Obesity management in primary care: systematic review exploring the influence of therapeutic alliance.

PURPOSE: To identify the influence of the therapeutic alliance on the effectiveness of obesity interventions delivered in primary care. METHOD: Systematic review of randomized controlled trials of primary care interventions for adult patients living with obesity. Comprehensive search strategy using the terms 'obesity', 'primary care' and 'intervention' of seven databases from 1 January 1998 to March 2018. Primary outcome was difference in weight loss in interventions where a therapeutic alliance was present. RESULTS: From 10 636 studies, 11 (3955 patients) were eligible. Only one study had interventions that reported all aspects of therapeutic alliance, including bond, goals and tasks. Meta-analysis was not included due to high statistical heterogeneity and low numbers of trials; as per our protocol, we proceeded to narrative synthesis. Some interventions included the regular primary care practitioner in management; very few included collaborative goal setting and most used prescriptive protocols to direct care. CONCLUSIONS: We were surprised that so few trials reported the inclusion of elements of the therapeutic alliance when relational aspects of primary care are critical for effectiveness. Interventions could be developed to maximize therapeutic relationships and research reports should describe interventions comprehensively. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42018091338 in PROSPERO (International prospective register of systematic reviews).

Social and community networks influence dietary attitudes in regional New South Wales, Australia.

INTRODUCTION: Rural populations in Australia have a higher prevalence of obesity, cardiovascular disease, type II diabetes and some cancers. The purpose of the present study was to determine associations between socioeconomic characteristics (socioeconomic position, income, wealth, debt, occupation, social network diversity), dietary attitudes, and fruit and vegetable intake for people living rurally in Australia. METHOD: A community based cross-sectional survey between February and July 2018 of 326 adults (median age 57 years, range 20-90 years, 64.4% female) who attended rural shows in four rural towns in south-eastern New South Wales, supplemented with data from patients attending general practices in two additional towns. Participants completed a questionnaire that recorded self-reported daily consumption of fruit and vegetables, a dietary attitude score, and items measuring social and economic circumstances. RESULTS: Using multivariable regression analysis, the odds of meeting Australian fruit intake guidelines was 13% higher for each unit increase in dietary attitude score (odds ratio (OR)=1.13, 95% confidence interval (CI)=1.03-1.23). The odds of meeting vegetable intake guidelines were 19% higher for each unit increase in score (OR=1.19, 95%CI=1.09-1.31). Social and economic factors were not independently associated with fruit or vegetable intake. Dietary attitude score, in turn, increased on average by 0.07 points (95%CI=0.01-0.12) for each additional occupation type among the participants' social networks. For women who socialised regularly in small towns the score was 1.97 points higher (95%CI=0.93-3.00). Men in outer regional areas were more likely to meet vegetable intake guidelines than men in inner regional areas, whereas women in outer regional areas were more likely to meet fruit intake guidelines than women in inner regional areas. CONCLUSIONS: Greater fruit and vegetable intake was predicted by healthier dietary attitudes which in turn were related to social and community connections, rather than economic factors.

Predicting future performance in medical students. A longitudinal study examining the effects of resilience on low and higher performing students.

Introduction: Medical students have high rates of distress and burnout, exacerbated by a high academic workload. Resilience is stated to mitigate such stress, and even allow positive adaptations in the face of such challenges. Despite this, no research has examined the relationship of resilience on the academic performance of medical students. Methods: The goal of our study was to investigate the association between resilience on academic performance. We surveyed all year 2, 3, and 4 medical students (n = 160), and combined this with data on past and future course performance. We conducted an analysis of the internal consistency and validity of the RS-14, suggesting two factors: which we represent as self-assuredness and drive. We then analyzed future course performance using multiple regression. Results: Models utilizing the combined RS-14 score suggested past-performance as the only significant predictor of future course performance. Considering self-assuredness and drive as separate predictors demonstrated self-assuredness to be a predictor of improved performance in lower-than-average students, whilst drive was a predictor of improvement in higher-than-average students. Conclusions: We suggest that the conceptualization of resilience needs greater nuance, and consideration in tandem with broader psychosocial concepts, as it may exert different effects for different students.

How does studying rurally affect peer networks and resilience? A social network analysis of rural- and urban-based students.

OBJECTIVE: To examine differences in peer networks between urban-based students and rural-stream students in an Australian medical school and to examine how characteristics of networks relate to resilience. DESIGN: Cross-sectional survey asking students to signify social, academic and support relationships with students in the same year and to complete a survey on their resilience. SETTING AND PARTICIPANTS: All second-, third- and fourth-year students at the Australian National University Medical School. MAIN OUTCOME MEASURES: Social network analysis comparing peer networks, t-test comparing mean resilience of urban and rural students. RESULTS: A visual analysis of the peer networks of year 2, 3 and 4 medical students suggests greater integration of rural-stream students within the year 2 and 4 urban cohorts. Resilience is similar between year 2 and 3 students in both urban and rural streams, but is significantly higher in year 4 rural-stream students, compared to their urban-based peers. Networks of rural-stream students suggest key differences between their period spent rurally and on their return and integration within the larger student cohort. Furthermore, rural students, once reintegrated, had larger and stronger social networks than their urban counterparts. CONCLUSION: The results of the study suggest that the rural experience can instruct support systems in urban settings. However, whether the rural placement creates a more resilient student or resilient students are selected for rural placement is unclear.

The influence of therapeutic alliance on adult obesity interventions in primary care: A systematic review protocol.

BACKGROUND AND OBJECTIVES: Obesity is a common chronic condition, and general practitioners are seeking more effective strategies for assisting their patients. The therapeutic relationship between patients and practitioners is increasingly recognised as a fundamental part of intervention effectiveness. The influence of therapeutic relationships in obesity interventions in primary care has not been systematically studied. We plan to undertake a systematic review and meta-analysis to identify the influence of the therapeutic alliance on the effectiveness of obesity interventions in primary healthcare. The aim of this article is to outline the study protocol. METHOD: A systematic review of primary care interventions for patients with obesity will be undertaken. Using Bordin's framework for the therapeutic alliance, interventions will be categorised as to whether they incorporate the alliance or not. A meta­analysis will be performed if studies of sufficiently homogenous primary outcome data are found. DISCUSSION: Understanding the role of the therapeutic alliance on interventions for obesity management will have implications for both future intervention development and the translation of current interventions from trial settings to the real world.

Metabolic syndrome and weight management programs in primary care: a comparison of three international healthcare systems.

Lifestyle behaviours are contributing to the increasing incidence of chronic disease across all developed countries. Australia, Canada and the UK have had different approaches to the role of primary care in the prevention and management of lifestyle-related diseases. Both obesity and metabolic syndrome have been targeted by programs to reduce individual risk for chronic disease such as type 2 diabetes. Three interventions are described - for either obesity or metabolic syndrome - that have varying levels of involvement of GPs and other primary care professionals. The structure of a healthcare system for example, financing and physical locations of primary care clinicians, shapes the development of primary care interventions. The type of clinicians involved in interventions, whether they work alone or in teams, is influenced by the primary care setting and resource availability. Australian clinicians and policymakers should take into account the healthcare system where interventions are developed when translating interventions to the Australian context.

Role of the family doctor in the management of adults with obesity: a scoping review.

OBJECTIVES: Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology. SETTING: Primary care. Adult patients. INCLUDED PAPERS: Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review. PRIMARY AND SECONDARY OUTCOME MEASURES: Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned. RESULTS: 110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations. CONCLUSIONS: There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.

Feasibility and acceptability of a physician-delivered weight management programme.

BACKGROUND: Primary health care requires new approaches to assist patients with overweight and obesity. This is a particular concern for patients with limited access to specialist or allied health services due to financial cost or location. The Change Program is a toolkit that provides a structured approach for GPs working with patients on weight management. OBJECTIVE: To assess the acceptability and feasibility of a GP-delivered weight management programme. METHODS: A feasibility trial in five Australian general practices with 12 GPs and 23 patients. Mixed methods were used to assess the objective through participant interviews, online surveys and the NOrmalization MeAsure Development (NoMAD) tool based on Normalization Process Theory. Content analysis of interviews is presented alongside Likert scales, free text and the NoMAD tool. RESULTS: The Change Program was acceptable to most GPs and patients. It was best suited to patient-GP dyads where the patient felt a strong preference for GP involvement. Patients' main concerns were the time and possible cost associated with the programme if run outside a research setting. For sustainable implementation, it would have been preferable to recruit a whole practice rather than single GPs to enable activation of systems to support the programme. CONCLUSION: A GP-delivered weight management programme is feasible and acceptable for patients with obesity in Australian primary health care. The addition of this structured toolkit to support GPs is particularly important for patients with a strong preference for GP involvement or who are unable to access other resources due to cost or location.

Increasing general practitioners' confidence and self-efficacy in managing obesity: a mixed methods study.

OBJECTIVES: Internationally, general practitioners (GPs) are being encouraged to take an active role in the care of their patients with obesity, but as yet there are few tools for them to implement within their clinics. This study assessed the self-efficacy and confidence of GPs before and after implementing a weight management programme in their practice. DESIGN: Nested mixed methods study within a 6-month feasibility trial. SETTING: 4 urban general practices and 1 rural general practice in Australia. PARTICIPANTS: All vocationally registered GPs in the local region were eligible and invited to participate; 12 GPs were recruited and 11 completed the study. INTERVENTIONS: The Change Programme is a structured GP-delivered weight management programme that uses the therapeutic relationship between the patient and their GP to provide holistic and person-centred care. It is an evidence-based programme founded on Australian guidelines for the management of obesity in primary care. PRIMARY OUTCOME MEASURES: Self-efficacy and confidence of the GPs when managing obesity was measured using a quantitative survey consisting of Likert scales in conjunction with pro forma interviews. RESULTS: In line with social cognitive theory, GPs who experienced performance mastery during the pilot intervention had an increase in their confidence and self-efficacy. In particular, confidence in assisting and arranging care for patients was improved as demonstrated in the survey and supported by the qualitative data. Most importantly from the qualitative data, GPs described changing their usual practice and felt more confident to discuss obesity with all of their patients. CONCLUSIONS: A structured management tool for obesity care in general practice can improve GP confidence and self-efficacy in managing obesity. Enhancing GP 'professional self-efficacy' is the first step to improving obesity management within general practice. TRIAL REGISTRATION NUMBER: ACTRN12614001192673; Results.

The role of the family doctor in the management of adults who are obese: a scoping review protocol.

BACKGROUND: The role of family doctors in the management of obesity in primary care will become increasingly important as more of the adult population become overweight or obese. Having a solid understanding of the family doctor's role as a sole practitioner is important for supporting practitioners in providing patient care and for informing future research. OBJECTIVE: The purpose of this paper is to describe a protocol for a scoping review that aims to examine and map the current research base for the role of the family doctor in managing adults who are overweight or obese. METHODS: This scoping review is based on the methodology as described by the Joanna Briggs Institute which involves final consultation with stakeholders. Two reviewers (ES, NE) will be responsible for the iterative development of a search strategy based on the basic initial search terms obesity, doctor and primary care. Black and grey literature will be searched to elucidate any manuscripts involving the family doctor in the management of adults who are overweight or obese. A customised data extraction tool will be used to collect relevant items from each manuscript. RESULTS: Data extraction will expose the role family doctors are playing in obesity management in all stages of research including recruitment, intervention or as a control group. By looking at a broad scope of manuscripts we will discover the family doctor's role as portrayed in research, in international guidelines and by peak bodies. We will also determine if there are any gaps in the research base. CONCLUSION: This protocol describes a scoping review that will illustrate the supporting international research for the role family doctors are playing in the management of adults who are overweight or obese. Scoping of the international literature will then be translated for Australian primary care.