Obesity Screening Training for Primary Care Providers

Introduction

Obesity is an ongoing healthcare issue in the United States. The prevalence of the chronic condition is approaching pandemic levels affecting an estimated 39.8%, or 93.3 million of US adults between the years of 2015 and 2016 (Center for Disease Control and Prevention, 2018). This represents a major health concern due to the increased risk for co-morbid conditions associated with obesity. Obesity is also associated with premature mortality, lowered quality of life, and high economic burden. Therefore, healthcare providers must consider the best evidence-based practices that will help to address the condition and reduce its prevalence in the country.

Administration of routine obesity intervention programs in the primary care setting is one effective way to manage obesity. According to Brown and Perrin (2018), healthcare providers should administer routine intervention programs using an effective framework. One such framework that has been proven effective in helping patients improve their health behavior is the 5 As framework. The framework was used to develop a quality improvement program for obesity management in a primary care setting where patients are disproportionately affected by high rates of obesity. The project involved educating PCPs to increase obesity screening rates and on the use of the 5As framework to help patients reduce their basal metabolic index (BMI).

Problem Statement

Obesity is associated with significant co-morbid conditions such as coronary artery disease, hypertension, osteoarthritis, type II diabetes mellitus, obstructive sleep apnea, multiple cancers, and dementia (Blüher, 2019). It is also associated with lowered quality of life and premature mortality. Healthcare costs linked to obesity in the US are estimated to be $147 billion causing a substantial economic burden to society (CDC, 2018). Other burdens for obese patients include higher rates of unemployment, social disadvantage, and lost productivity (Blüher, 2019). Despite multiple campaigns to help reduce the prevalence of obesity, the trend in obesity has been rising from 30.5% of adults in 1999/2000 to 39.6% of adults in 2015/2016 (CDC, 2018). Additionally, studies suggest that less than half of PCPs will offer counseling to patients with obesity even though clinically meaningful weight loss can occur with moderate intensity behavioral counseling and strategies (Wadden et al., 2013).

Without the participation of PCPs in overcoming the obesity pandemic, trends for obesity may continue to grow. Therefore, the problem of obesity, as well as the under-diagnosis and treatment are widely recognized as major healthcare problems throughout the United States (Kahan, 2018). This quality improvement program targeted a primary care center in Florida. The location of the intervention had no formalized program of pre-screening for obesity. BMIs of patients were also not routinely logged in patients’ medical records; instead, it was done on a voluntary basis by providers. Additionally, a majority of patients with obesity failed to meet guidelines on healthy diets physical activity, among others. The failure to address these issues within the facility necessitated the implementation of a quality improvement to improve healthcare providers’ knowledge and skills in the screening and management of obesity among their patients.

Purpose of the Project

The overall goal of the project was to decrease obesity rates at a community health and wellness center. The specific aims were1) to increase PCPs obesity screening rates and 2) to reduce patient body mass index (BMI). The project involved training PCPs on the implementation of the 5 As framework with the goal of improving screening rates and helping patients reduce their body mass index (Welzel et al., 2018). This technique is similar to what has been successfully used in smoking cessation programs which includes the elements of assessing, advising, agreeing, assisting, and arranging (Van Dillen et al., 2015). PCPs received a 90-minute training course on the implementation of the 5 As a model. The variables that were measured include demographics of the PCPs, frequency of obesity screening and counseling within primary care, and patient BMIs. These variables were measured using pretest/posttest assessment and analyzed for any statistical significance differences and improvements. The patient demographic information and BMIs were also obtained from their electronic health record. The patient’s BMI was recorded at the beginning of the intervention and re-recorded at the end of the 6-month intervention. The information was used to assess for any improvements in BMI as a result of the intervention.

The Need for PCP Obesity Training

PCPs can play a crucial role in helping patients overcome obesity. Studies have shown that patients are more motivated to reduce weight when they have received counseling from a healthcare provider (Welzel et al., 2018). The Center for Medicare and Medicaid Services has recognized this issue and, in 2011, began reimbursing PCPs for delivering intensive behavioral therapy to treat obese patients (Fitzpatrick et al., 2016). Similarly, other organizations, such as the US Preventative Services Task Force (USPSTF), American Heart Association, Obesity Society, and American College of Cardiology, have agreed that obesity interventions are necessary for primary care. These organizations have issued a joint statement that obesity screening along with intensive behavioral counseling can significantly reduce the risk factors for cardiovascular disease (Fitzpatrick et al., 2016).

In the joint statement, USPSTF recommended screening of all adults for obesity, and patients should be recommended behavioral interventions when the body mass index is equal to or exceeds 30 kg/m² (Moyer, 2012). The basis for this recommendation is that early detection and intervention can imply several health benefits such as improved glucose tolerance, reduced risk for cardiovascular disease, and reduced risk for other physiologic factors (Moyer, 2012). However, these obesity interventions are not frequently delivered, with only 30% of PCPs reporting that they assess, diagnose, and counsel patients concerning obesity. Additionally, PCPs in the US may be inadequately educated on how to provide proper obesity treatment (Stanford et al., 2015). Specifically, only 59% of adult primary care physicians who responded to a survey (n=41) reported receiving at least one hour of obesity training and acknowledged their knowledge was insufficient (Stanford et al., 2015). This is concerning given the high prevalence of obesity combined with this lack of knowledge and training concerning obesity treatment implies the need for better preparation of PCPs.

The 5 As Framework for Obesity Screening

A simple pneumonic device that PCPs can utilize with patients who are obese is the 5 As Framework. This framework is a type of behavioral counseling which can be delivered in a primary care setting that follows a sequence of evidence-based practice actions that have been shown to be effective in helping patients improve their health behaviors. This framework has been endorsed by the Centers for Medicare and the US Preventive Services Task Force (Van Dillen et al., 2015). The framework consists of five main elements, namely; assess, advise, agree, assist, and arrange. The assessment element involves identifying the patient’s current behavior, measuring their BMI, and determining the readiness to change. The second element of advice involves recommending the patient to consider lifestyle and behavioral changes and an explanation of the associated health benefits. The agree element involves collaboratively setting weight loss and lifestyle changes goals with the patient. In the next stage of assistance, the PCP offers additional including pharmaceutical, counseling, or surgical interventions to address barriers and to further secure support. Lastly, in the arranging stage, a follow-up plan is established with the patient as well as referral and involves other professionals in inpatient care (Van Dillen et al., 2015).

Other studies have used slight variations of the 5 As framework in various elements and stages, such as asking the patient the causes for the weight gain in the assessment stage (Welzel et al., 2018). The PCP may also ask the patient about current nutrition and physical activity habits as well as measure the patient’s waist circumference and considering their obesity (Sherson et al., 2014). During the assessment, the PCP may try to discover the root cause of the obesity,assessment including psychosocial factors. During the assist phase, the PCP can help the patient acquire the confidence, skills, and social support to lose weight (Sherson et al., 2014). The PCP can consider helping the patient change environmental factors and provide other adjunctive medical treatments or interventions such as physiotherapy and specific guidance from a nutritionist (Sherson et al., 2014). During the assist phase, the PCP can provide facilitators, motivational support, and recommendations to overcome economic barriers to reach the goals of the treatment plan (Vallis et al., 2013). The PCP should provide continuous assistance in educating, recommending, supporting, and identifying factors related to obesity treatment.

5 As Training to PCPs

The 5As framework has a better chance of being implemented in a primary care setting if PCPs are properly trained. According to a Dutch study, practicing nurses felt a higher level of confidence to deliver motivational interviewing and counseling when specifically trained on the 5 As framework (Van Dillen et al., 2015). Proper training also directly affected the quality of the counseling when a proper communication style was utilized alongside the 5 As framework. These conclusions were based on an observational design where 100 real-life nurse practitioners and patient consultations were videotaped. An observation checklist was used to discern the use of the 5 As by the nurse practitioner. Also, the quality of the weight-loss counseling was assessed for communication style in terms of its informational, confrontational, motivational, reference, and holistic characteristics (Van Dillen et al., 2015). The statistical analysis showed that the combination of three communication styles for the consultation that was most frequently used included motivational, informational, and holistic (Van Dillen et al., 2015). For nutritional consultations, the informational style was used while physical activity counseling used a more motivational approach. The components of the 5 As that were found to be the major predictors of weight loss were the advice, agree, and assess components.

According to a systematic literature review of 15 articles, patients would like their PCPs to implement the 5 As framework (Sherson et al., 2014). However, considering the significant gap between the patient’s needs and actual practice, it was evident the need for a training program for PCPs to help them implement the 5 As framework (Welzel et al., 2018). The study made several recommendations as it relates to the intervention framework, such as inclusion and exclusion criteria, randomization and blinding, outcome and measures, duration, questionnaires, primary/secondary outcomes, data collection and management, and data analysis (Welzel et al., 2018). Pollak et al. (2016) also analyzed the delivery of physician-based obesity intervention using the 5 As as a randomized controlled trial (n = 527) comparing a group that received intervention training versus the control group delivering regular care. The study found that the trained physicians had a significantly greater frequency of assessing (p = 0.004), assisting (p = 0.001), and arranging (p = 0.02) portion of the 5 As framework than the control group. The intervention was delivered as an online program and concluded that training should be provided to physicians to improve the rate of 5 As behavioral counseling approach in clinical practice (Pollak et al., 2016).

5 As and Clinically Significant Patient Weight Loss

Helping patients achieve sustained weight loss can be challenging; therefore, using evidence-based practice, such as the 5 As a framework, can help increase the success rate as a primary care-driven effort to decrease the prevalence of obesity in a community. According to Pool et al. (2014), patients can implement behavioral changes if physicians effectuate the 5 As method along with other techniques such as motivational interviewing and the use of visual prompts. Using a sample of 5054 participants, patients who lost at least 5% of their body weight over a year were considered clinically significant for weight loss (Pool et al., 2014). The results were significant with an adjusted odds ratio of 1.88 (95% CI 1.45 – 2.44) for overweight patients and 1.79 (95% CI 1.30 – 2.46) as a result of the intervention. Pool et al. (2014) also suggested that healthcare providers implementing only the first two steps of the 5 As, ask/advise, can have a powerful effect to encourage patients to lose weight. These minimal intervention sessions that included suggestions on diet, exercise, and weight management strategies led to three times more patients that reported attempting to lose weight than those not advised.

Similarly, a systematic review of behavioral counseling for overweight and obese patients delivered by a PCP identified 12 trials that involved 3893 participants (Wadden et al., 2014). The participants received the 5 As an intervention, or similar strategy, that included advice to reduce energy intake and to increase physical activity combined with behavioral therapy. The mean weight loss within the first six months amongst the studies ranged between 0.3 and 6.6 kg. The percentage of patients losing at least 5% of body weight due to the intervention ranged from 10.2% to 26.0% when the intervention was provided by PCP; the results ranged from 18.8% to 65% for trained interventionists (Wadden et al., 2014). The study found that results improved when medical sessions and/or contact was frequent during the first six months with a mean weight loss of 6.1 kg with 52.7% of participants losing at least 5% of baseline weight. Results also confirmed that intensive face-to-face intervention was more productive than telephone sessions.

Tsai et al. (2010) conducted a study that implemented the 5 As using medical assistants as weight loss counselors. The study was conducted at two primary care offices as randomized controlled trials (n = 50). Results were statistically significant with a mean of 4.4 kg lost at the six-month interval (p = 0.001), with 18% losing 5% of body mass or more. Other outcomes were measured, such as glucose, blood pressure, and lipids; however, there was no significant improvement. Kumanyika et al. (2012) evaluated the program that included the advice and assists step to reduce calorie levels depending on body weight. The intervention included handouts, audio CDs, and 12 one-on-one sessions that focused on food intake and activity levels; the treatments were delivered by PCPs. Of the 124 participants (n = 24), 22.5% lost 5% of baseline weight (p = 0.022) who participated in the “basic plus program” which included weekly sessions between 30 and 60 minutes for the first six months, and10 to15-minute sessions every four months for the remaining 18 months (Kumanyika et al., 2012). These interventions, along with many others, demonstrate the efficacy of weight-loss interventions by PCPs using elements of the 5 As framework.

Conceptual and Theoretical Framework

Kurt Lewin’s Three-Step Model for Change is an applicable theoretical framework for this study since PCPs must develop their professional skills towards delivering quality care as it relates to obesity reduction (Wojciechowski et al., 2016). This change model was used in the design of the quality improvement project intervention to help PCPs adapt to an organizational-wide change of implementing the 5 As model. The first step is to “unfreeze” the status quo of not addressing obesity or treating without the use of a clinical standard or one that is not evidence-based. Here, the PCPs were made aware of the problem of obesity trends and the availability of interventions such as the 5 As model. As a change manager, it is important to be aware of restraining forces, obstacles, and barriers amongst the PCPs towards implementing change (Wojciechowski et al., 2016). The second step of the change model includes “changing and moving” which require coaching and training of the PCPs on techniques akin to the 5 As model. This included demonstrating the benefits of the change as well as addressing forces that can negatively affect change (Wojciechowski et al., 2016). The change process is concluded with “refreezing” which required monitoring to ensure that change has become the new standard of care. The change manager must ensure its complete integration, and success must be measured using performance indicators (Wojciechowski et al., 2016).

Study Design

This quality improvement project used a pre-test/post-test study design. This design is key for interventional studies because it optimizes and economizes study completion (Nair, 2019).

Target Population

The study was conducted at Community Health and Wellness Center, a primary care clinic in Miami – Dade County. This clinic was selected due to the focus on primary care and the opportunity for conducting training sessions. Prior to recruiting and conducting the QI project, a formal introduction was sent to the Chief Executive Officer (CEO) of the facility requesting permission to carry out QI improvement in the clinic. Thereafter the PD held a formal meeting with the CEO, and all PCPs, including physicians and nurse practitioners who were the population of interest in the study. Additionally, the PD requested PCPs to refer patients as participants.

Sampling Procedure

The Project Director (PD) had PCP participants sign a consent form that detailed study information. A similar consent was signed by patient participants at the facility to allow de-identified data to be used. The consent form included all the information which addressed the ethical concerns which could prevent the PCPs and patients from taking part in the study. The study adopted a convenient non – probability sampling technique because it was easy to use considering that the PD only selected clinical participants who were available in the facility at the time (Stratton, 2021). In addition, it was the best use as the PD only sampled those who were willing and ready to volunteer to partake in the study (Stratton, 2021).

Conveniently, the researcher recruited a total of 20 Primary Care Providers (PCP), including physicians, nurse practitioners, and registered nurses. This number was arrived at by taking 5 PCPs from each seminar which took part in the training. There were a total of 4 seminars with the total of 20 PCPs. The researcher conveniently sampled 5 from each training bringing up the number to 20. This was based on the researcher’s discretion that all the PCPs who trained were willing and happy to volunteer to participate in the study (Etikan & Bala 2017). There was no exclusion applied when recruiting the PCPs other than the willingness to participate, so anybody selected was good for the study. A sample of 100 patients was also conveniently recruited to participate in the study (Etikan & Bala, 2017). The age and gender of the participants are dispayed in Table 5 from Appendix H. Since the patients did not receive the training, they were included through chart reviews as subjects of the 5As model once the PCPs had completed the training.

The study excluded patients under 18 and over 64; those under 18 were excluded because the BMI parameters are determined by data from individuals age 18 and older (“US Department of Health,” 2020). Patients over 64 were excluded because weight reduction or gain can complicate their underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, and nutritional deficiencies. Collectively, 20 PCPs and 100 patients were sampled as respondents for this study, making up a total of 120 participants.

Pre-Test Results

All the PCPs who took part in the project indicated that they had participated in at least one quality improvement training on obesity in the past three years as revealed in the pre-test report. The details about their past training expereince are shown in Figure 1 in the Appendix. However, only two (10%) of the participants indicated that just one training they attended in the past on obesity quality improvement training covered the use of 5A’s framework. Further, before this study, 46% of PCPs participating in this study said they had been trained on cognitive behavioral therapy; 21% and 4% of them were trained on motivational interviewing and family involvement respectively; 25% ± 0.91 of PCPS were always screening obese patients before providing primary care as shown in the pre-training intervention report. The results of the pre-tests are shown as Table 1 in Appendix H.

Another 20% ± 0.91 of them were rarely screening the patients before the intervention, while 50% ± of PCPS said they sometimes screened the patients. Pre-training intervention results as indicated by the pre-testing report showed only 25% of the patients with obesity experienced a reduction in weight due to PCPs’ direct involvement in their treatment. In terms of knowledge and skill, 36% ± 1.18 could screen, counsel, treated patients with obesity and were competent with 5A’s framework for patients with obesity, as seen in Table 2 in Appendix F.

Post-Test Results

The post-test report showed that 90% of participants had participated in one training on 5A’s, with the other 10% of them confirming taking part in two pieces of training of 5A’s framework. The proportions of PCPs who trained on cognitive behavioral therapy, motivational interviewing, and family involvement remained at 46%, 21%, and 4%, respectively. After the training intervention, 80% ± 0.64 of PCPs said they always screened adults for obesity when providing primary care; representing an improvement of 55% from 25% before the intervention. In addition, post-intervention had an improvement on patients 42.5% who experienced a reduction in body weight loss due to direct involvement of PCPs in their treatments. In terms of knowledge and skills application, 92.5% ± 0.71 of PCPs could screen, counsel, treat patients with obesity and were competent with 5A’s framework for patients with obesity after the intervention. Clearly, the training improved the PCPs’ knowledge and skills by 56.5% from 36% before the seminars. The participants responses to the obesity-related questions are shown in Figures 6-10 in Appendix H.

Paired T-Test Results

The descriptive results indicated improvement in PCPs’ knowledge and skills application of the 5As framework after they took part in the training intervention. The means scores and standard deviations results were higher in the post-test report compared to the pre-test report. Additionally, the reduction in patients’ weight loss (BMI) was higher in post-training compared to pre-training. However, this difference could be due to sampling error or chance; so to confirm if the difference was statistically significant, a paired t-test was run (Gleichmann, 2020). The two groups that were compared were essentially the same apart from giving two different results, one before training intervention and the other after the seminars. The pre-test/post-test correlation results for PCPs knowledge and skills application of the 5As framework was a weak positive association ( r = 0.140, p < 0.001). The BMI results showed weak positive a pre-test/post-test correlation (r = 0.169, p < 0.001). The results of the paired t-test are displayed as Table 1 and Table 2 in Appendix H.

Paired sample testing was the best statistical measure because the same groups were tested twice before and after the intervention. This test uses the same participants, thus, it reduces the chances of variation between the samples that could occur due to other factors than what is supposed to be tested (Gleichmann, 2020). It assumed two hypotheses; One (null hypotheses – H₀) that there is significant no difference in the means of the groups (Gleichmann, 2020). Secondly, (alternative hypothesis – H₁) that there is a significant difference between the means of the two groups (Gleichmann, 2020). The paired t-test results for PCPs knowledge and skills application of the 5As framework showed a significant mean difference between post-training and pre-training (t₁₉ = 33.927, p < 0.001). On average post-training intervention, scores were 55.1 higher than pre-training scores (CI [58.50, 61.70]). For BMI reduction, the t-test revealed a significant mean difference between post-training and pre-training (t₁₉ = 29.582, p < 0.001). The post-training BMI reductions score were 18.2 higher than the pre-training scores (CL [. 19.43, 21.87]).

Attitudes of PCPs Regarding Obesity

Before the intervention, a majority of the healthcare providers either rarely, never, or only sometimes screened for obesity in adult patients they encountered while providing primary care. Despite the training in different obesity screening and counseling strategies, 20% of the participants reported rarely screening for obesity while providing primary care. Others only conducted obesity screening sometimes (50%) while only 25% always conducted obesity screening. Some of the reasons that were reported as hindering regular screening and counseling for obese patients included many patients (38%), lack of time (35%), and lack of a standardized framework to follow (27%). Additionally, only 15% of the providers reported a 50% reduction in weight among their patients as a direct result of their involvement in their care. After the intervention, 80% of the providers reported that they always screened adults for obesity while providing primary care. A bigger proportion of the providers (45%) also noted that over 50% of their patients with obesity experienced a reduction in body weight as a result of their involvement in their treatment.

With regards to PCPs” opinions about obesity, all providers agreed that obesity is a treatable condition. However, only 55% of the providers felt qualified to screen and treat obese patients. A majority of the providers (85%) also either strongly agreed or agreed that patients with obesity can reach a normal BMI if motivated. This number grew to 100% after the intervention. Nonetheless, 30% of the providers reported that treating patients with obesity is very frustrating. This number was reduced to 15% after the intervention. Additionally, 40% of the providers had been successful in treating patients for obesity before the intervention. The number grew to 85% after the intervention. Lastly, after the intervention, all participants in the quality improvement project either strongly agreed or agreed that they were competent with using the 5As framework on patients with obesity. This was an increase from 20% pre-intervention.

5A’s Screening and Counseling Competencies

The healthcare providers were asked to rate their perceived 5As’ obesity screening and counseling competencies using a series of 15 questions. The questions covered all aspects of the 5As namely; ask, advise, agree assist, and arrange.

Questions on the “ask” investigated competencies in behavioral and physical examination, measuring BMI, and determining readiness to change among patients with obesity. After the intervention, all participants (100%) reported having good to excellent abilities in taking a targeted history of the patient and conducting a physical examination to identify common co-morbidities. This was an increase from 55% pre-interventions. There was also a slight increase in the providers’ knowledge on the calculation of BMI since 95% of the participants were already knowledgeable on the process. All providers (100%) were also able to ascertain patients’ readiness and ability to manage their obesity and screen for common psychosocial problems in obese patients. This was an increase from 60% and 35% respectively from pre-intervention. Three questions addressed the “advise” component of the 5As framework. These were discussing the risk and effect of obesity on the patients’ present and future, discussing the benefits of weight loss to the patient, and responding to patients’ questions regarding treatment options. Post-intervention, all healthcare providers reported either being able to perform well or able to teach others how to perform for all questions in the advise component.

For the “Agree” component, one question was used to assess competency in assessing patients’ physical activity and guiding them to set effective physical activity goals. There was an increase of 45% increase in healthcare providers’ ability in the “agree” competency. Concerning the “Assist” component, four competencies were investigated pre and post-intervention. There was an increase in the provider’s knowledge and skills in all competencies tested including the use of motivational interviewing to change behavior, provision of weight-loss counseling, and determining the need for additional help such as pharmaceuticals and surgery. Lastly, competencies in the “arrange” component were assessed using two questions on the referral of patients with psychological problems and collaboration with other professionals, and the use of community resources to assist patients to lose weight. Like other components, there was an increase in competency post-intervention with an 80% and 85% increase for both competencies. Nonetheless, 7 participants (35%) were still not fully competent as they reported only knowing something about and somewhat able to perform.

Findings

The outcomes of the intervention were measures concerning the overall goal of the project which was to find ways to decrease obesity rates at a community health and wellness center. This was accomplished by improving the knowledge of the participants, such as the PCP are patients regarding obesity itself and ways of addressing this health condition. Concerning the first aim of increasing primary providers’ obesity screening knowledge and skills, the study showed that training of healthcare providers on the use of 5As was effective at increasing providers’ skills, knowledge, and competencies with regards to the screening and counseling of patients with obesity. This was in line with previous studies that have successfully used the 5As framework to improve obesity screening and management (Welzel et al., 2018). There was an increase in competency in all the five components of the 5 As framework including asking, advising, agreeing, assisting, and arranging as outlined in the results. An overall group improvement was recorded from the pre-intervention to post-intervention for the PCPs. This was a statistically significant improvement, as shown in Appendix H in Tables 1-2; thus confirming the hypothesis that training of healthcare providers on the implementation of the 5As framework in obesity management is effective at improving their knowledge and skills and reducing the BMIs of their patients with obesity.

Implications for Practice

As noted in the findings from the quality improvement project, training PCPs on implementation of the 5As framework can improve their skills and knowledge in the management of obesity and reduce patients” BMI. Training of all PCPs and new PCPs on the 5As framework should thus be adopted as a way to improve obesity outcomes among their patients. The importance of focusing on patient outcomes by translating acquired knowledge and skills from 5As training is also emphasized in the findings. Regular collection and monitoring of all patients’ BMIs can allow for effective comparison and care for patients with obesity to ensure interventions applied on them provide sustainable improvements in the patients. In summary, the results of this quality improvement plan can serve as the evidence and impetus for the adoption of similar quality improvement training for PCPs at other healthcare facilities.

Summary

In conclusion, this quality improvement project demonstrated that an educational intervention for PCPs on the implementation of the 5As framework for the screening and counseling of patients with obesity was a feasible way to improve their knowledge and skills and reduce the BMIs of patients with obesity. The findings, as shown in Appendix H, were statistically significant for both improvement in 5A competencies among PCPs and reduction of BMIs among patients. Before the project, it was not routine practice at the project site to screen and provide 5As intervention to patients with every visit. Implementation of the 5As education reinforced the healthcare providers’ awareness of the importance of routine screening and the use of a standardized framework to screen and counsel their patients with obesity.

Evaluation Plan and Sustaining practice change

The outcomes of the project will be monitored even after the completion of the project. Six months after the intervention, the PCPs will be evaluated to determine the impact of the intervention on their skills, knowledge, and practice. These future evaluations will help to monitor the benefits of the project on both the PCPs and patients. This will help to develop better evidence-based interventions to inform obesity management practice in the future. The investigator will also widely publicize the findings from this quality improvement project. Additionally, any necessary improvements determined from the evaluation of the project will also be presented to assist other providers that may implement the project in other clinical settings. To disseminate the evidence from this project, the investigator will submit an abstract to present a poster at nursing conferences focused on obesity

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Approval Letter

Informed Consent

Please read this informed consent carefully before you decide to participate in the study.

Consent Form Key Information:

• Participate in a 90-minute training course on implementation of 5 As model
• Complete a pre and post-test questionnaire including a demographics quiz
• No information collected will connect identity with responses

Purpose of the research study: The purpose of the quality improvement project is to provide training to healthcare providers to improve obesity detection and increase the use of the 5 As framework to help patients reduce their body mass index.

What you will do in the study: Participants will be required to participate in a 90-minute training course on the implementation of 5 As framework in obesity screening and counseling. You will first complete a pre-test questionnaire which includes questions related to demographics such as gender, age, licensure, and years of experience working in primary care. A link to the online questionnaire will be sent to your email address once you provide consent. The questionnaire will also contain multiple-choice questions that will be completed before the intervention and 6-months after the quality improvement training to assess the changes in screening and use of the 5 As framework. You can skip any questions that make you uncomfortable and you can stop participation at any time. You will be invited to complete an online pre-test questionnaire via your email address 6-months post-intervention.

Time required: The quality improvement plan will require about 3 hours of your time. This will include participation in a 90-minute training program and completion of the pretest and posttest questionnaires. The time will be spread over a 6-month period that the quality improvement plan will be running.

Risks: There are no anticipated risks for participating in this quality improvement project and participation in the project will not interfere with normal office performance.

Benefits: Projected benefits include enhancing your care for patients with obesity by equipping you with relevant knowledge and skills. Training on the 5 As framework will increase the frequency of obesity screening, diagnosis, and treatment and thus reduce obesity rates/

Confidentiality: The information that you provide in this project will be handled confidentially. Your information will be assigned a code number and a list connecting your name to this code will be kept in a secure file. When the study is completed, and the data have been analyzed, this list will be destroyed. Your information collected as part of the project will not be used or distributed for future studies even if identifiers are removed. In any report we publish, we will not include any information that will make it possible to identify you.

Voluntary participation: Your participation in the study is completely voluntary. Your work will not be affected by choosing to continue or withdraw from the project.

Right to withdraw from the study: You have the right to withdraw from the study at any time without penalty. The investigator reserves the right to remove you without your consent at such a time that she feels it is in the best interest.

How to withdraw from the study: If you want to withdraw from the study, you can do so by writing to Ivania Grenier at [email protected]. If you would like to withdraw after your materials have been submitted, please contact Ivania Grenier at [email protected] so that your data can be destroyed. There is no penalty for withdrawing.

Compensation/Reimbursement: You will receive no payment for participating in the study.

If you have questions about the study or need to report a study-related issue please contact, contact:

• Name of Principal Investigator: Ivania Grenier
• Department Name: the University of Alabama, Capstone College of Nursing
• Telephone: (786)-587-7981
• Email address: [email protected]
• Faculty Advisor’s Name: Dr. Ann Graves
• Department Name: the University of Alabama, Capstone College of Nursing
• Telephone: (205)348-9875
• Email address: [email protected]

If you have questions about your rights as a participant in a research study, would like to make suggestions or file complaints and concerns about the research study, please contact:

Ms. Tanta Myles, the University of Alabama Research Compliance Officer at (205)-348-8461 or toll-free at 1-877-820-3066. You may also ask questions, make suggestions, or file complaints and concerns through the IRB Outreach Website. You may email the Office for Research Compliance at [email protected].

Agreement:

• € I agree to participate in the research study described above.
• € I do not agree to participate in the research study described above.
• € I agree to video (audio, photograph) in the research study described above.
• € I do not agree to video (audio, photograph) in the research study described above.

Signature of Research Participant___________________________________

Date_____________________________________________

Print Name of Research Participant_________________________________________

Signature of Investigator or other Person Obtaining Consent_________________________________

Date_____________________________________________________

Print Name of Investigator or other Person Obtaining Consent___________________________________________

Recruitment Flier

Pre-test/Post-test Questionnaire

Please complete the questionnaire as accurately as possible

Introduction

This quality improvement aims to decrease obesity rates through training of primary care providers (PCPs) to increase screening and the use of the 5 As framework to help patients reduce their body mass index. The questions in this questionnaire are structured differently and instructions are provided on how to answer each question. Completing the questions will enable us to determine the effectiveness of the intervention and will help improve future training programs to improve screening and reduce rates of obesity.

Personal Information

Gender:

•  Male
•  Female

Age:…………………………

Position/licensure:

•  Physician
•  Nurse Practitioner
•  Registered Nurse
•  Other………………………….

Years of experience working in primary care:…………………………………

How many quality improvement trainings on obesity have you participated in the past three years?

•  None
•  1
•  2
•  3
•  More than 3
•  I don’t know

If attended at least 1 obesity quality improvement training, how many covered the use of 5 As framework?

•  None
•  1
•  2
•  3
•  More than 3
•  I don’t know

What other obesity screenings and counseling strategies have you been trained on?

•  None
•  Cognitive Behavioral Therapy
•  Other……………………..
•  Motivational interviewing
•  Family involvement

How often do you screen adults for obesity while providing primary care?

•  Always
•  Rarely
•  Sometimes
•  Never

What proportion of your patients with obesity experience a reduction in body weight as a result of your direct involvement in their treatment?

•  0-25%
•  50-75%
•  25-50%
•  75-100%

In your opinion which of the following factors hinder primary care providers from performing regular screening and counseling for obese patients (Mark all that apply)

•  A large number of patients
•  Lack of time
•  Lack of a standardized framework
•  A belief that it is not necessary

For the following statements, please choose whether you strongly Agree (SA); Agree (A); Undecided (U); Disagree (D); or Strongly Disagree (SD).

Attitudes:

Application of knowledge and skills:

What are your perceived obesity screening and counseling competency with regards to the 5 As framework? Please select a number between 1 and five with 1 = Know nothing about; 2 = Know very little about and not able to perform; 3 = Know something about and somewhat able to perform; 4 = Able to perform well; 5 = Able to teach others how to perform.

Ask (Identifying behavior, BMI measurement, determining readiness for change):

Advise (Recommending change and outlining associated benefits):

Agree (Setting goals with the patient):

Assist (Provision of additional help such as pharmaceutical and counseling)

Arrange (Establishing follow-up and referral to other professionals:

Data Abstraction Form

Date Abstracted: __ __/__ __/__ __ M/D/Y

Patient code# _________________

Age _________________

Sex:

• □ Male
• □ Female

Height _________________

Weight _________________

Existing Conditions _________________

Blood Pressure _________________

BMI _________________

Letter of Support

Signature Assurance Form

Table 5: Personal Information

Table 6: Position/licensure

Table 7: Years of experience working in primary care

How many quality improvement trainings on obesity have you participated in the past three years?

If attended at least 1 obesity quality improvement training, how many covered the use of 5 As framework?

What other obesity screenings and counseling strategies have you been trained on?

How often do you screen adults for obesity while providing primary care?

In your opinion which of the following factors hinder primary care providers from performing regular screening and counseling for obese patients.

Table 8: Obesity is a treatable condition

Table 9: Most obese patients could reach a normal BMI if motivated

Table 10: Obesity is primarily caused by behavioral factors

Table 11: Treating obese patients is very frustrating

Table 12: I feel qualified to screen and treat obese patients

Table 13: I routinely provide clients with behavioral counseling to treat obesity

Table 14: I have been successful in treating patients for obesity

Table 15: I am competent with the 5 As framework on patients with obesity