Interventions targeted at primary care practitioners to improve the identification and referral of patients with co-morbid obesity: a realist review protocol

<b>Background </b>Obesity is one of the most significant public health challenges in the developed world. Recent policy has suggested that more can be done in primary care to support adults with obesity. In particular, general practitioners (GPs) and practice nurses (PNs) could improve the identification and referral of adults with obesity to appropriate weight management services. Previous interventions targeted at primary care practitioners in this area have had mixed results, suggesting a more complex interplay between patients, practitioners, and systems. The objectives of this review are (i) to identify the underlying ‘programme theory’ of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity and (ii) to explore how and why GPs and PNs identify and refer individuals with obesity, particularly in the context of weight-related co-morbidity. This protocol will explain the rationale for using a realist review approach and outline the key steps in this process. <p></p> <b>Methods</b> Realist review is a theory-led approach to knowledge synthesis that provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, how, and why. In this review, scoping interviews with key stakeholders involved in the planning and delivery of adult weight management services in Scotland helped to inform the identification of formal theories - from psychology, sociology, and implementation science - that will be tested as the review progresses. A comprehensive search strategy is described, including scope for iterative searching. Data analysis is outlined in three stages (describing context-mechanism-outcome configurations, exploring patterns in these configurations, and developing and testing middle-range theories, informed by the formal theories previously identified), culminating in the production of explanatory programme theory that considers individual, interpersonal, and institutional/systems-level components. <p></p> <b>Discussion </b>This is the first realist review that we are aware of looking at interventions targeted at primary care practitioners to improve the weight management of adults with obesity. Engagement with stakeholders at an early stage is a unique feature of realist review. This shapes the scope of the review, identification of candidate theories and dissemination strategies. The findings of this review will inform policy and future interventions. Systematic review registration PROSPERO CRD4201400939

The role of primary care in adult weight management: qualitative interviews with key stakeholders in weight management services

Background: Primary care has a key role to play in the prevention and management of obesity, but there remain barriers to engagement in weight management by primary care practitioners. The aim of this study was to explore the views of key stakeholders in adult weight management services on the role of primary care in adult weight management. Methods: Qualitative study involving semi-structured interviews with nine senior dietitians involved in NHS weight management from seven Scottish health boards. Transcripts were analysed using an inductive thematic approach. Results: A range of tensions were apparent within three key themes: weight management service issues, the role of primary care, and communication with primary care. For weight management services, these tensions were around funding, the management model of obesity, and how to configure access to services. For primary care, they were around what primary care should be doing, who should be doing it, and where this activity should fit within wider weight management policy. With regard to communication between weight management services and primary care, there were tensions related to the approach taken (locally adapted versus centralised), the message being communicated (weight loss versus wellbeing), and the response from practitioners (engagement versus resistance). Conclusions: Primary care can do more to support adult weight management, but this requires better engagement and communication with weight management services, to overcome the tensions highlighted in this study. This, in turn, requires more secure, sustained funding. The example of smoking cessation in the UK, where there is a network of well-resourced NHS Stop Smoking Services, accessible via different means, could be a model to follow

Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study

Objective: To determine the association between patient and referring practice characteristics and attendance and completion at a specialist health service weight management service (WMS). Design: Cross-sectional study. Setting: Regional specialist WMS located in the West of Scotland. Participants: 9677 adults with obesity referred between 2012 and 2014; 3250 attending service and 2252 completing. Primary and secondary outcome measures: Primary outcome measure was attendance at the WMS; secondary outcome was completion, defined as attending four or more sessions. Analysis: Multilevel binary logistic regression models constructed to determine the association between patient and practice characteristics and attendance and completion. Results: Approximately one-third of the 9677 obese adults referred attended at least one session (n=3250, 33.6%); only 2252 (23%) completed by attending four or more sessions. Practice referrals ranged from 1 to 257. Patient-level characteristics were strongest predictors of attendance; odds of attendance increased with age (OR 4.14, 95% CI 3.27 to 5.26 for adults aged 65+ compared with those aged 18–24), body mass index (BMI) category (OR 1.83, 95% CI 1.56 to 2.15 for BMI 45+ compared with BMI 30–35) and increasing affluence (OR 1.96, 95% CI 1.17 to 3.28). Practice-level characteristics most strongly associated with attendance were being a non-training practice, having a larger list size and not being located in the most deprived areas. Conclusions: There was wide variation in referral rates across general practice, suggesting that there is still much to do to improve engagement with weight management by primary care practitioners. The high attrition rate from referral to attendance and from attendance to completion suggests ongoing barriers for patients, particularly those from the most socioeconomically deprived areas. Patient and practice-level characteristics can help us understand the observed variation in attendance at specialist WMS following general practitioner (GP) referral and the underlying explanations for these differences merit further investigation

'Learning together': Sharing international experience on new models of primary care

No abstract available

The evaluation of a self-enumerated scale of quality of life (CASP-19) in the context of research on ageing : a combination of exploratory and confirmatory approaches

This paper describes the conceptual development of a self-enumerated scale of quality of life (CASP-19) and presents an empirical evaluation of its structure using a combination of exploratory and confirmatory factor analytic approaches across three different survey settings for older people living in England and Wales in the new millennium. All evaluations are conducted using MPlus which allows the analyst to evaluate the properties of the scale for a set of multivariate categorical items which are subject to item non-response. CASP-19 is a subjective measure of well-being derived from an explicit theory of human need spanning four life domains: control, autonomy, self-realisation and pleasure. Put formally, CASP-19 is a self-reported summative index consisting of 19 Likert scale items. The three survey settings include a postal survey of 263 people in early old age followed up from childhood when the respondents were first interviewed in the 1930's, the first wave (2002) of the English Longitudinal Study of Ageing (ELSA_1) and the eleventh wave of the British Household Panel Survey (BHPS_11) also conducted in 2002. These nationally representative surveys consisted of 9300 and 6471 respondents aged 55 years and older. The Boyd-Orr sample provides an exploratory context for the evaluation and ELSA_1 together with BHPS_11 provide the opportunity for confirmatory analyses of three measurement models. There is some support for the use of CASP-19 as a stand alone summative index. However, the analysis reveals that a shortened 12-item scale which combines the life domains 'control and autonomy' in a second order measurement model is the recommended model for analysts. The work was funded under the UK's Economic and Social Research Council's Growing Older Programme and their Priority Network on Human Capability and Resilience. Grant Nos. L480254016 & L326253061. © Springer Science+Business Media B.V. 2007

Poverty Safari: Understanding the Anger of Britain's Underclass

No abstract available

Smoking cessation interventions for patients with coronary heart disease and comorbidities:an observational cross-sectional study in primary care

Background: Little is known about how smoking cessation practices in primary care differ for patients with coronary heart disease (CHD) who have different comorbidities. Aim: To determine the association between different patterns of comorbidity and smoking rates and smoking cessation interventions in primary care for patients with CHD. Design: and setting Cross-sectional study of 81 456 adults with CHD in primary care in Scotland. Method: Details of eight concordant physical comorbidities, 23 discordant physical comorbidities, and eight mental health comorbidities were extracted from electronic health records between April 2006 and March 2007. Multilevel binary logistic regression models were constructed to determine the association between these patterns of comorbidity and smoking status, smoking cessation advice, and smoking cessation medication (nicotine replacement therapy) prescribed. Results: The most deprived quintile had nearly three times higher odds of being current smokers than the least deprived (odds ratio [OR] 2.76; 95% confidence interval [CI] = 2.49 to 3.05). People with CHD and two or more mental health comorbidities had more than twice the odds of being current smokers than those with no mental health conditions (OR 2.11; 95% CI = 1.99 to 2.24). Despite this, those with two or more mental health comorbidities (OR 0.77; 95% CI = 0.61 to 0.98) were less likely to receive smoking cessation advice, but absolute differences were small. Conclusion: Patterns of comorbidity are associated with variation in smoking status and the delivery of smoking cessation advice among people with CHD in primary care. Those from the most deprived areas and those with mental health problems are considerably more likely to be current smokers and require additional smoking cessation support

Commentary: Supporting GP training in areas of socio-economic deprivation

No abstract available

A web-based, database bound, WYSIWYG development environment for web applications

This project, WebAppDesigner, combines a What You See Is What You Get (WYSISYG) web page designer, database table designer, query tool, and an automatic deployment process into a single easy to use solution for small businesses and individuals

Medical education in (and for) areas of socio-economic deprivation in the UK

No abstract available