To identify the barriers and facilitators to the implementation of effective obesity management for adults in primary care as viewed by healthcare professionals.
MEDLINE, Web of Science, EMBASE, DARE, CINAHL, Scopus, PsycINFO, Social science abstracts, ASSIA.
Restricted to: adults (>18yrs), English language, qualified health care professionals, published studies from the UK.
Excluded: eating disorders, weight gain in pregnancy, non-primary care.
There will be no time restriction.
Types of study to be included
Condition or domain being studied
The obesity epidemic is one of the major health concerns of our time. Projections for 2030 suggest there will be 11 million more obese people in UK (prevalence 48% in men and 43% in women) which will cost the NHS up to £2 billion more per year. Costs are high because an increase in Body Mass Index (BMI) over 30 increases the risks of associated chronic disease such as ischaemic heart disease, diabetes and cancer disproportionately. With NHS resources already significantly stretched this has implications not only for the individuals concerned but also for the future of healthcare provision. Primary care acts as the gatekeeper for most of the NHS and as GPs and practice nurses are often the initial contacts for those who are overweight they have an essential role in assessing and managing this. While effective weight management interventions exist, the implementation of such interventions into routine care is variable and there is a need to understand which barriers and facilitators to successful implementation have been identified.
1. Population: Healthcare professionals working with patients who are adults age 18+ and have a BMI>25.
2. Setting: Primary care in the UK.
3. Outcomes: Barriers and facilitators to implementation of weight management strategies in terms of self-reported views of HCPs.
4. Study design: Controlled trials, quasi-experimental studies, observational studies, qualitative studies. The primary interest is in surveys regardless of method so these might be conducted within various other study designs eg an interview study embedded in a trial.
5. Publication status: Published studies.
6. Papers concerned with the diagnostic process of obesity if this represents a barrier to treatment eg waist circumference and BMI measurement.
1. Children and adolescents (age<18).
2. Non-English language studies.
3. Ongoing studies. Excluded if not complete at time of writing but will be recorded with “ongoing” as reason for exclusion for future update reviews.
4. Time limitation – no time limitation
5. Patients with eating disorders as treatment for this group differs from that described in the guidelines for obesity management.
6. Non-qualified HCPs
7. Non primary care
8. Papers concerned with onward referral from primary care as these will be heterogeneous and reflect general referral attitudes for various conditions outside of obesity.
9. Weight gain in pregnancy
10. Patient views on barriers to obesity management
Views elicited from primary healthcare professionals on barriers and facilitators to successful implementation of weight management strategies (as described in NICE and SIGN guidelines on obesity).
These views will be coded onto the 14 domains of the Theoretical Domains Framework (TDF) [Cane, J., O'Connor, D. and Michie, S. (2012) 'Validation of the theoretical domains framework for use in behaviour change and implementation research', Implementation Science, 7(37)].
The TDF will allow us to theoretically assess implementation problems and examine professionals behaviours with the aim of informing development of a future intervention for weight management in primary care.
Effective interventions often fail to be successfully implemented into routine practice in primary care. Part of the implementation of effective obesity management involves health professionals changing the behaviours they engage in with their patients to reflect high quality care. There is a need to better understand what barriers and facilitators have been identified in relation to obesity management related behaviours that primary care health professionals engage in. The TDF can be used to code and summarise barriers and facilitators to implementation of effective weight management using theoretical factors that relate to behaviour and behaviour change. This framework can help identify theory-based barriers and facilitators to weight management, which can help inform future quality improvement interventions. Primary healthcare professionals for the purposes of this review include doctors, nurses and dieticians.
We will identify the views of primary care health professionals on the barriers and facilitators to weight management in primary care and use the 14 domains described in the Theoretical Domains Framework (Cane et al, 2012) to code these. Use of the TDF will allow us to theoretically assess implementation problems and examine professionals behaviours' to better understand the reasons why weight management strategies are not implemented more successfully in primary care in the UK.
Data extraction, (selection and coding)
Selection of studies: One reviewer will select studies eligible for inclusion from the database searches using inclusion and exclusion criteria by screening titles and abstracts (AMH). The studies identified by the search strategy will be sifted three times. For the third sift a second reviewer (JP) will also select studies eligible for inclusion using the same criteria. These choices will be compared by reviewers AMH and JP and full text will be available for decision making on inclusion. Any discrepancies identified in this process will be discussed by both reviewers and if necessary additional advisors (AA, ME).
Data extraction: A data extraction form was piloted on 5 studies selected for inclusion to ensure all appropriate data could be adequately collected.
Once selected and quality assessed, information from selected studies will be extracted independently by AMH and JP, reconciled and entered onto the finalised data extraction form in MS Excel. Details to be extracted include citation, study setting, aims of study, theoretical background, population characteristics, intervention, sampling approach, data collection methods, data analysis approach, outcomes, quality assessment, results and any comments. In addition, views expressed in the studies on barriers and facilitators to weight management in primary care will be extracted and mapped to the TDF (Cane et al, 2012) independently by two reviewers (AMH, JP). This coding will be reconciled by discussion and any disagreement remaining after this will be discussed with the other members of the team (ME, AA).
The flow of information and materials retrieved, excluded and selected will be recorded on a flow chart per PRISMA guidance.
Risk of bias (quality) assessment
The Critical Appraisal Skills Programme (CASP, 2010) will be used for the assessment of selected studies independently by two reviewers (AMH, JP). Inconsistencies will be reviewed by all team members if agreement cannot be reached by AMH and JP.
Strategy for data synthesis
Given the nature and likely heterogeneity of the results a narrative synthesis is planned. In addition the data will be presented in several tabular formats with the TDF domains identified as main barriers and facilitators for each included study. This will categorise the barriers and facilitators most cited by primary healthcare professionals in management of obesity in primary care and illustrate the main areas of behaviour change that need considered in improving implementation.
Analysis of subgroups or subsets
Publication in a peer reviewed journal relevant to primary care and use of the findings in further development of an intervention to improve weight management in primary care.
Contact details for further information
Institute of Health & Society
The Baddiley-Clark Building
Newcastle upon Tyne
Organisational affiliation of the review
Dr Angela McHenry, Newcastle University Professor Martin Eccles, Newcastle University Dr Justin Presseau, Newcastle University Professor Ashley Adamson, Newcastle University
Anticipated or actual start date
04 October 2011
Anticipated completion date
16 August 2012
Intramural funding, Northumbria GP training program.
Conflicts of interest
Subject index terms status
Subject indexing assigned by CRD
Subject index terms
Ambulatory Care Facilities; Body Mass Index; Directive Counseling; Humans; Obesity; Physicians, Primary Care; Primary Health Care; Weight Loss; Weight Reduction Programs
Date of registration in PROSPERO
01 August 2012
Date of publication of this revision
01 August 2012
Stage of review at time of this submission
Piloting of the study selection process
Formal screening of search results against eligibility criteria
Risk of bias (quality) assessment
PROSPERO This information has been provided by the named contact for this review. CRD has accepted this information in good faith and registered the review in PROSPERO. CRD bears no responsibility or liability for the content of this registration record, any associated files or external websites.