counselling.

Transforming Health Experience and Action through Shifting the Narrative on Obesity in Primary Care Encounters.

We sought to understand the impact of primary care conversations about obesity on people's everyday life health experience and practices. Using a dialogic narrative perspective, we examined key moments in three very different clinical encounters, the patients' journals, and follow-up interviews over several weeks. We trace how people living with obesity negotiate narrative alternatives that are offered during clinical dialogue to transform their own narrative and experience of obesity and self. Findings provide pragmatic insights into how providers can play a significant role in shifting narratives about obesity and self and how such co-constructed narratives translate into change and tangible health outcomes in people's lives.

Changing provider behaviour to increase nurse visits for obesity in family practice: the 5As Team randomized controlled trial.

BACKGROUND: There is increasing recognition that health care professionals often fail to provide meaningful obesity care in routine clinical practice. There is scant information on how to support practice change. The objective of the 5AsT trial was to assess whether a co-created educational intervention would increase the quantity of obesity visits conducted by family practice nurses. METHODS: We conducted a randomized controlled trial with convergent mixed-methods evaluation in a primary care network in Alberta, Canada. The intervention, based on the Theoretical Domains Framework and 5As of Obesity Management, included 12 2-hour interactive educational sessions from November 2013 to April 2014. Twenty-four teams of nurses, mental health workers and dietitians were randomly assigned to receive the intervention or regular training. The primary outcome measure was the rate ratio of nurse visits for adult obesity care to total clinical visits. Qualitative thematic analysis was previously used to identify barriers and facilitators to intervention uptake. In this study, mixed-methods analysis assessed the impact of these factors on individual nurses' outcomes. RESULTS: There was no significant increase in visits over the 6-month intervention (rate ratio 1.30, 95% confidence interval [CI] 0.83-2.03) nor the 9-month post-intervention period (rate ratio 1.38, 95% CI 0.87-2.19). However, provider confidence, views of obesity management, role identity and team and patient relationships were found to affect individual nurses' uptake of the intervention. INTERPRETATION: Although the intervention did not demonstrate a significant increase in nurse visits for obesity care, this study provides insights into health care practitioners' challenges in changing their approach to obesity management. To improve provider capacity to change effectively within their teams, interventions need to foster not only provider knowledge but also confidence. Trial registration: ClinicalTrials.gov, no. NCT01967797.

Using Concept Maps to compare obesity knowledge between policy makers and primary care researchers in Canada.

OBJECTIVE: Knowledge transfer is the process of information sharing between researchers, knowledge users and policy makers. Globally, public policies about obesity do not reflect the complexity of what is known about the cause and effects of obesity. We used Concept Maps, a qualitative method that represents mental models, to compare the understanding of obesity between policy makers in a Canadian province and local primary care researchers. Eight participants were interviewed during which a Concept Map was developed using "C-map Tools" software. Maps were then colour-coded to identify themes and concepts in the maps. Finally, the team synthesised the findings from each of the maps and presented them back to each of the participants. RESULTS: All participants had mental models with rich details on the complexity of obesity for individuals, community, and at the policy level. Clinician-researchers had more focus on medical management than policy makers although most participants lacked concepts on the role of primary care in obesity management. A shared understanding of obesity could assist researchers and policy makers in developing a relevant and effective strategy. Concept Mapping provides a novel and creative way to visually compare different understandings of health-related topics.

Facing obesity: Adapting the collaborative deliberation model to deal with a complex long-term problem.

OBJECTIVE: Care communication about obesity needs to respond to the complex biopsychosocial processes that affect weight and health. The collaborative deliberation model conceptualizes interpersonal work that underpins empathic communication and shared decision-making. The goal of this study was to elucidate how primary care practitioners can use the model to achieve shared obesity assessment and care planning. METHODS: This qualitative study used direct observation of clinical encounters with twenty patients with obesity sampled for maximum variation in context, semi-structured patient and provider interviews, patient journals and two follow-up interviews over eight weeks. Themes were compared to the original model. RESULTS: We identified five processes that may be relevant for collaborative deliberation about obesity in addition to the original model: (1) Exploring the story, (2) Reframing the story, (3) Co-constructing a new story, (4) Choosing a priority, and (5) Experimenting with alternatives. CONCLUSIONS: We propose an enhanced collaborative deliberation model for obesity that describes the interpersonal work needed before and after deliberation about preferences and courses of action. PRACTICE IMPLICATIONS: The enhanced model can support clinicians in achieving meaningful conversations about obesity and complex chronic disease resulting in care plans that are responsive to and achievable in the patient's lifeworld.

Understanding Implementation of Complex Interventions in Primary Care Teams.

BACKGROUND: The implementation of interventions to support practice change in primary care settings is complex. Pragmatic strategies, grounded in empiric data, are needed to navigate real-world challenges and unanticipated interactions with context that can impact implementation and outcomes. OBJECTIVE: This article uses the example of the "5As Team" randomized control trial to explore implementation strategies to promote knowledge transfer, capacity building, and practice integration, and their interaction within the context of an interdisciplinary primary care team. METHODS: We performed a qualitative evaluation of the implementation process of the 5As Team intervention study, a randomized control trial of a complex intervention in primary care. We conducted thematic analysis of field notes of intervention sessions, log books of the practice facilitation team members, and semistructured interviews with 29 interdisciplinary clinician participants. We used and further developed the Interactive Systems Framework for dissemination and implementation to interpret and structure findings. RESULTS: Three themes emerged that illuminate interactions between implementation processes, context, and outcomes: (1) facilitating team communication supported collective and individual sense-making and adoption of the innovation, (2) iterative evaluation of the implementation process and real-time feedback-driven adaptions of the intervention proved crucial for sustainable, context-appropriate intervention impact, (3) stakeholder engagement led to both knowledge exchange that contributes to local problem solving and to shaping a clinical context that is supportive to practice change. CONCLUSION: Our findings contribute pragmatic strategies that can help practitioners and researchers to navigate interactions between context, intervention, and implementation factors to increase implementation success. We further developed an implementation framework that includes sustained engagement with stakeholders, facilitation of team sense-making, and dynamic evaluation and intervention design as integral parts of complex intervention implementation. TRIAL REGISTRATION: NCT01967797. 18 October 2013.

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

BACKGROUND: The 5As [Ask, Assess, Advise, Agree, Assist] of Obesity Management Team study was a randomized controlled trial of an intervention that was implemented and evaluated to help primary care providers improve clinical practice for obesity management. This paper presents health care provider perspectives of the impacts of the intervention on individual provider and team practices. METHODS: This study reports a thematic network analysis of qualitative data collected during the 5As Team study, which involved 24 chronic disease teams affiliated with family practices in a Primary Care Network in Alberta. Qualitative data from 28 primary care providers (registered nurses/nurse practitioners [n = 14], dietitians [n = 7] and mental health workers [n = 7]) in the intervention arm were collected through semistructured interviews, field notes, practice facilitator diaries and 2 evaluation workshop questionnaires. RESULTS: Providers internalized 5As Team intervention concepts, deepening self-evaluation and changing clinical reasoning around obesity. Providers perceived that this internalization changed the provider-patient relationship positively. The intervention changed relations between providers, increasing interdisciplinary understanding, collaboration and discovery of areas for improvement. This personal and interpersonal evolution effected change to the entire Primary Care Network. INTERPRETATION: The 5As Team intervention had multiple impacts on providers and teams to improve obesity management in primary care. Improved provider confidence and capability is a precondition of developing effective patient interventions. Trial registration: ClinicalTrials.gov, no.: NCT01967797.

The 5As team patient study: patient perspectives on the role of primary care in obesity management.

BACKGROUND: Over 60% of people have overweight or obesity, but only a third report receiving counselling from primary care providers. We explored patients' perspectives on the role of primary care in obesity management and their experience with existing resources, with a view to develop an improved understanding of this perspective, and more effective management strategies. METHODS: Qualitative study employing semi-structured interviews and thematic analysis, with a sample of 28 patients from a cohort of 255 patients living with obesity and receiving care to support their weight management in a large Primary Care Network of family practices in Alberta. RESULTS: Four illustrative themes emerged: (1) the patient-physician relationship plays an important role in the adequacy of obesity management; (2) patients have clear expectations of substantive conversations with their primary care team; (3) complex conditions affect weight and patients require assistance tailored to individual obesity drivers; (4) current services provide support in important ways (accessibility, availability, accountability, affordability, consistency of messaging), but are not yet meeting patient needs for individual plans, advanced education, and follow-up opportunities. CONCLUSIONS: Patients have clear expectations that their primary care physician asks them about weight within a supportive therapeutic relationship. They see obesity as a complex phenomenon with multiple drivers. They want their healthcare providers to assess and address their root causes - not simplistic advice to "eat less, move more". Patients felt that the current services were positive resources, but expressed needs for tailored weight management plans, and longer-term follow-up.

Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As Team (5AsT) randomized control trial.

BACKGROUND: Obesity is a pressing public health concern, which frequently presents in primary care. With the explosive obesity epidemic, there is an urgent need to maximize effective management in primary care. The 5As of Obesity Management™ (5As) are a collection of knowledge tools developed by the Canadian Obesity Network. Low rates of obesity management visits in primary care suggest provider behaviour may be an important variable. The goal of the present study is to increase frequency and quality of obesity management in primary care using the 5As Team (5AsT) intervention to change provider behaviour. METHODS/DESIGN: The 5AsT trial is a theoretically informed, pragmatic randomized controlled trial with mixed methods evaluation. Clinic-based multidisciplinary teams (RN/NP, mental health, dietitians) will be randomized to control or the 5AsT intervention group, to participate in biweekly learning collaborative sessions supported by internal and external practice facilitation. The learning collaborative content addresses provider-identified barriers to effective obesity management in primary care. Evidence-based shared decision making tools will be co-developed and iteratively tested by practitioners. Evaluation will be informed by the RE-AIM framework. The primary outcome measure, to which participants are blinded, is number of weight management visits/full-time equivalent (FTE) position. Patient-level outcomes will also be assessed, through a longitudinal cohort study of patients from randomized practices. Patient outcomes include clinical (e.g., body mass index [BMI], blood pressure), health-related quality of life (SF-12, EQ5D), and satisfaction with care. Qualitative data collected from providers and patients will be evaluated using thematic analysis to understand the context, implementation and effectiveness of the 5AsT program. DISCUSSION: The 5AsT trial will provide a wide range of insights into current practices, knowledge gaps and barriers that limit obesity management in primary practice. The use of existing resources, collaborative design, practice facilitation, and integrated feedback loops cultivate an applicable, adaptable and sustainable approach to increasing the quantity and quality of weight management visits in primary care. TRIAL REGISTRATION: NCT01967797.

ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction.

The American College of Cardiology and American Heart Association, in collaboration with the Canadian Cardiovascular Society, have issued an update of the 2004 guideline for the management of patients with ST-segment elevation myocardial infarction. The American Academy of Family Physicians endorses and accepts this guideline as its policy. Early recognition and prompt initiation of reperfusion therapy remains the cornerstone of management of ST-segment elevation myocardial infarction. Aspirin should be given to symptomatic patients. Beta blockers should be used cautiously in the acute setting because they may increase the risk of cardiogenic shock and death. The combination of clopidogrel and aspirin is indicated in patients who have had ST-segment elevation myocardial infarction. A stepped care approach to analgesia for musculoskeletal pain in patients with coronary heart disease is provided. Cyclooxygenase inhibitors and nonsteroidal anti-inflammatory drugs increase mortality risk and should be avoided. Primary prevention is important to reduce the burden of heart disease. Secondary prevention interventions are critically important to prevent recurrent events in patients who survive.

Hypertension.

For primary care physicians, managing hypertension is a challenging undertaking because it is a good example of the balance be-tween implementing evidence and working with patients' beliefs, ideas, and resources to help them improve their health. In this article the authors review the evidence supporting aggressive recommendations on prevention and treatment of hypertension to decrease cardiovascular, cerebrovascular, and renal disease. They review the public health implications of hypertension, but focus on the challenges clinicians face in working with patients to optimize their health with the financial and personal resources they have available.