title: Understanding the role of primary care in the management of adults with co-morbid obesity: A mixed methods programme
Creators: name: Blane, David Nicholas
Publisher: name: University of Glasgow
Year: 2018
Subjects: subject: obesity, general practice, primary care, health services research, access to health care, inequalities.

description: Introduction: Obesity is widely regarded as one of the biggest public health problems in the UK today. Policy suggests more can be done in primary care to support adults with obesity, particularly identifying and referring individuals with “high risk” obesity (obesity with co-morbidities) to weight management services. The aims of this thesis were to examine the role of primary care in the management of adults with co-morbid obesity; to understand the barriers facing patients and practitioners in accessing NHS adult weight management services via primary care; and to explore theory-driven, evidence-based interventions targeted at primary care practitioners to improve the management of co-morbid obesity. Methods: This was a mixed methods study, integrating qualitative and quantitative approaches. There were 4 phases of research in this thesis: Phase 1) Semi-structured interviews with 9 senior dietitians involved in planning and delivery of adult weight management in Scotland; Phase 2) A realist review of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity; Phase 3) Analysis of 9,677 GP referrals to the largest NHS weight management service in Scotland, the Glasgow and Clyde Weight Management Service (GCWMS); Phase 4) Analysis of interviews with 20 patients who had been referred to GCWMS, as well as 17 primary care practitioners (GPs and practice nurses) from referring practices. Key results: Phase 1) identified that there is no consensus among key stakeholders (senior dietitians) about the role of primary care in adult weight management, with a number of tensions apparent related to who should be doing what, where, and how. Phase 2) found 12 mechanisms that were characteristic of successful interventions targeting primary care practitioners, many of which could be activated by improving communication between primary care and weight management services. A number of important contextual factors that influence these interventions were also identified, at micro (individual/interpersonal), meso (institutional) and macro (infrastructural) levels. Phase 3) found that roughly a third (n=3250, 33.6%) of 9,677 adults with obesity referred to GCWMS attended at least one session. The likelihood of attendance increased with age, BMI category, and increasing affluence. Practice-level characteristics that were most strongly associated with attendance were being a non-training practice, having a larger list size, and not being in the most deprived areas. Phase 4) helped to explain some of this variation in attendance, related to geographical and structural barriers, particularly for working adults and those from areas of high socio-economic deprivation. An expanded conceptual model of candidacy theory is proposed, advancing our understanding of access to weight management. Conclusion: GPs and practice nurses are well placed to discuss weight and related health issues and to refer patients to further sources of support. This support should ideally be local, familiar, and relatively quick and easy to access, particularly important in areas of high socio-economic deprivation, which have the highest proportion of referrals to GCWMS but the lowest likelihood of attendance. To improve the identification and referral of adults with obesity, future interventions should consider training of practitioners, audit/feedback on referrals, and tools to aid both identification (e.g. automatic BMI calculators, posters in waiting area) and referral. To improve attendance following referral, however, greater emphasis needs to be placed on improved communication between weight management services and primary care, and improved accessibility of services.