International Journal of Obesity (1997) 21, 141±146 ß 1997 Stockton Press All rights reserved 0307±0565/97 $12.00 Practice nurses' beliefs about obesity and weight related interventions in primary care R Hoppe and J Ogden Department of General Practice, UMDS, London Objective: To examine practice nurses' beliefs about obesity and their current practices and the role of the weight management context and their own BMI on these factors. Design: Cross sectional questionnaire. Subjects: Questionnaires concerning beliefs about obesity and current practices were completed by 586 practice nurses. Results: The subjects rated lifestyle as the main cause and cardiovascular problems as the main consequences of obesity, regarded weight loss as bene cial and reported high con dence in their ability to give advice to obese patients. However, their expectations of patient compliance and actual weight loss were low indicating that practice nurses rate their advice giving skills as independent to the outcome of this advice. Further, failed weight loss was explained in terms of patient and not professional factors. In addition, the results indicated variability in their beliefs and behaviour according to the location of this advice and the practice nurse's own BMI. In particular, practice nurses who run weight loss clinics reported giving weight loss advice more frequently, spending longer counselling obese patients, reported greater con dence in giving weight loss advice and more optimism about outcomes. Further, those with low BMIs rated obesity as more preventable, reported being less likely to advise patients to use a calorie controlled diet and more likely to suggest eating less in general. Conclusion: Education programmes for practice nurses should not only include skills training but emphasise both the factors involved in advice giving and self appraisal. Such appraisal should include a role for both the practice nurse's and the patient's behaviour to minimise the `operation was a success but the patient died' approach to obesity management. Keywords: primary care; nurses; beliefs; obesity management; decision making Introduction One area of health promotion targeted by the Health of the Nation 1 is dietary change as a strategy for reducing the prevalence of obesity. Obesity is associated with cardiovascular disease, diabetes, joint trauma, cancer and hypertension. 2 Consequently, weight management has been identi ed as one of the most common health promotion clinic activities engaged in by practice nurses who undertake the majority of routine health promotion work within primary care. 3±5 However, the success rates from primary health care interventions for weight loss are low. 6,7 Consequently, health education and promotion have been identi ed as a key area for further training in general practice. 4 Traditional explanations of the behaviour of health care professionals, have emphasized the role of Correspondence: Dr J Ogden, Senior Lecturer in Health Psychology, Department of General Practice, United Medical and Dental Schools of Guy's and St Thomas's, 5 Lambeth Walk, London SE11 6SP. Received 1 May 1996; revised 13 September 1996/29 October 1996; accepted 1 November 1996 knowledge. Accordingly, evidence suggests that the primary health care team lack the knowledge and skills to give appropriate lifestyle advice, particularly in relation to diet. 8 10 However, knowledge is only one of a number of variables which may in uence patient care. Recently an attempt has been made to progress beyond the traditional knowledge based explanations of health professionals' behaviour, towards identifying the role of beliefs in behaviour. The application of social cognition models of healthrelated behaviour, for example, Bandura's Self-ef cacy Model and the Health Belief Model, 11,12 originally developed to predict patient behaviour, has suggested that the attitudes and beliefs of health professionals differ along the dimensions suggested by the various psychological models. 13±16 This variation in beliefs between health professionals has been shown to in uence the decision-making processes leading to differences in both treatment and patient health outcomes. Therefore, health professionals' beliefs represent a potential target for change in maximizing the effectiveness of current health promotion programmes within general practice. Accordingly, the present study aimed to examine practice nurses' beliefs about obesity.
142 However, although the emphasis on beliefs represents a shift away from knowledge as the explanation of behaviour, this itself has been criticised for its focus on individual cognitions and the neglect of the surrounding context. In terms of weight management, practice nurses' beliefs and practices may be in uenced by the context in which the weight loss advice takes place. In particular, this advice is located within both the practice nurse's professional and personal experience of weight management. Previous research indicates that past behaviour is particularly related to future behaviour when the behaviour is performed as part of a routine. 17 In line with this the present study aimed to examine the role of the weight management context (weight management clinic vs surgery based) in determining beliefs and behaviour. Further, previous research also indicates a role for professionals' own personal experiences with smoking doctors spending more time counselling about smoking than their non smoking counterparts. 18 Accordingly, the present study also aimed to explore the relationship between the practice nurse's beliefs and behaviour and their own body mass index (BMI). Therefore the present study aimed to explore practice nurse's beliefs about obesity and their current practices and to locate these factors within both the professional and personal context. Methods Subjects Ten FHSAs were randomly selected using the Directory of Health Services Authorities (1992) as a sampling frame. Using FHSA records, 900 practices were randomly selected and one practice nurse was contacted from each practice. A structured questionnaire was mailed to the 900 practice nurses. A follow-up reminder was sent 6±8 weeks after the rst mailing. Procedure A cross-sectional survey design was used. Subjects were asked to complete the following questions: Pro le characteristics Subjects recorded their age, sex, year of quali cation, number of years in general practice, whether or not they currently ran a weight loss clinic within their practice and their body mass index. Subjects were subsequently divided into those who did/did not run a clinic and those with a high/low BMI on the basis of median splits. Beliefs about obesity Beliefs about the causes and consequences of obesity. Causes of obesity were measured by asking practice nurses: `to what extent do you agree that the following factors play a significant role in the development of obesity...', a list of 16 different possible causes of obesity were provided, 4 covering biological causes (for example genetic factors, low metabolic rate, increased fat cell number) and 12 covering lifestyle factors (for example excessive calorie intake, sedentary lifestyle, parental eating habits). Responses ranged from `strongly disagree' (1) to `strongly agree' (7). The items were summated to create a biological score and a lifestyle score (cronbachs alphas; 0.77 and 0.78 respectively). Beliefs about the causes of obesity were only measured for 38% (n ˆ 221) of the sample. Subjects completed a general question about the seriousness of obesity to health. In addition, consequences of obesity were assessed by asking practice nurses: `in comparison to patients of average weight, what is the likelihood that obese patients will suffer from the following health problems in the future...'. A list of 7 common weight related health problems were provided, 3 cardiovascular consequences (for example coronary heart disease, stroke, hypertension) and 4 non-cardiovascular consequences (for example diabetes, psychological problems, joint trauma). Responses ranged from `much below average' (1) to `much above average' (7). The items were summated to create a cardiovascular score and non-cardiovascular consequences score (cronbachs alphas; 0.81 and 0.71 respectively). Beliefs about the solutions to obesity and the causes of failed weight loss attempts. Beliefs about the solutions to obesity were assessed by asking practice nurses to rate (a) the benefits of weight loss to health, (b) the preventability of obesity and (c) the treatability of obesity. Responses ranged from `not at all' (1) to `extremely' (7). Beliefs about the causes of failed weight loss attempts were measured by asking practice nurses `to what extent do you feel failure to lose weight is due to... ', a list of 3 possible reasons for why people may not lose weight was provided (`lack of motivation', `inadequacy of current weight loss methods' and `noncompliance with weight loss advice'). Responses ranged from `not at all' (1) to `completely' (7). Beliefs about the outcomes of giving weight loss advice. Counselling self-efficacy was measured by asking practice nurses to rate how confident they were at giving weight loss advice. Response efficacy was measured by asking practice nurses (a) how confident they were that patients would follow their advice, (b) how confident they were that patients would lose weight and (c) how successful they had been in
bringing about weight loss in the last six months. Responses ranged from `not at all' (1) to `completely' (7). Actual behaviour Behaviour was assessed for the following: Involvement in giving advice. Involvement in giving advice was assessed by frequency of giving weight loss advice (less than once a week/once a week/more than once a week) and duration of weight loss advice sessions (less than 10 minutes/10 minutes/more than 10 minutes). Type of intervention. Practice nurses were asked how frequently they usually used a variety of weight loss interventions (for example calorie controlled diets, general nutritional advice, referral, exercise, eating less in general, and medical interventions). Responses ranged from `Never' (1) to `Always' (7). Results Data were analysed using SPSS for Windows. Due to the normal distribution of the data parametric statistics were deemed appropriate. The results were analysed to examine the subjects' pro le characteristics using descriptive statistics, to examine the practice nurses' beliefs and behaviours using means and to examine the role of weight management context (clinic/no clinic) and personal BMI (high/low) using one way ANCOVAs to examine main effects of clinic and BMI with age, year of quali cation, frequency of giving advice and time spent counselling patients about weight loss as covariates. Pro le characteristics The questionnaire was completed by 586 practice nurses giving a response rate of 65%. All practice nurses were female. The mean age for practice nurses was 42.3 y 8.41, ranging from 23±70. The mean year of quali cation was 1975 8.99 ranging from 1936±1995, with 49% of practice nurses working in general practice for less than 5 y. The mean body mass index for the practice nurses was 23.48 ( 3.43). In total, 35.9% of practice nurses were currently overweight (BMI > 25). Weight loss clinics were run by 30% of the practice nurses surveyed. Chi-square and t- tests were used to examine differences in pro le characteristics for subgroups of practice nurses by BMI and clinic. No signi cant differences were found on any of the pro le characteristics between those practice nurses who reported running a weight loss clinic and those that did not. Signi cant differences between practice nurses with high/low BMI were found for age (t ˆ 7 4.70, 584; P < 0.001) and year quali ed (t ˆ 3.51, 584; P < 0.001); practice nurses with higher BMI's were signi cantly older and obtained their nursing quali cations earlier than practice nurses with lower BMIs. Year quali ed and age were used as covariates in all subsequent analysis. Beliefs about obesity The means for the beliefs about obesity, split into subgroups by clinic and BMI, are shown in Table 1. Beliefs about the causes and consequences of obesity. The overall means suggests that as a group practice nurses rated lifestyle factors as more important causes of obesity than biological factors. Further, practice nurses rated obesity as a serious threat to health and obese patients were considered to be more likely to suffer from both cardiovascular and non-cardiovascular illnesses (for example diabetes, joint trauma and psychological problems) in comparison to average weight patients, although cardiovascular consequences were rated as most likely. The results showed no main effects for either clinic or BMI on beliefs about causes or consequences. Solutions to obesity and causes of failed weight loss attempts. The means indicate that practice nurses rated obesity as preventable and treatable and weight loss as beneficial to health. In addition, subjects rated patient non-compliance with advice as the most likely reason for patients' failure to lose weight and regarded the inadequacy of current methods as the least important factor, while lack of motivation was rated just below the centre of the scale. The results showed no main effect of clinic for beliefs about solutions and no main effects of either clinic or BMI for reasons for failed weight loss attempts. However, the results showed a significant main effect of BMI for beliefs about the preventability of obesity with subjects with a high BMI rating obesity as less preventable than those with a low BMI. Beliefs about the outcomes of weight loss advice. The means for the beliefs the outcomes of weight loss advice were split into subgroups by clinic and BMI are shown in Table 2. The means suggest that overall practice nurses were confident about giving weight loss advice but were not optimistic about the actual outcome of this advice in terms of the patient either following the advice or losing weight or their ratings of success over the past six months. The results show no main effects of BMI for beliefs about the outcomes of advice. However, the results showed significant main effects of clinic for all measures. The means indicate that subjects who run a clinic are more confident in giving advice, more confident that patients would take their advice, more confident that patients would lose weight and perceive themselves to be more successful in bringing about weight loss in the previous six months than the other subjects. 143
144 Table 1 Means for the beliefs about obesity split into subgroups by clinic and BMI No weight loss clinic Weight loss clinic Univariate f-values Low BMI n ˆ 201 High BMI n ˆ 207 Low BMI n ˆ 91 High BMI n ˆ 87 Clinic BMI Causes of obesity a Biological causes of obesity 4.16 4.36 4.43 3.74 1.13 2.37 (1.09) (1.04) (1.30) (1.20) Lifestyle causes of obesity 5.47 5.52 5.46 5.37 0.63 0.11 (0.53) (0.69) (0.65) (0.66) Consequences of obesity Seriousness of obesity 6.08 5.94 6.01 5.92 0.35 2.44 (0.88) (0.94) (0.84) (0.94) Cardiovascular consequences of obesity 6.01 5.94 6.04 5.84 0.10 2.63 (0.80) (0.82) (0.77) (0.91) Non-cardiovascular consequences of obesity 5.13 5.19 5.44 5.04 0.79 4.25 (0.90) (0.90) (0.81) (0.96) Solutions to obesity Preventability of obesity 5.17 5.10 5.41 4.99 0.25 7.32* (1.05) (1.00) (0.93) (1.01) Treatability of obesity 4.95 5.01 5.10 5.09 1.34 0.03 (1.07) (1.10) (0.86) (1.01) Bene ts of weight loss 6.31 6.26 6.27 6.28 0.06 0.51 (0.97) (0.93) (0.88) (0.91) Reasons for patients failure to lose weight Inadequacy of current weight loss methods 3.75 4.08 3.56 3.83 0.76 0.01 (1.49) (1.52) (1.70) (1.51) Patient non-compliance 5.54 5.38 5.54 5.51 0.39 1.74 (1.03) (1.09) (0.89) (1.07) Patient lack of motivation 4.25 3.95 3.92 3.51 3.28 5.30 (1.52) (1.57) (1.28) (1.62) * Main effects, P < 0.01. Table 2 Means for the beliefs the outcomes of weight loss advice split into subgroups by clinic and BMI No weight loss clinic Weight loss clinic Univariate f-values Low BMI n ˆ 201 High BMI n ˆ 207 Low BMI n ˆ 91 High BMI n ˆ 87 BMI Clinic Beliefs about the outcomes of giving weight loss advice Counselling self-ef cacy 4.78 4.78 5.15 5.38 1.54 23.75* (1.03) (1.15) (1.00) (1.00) Patient will follow the advice 3.74 3.86 4.16 4.39 3.09 23.65* (1.08) (1.15) (1.00) (1.09) Patient will lose weight 3.69 3.86 4.05 4.36 3.86 15.81* (1.19) (1.31) (0.97) (1.09) Perceived success 3.85 3.93 4.51 4.60 0.73 41.84* (1.10) (1.21) (1.05) (1.09) * Main effects, P < 0.001. Actual behaviour The means for involvement in giving advice and type of intervention offered, broken down into subgroups by clinic and BMI are shown in Table 3. Overall, the majority of practice nurses gave advice more than once a week but most spent 10 minutes or less discussing weight loss. Further, all subjects reported offering general nutritional advice and exercise most frequently, whereas advising patients to eat less in general and referrals to a self-help group were offered only sometimes, and calorie controlled diets were rated as offered the least frequently. The results showed a signi cant main effect of clinic for both measures of involvement in giving weight loss advice and for offering referrals and calorie controlled diets. The means showed that subjects who ran a weight loss clinic gave advice more frequently, spent longer on each consultation, were less likely to refer to a self help group and more likely to suggest a calorie controlled diet. The results also showed a signi cant main effect of BMI for advising eating less in general and offering a calorie controlled diet. The means showed that subjects with a high BMI were less likely to suggest eating less in general and more likely to recommend a calorie controlled diet than their thinner counterparts. Discussion The present study aimed to examine practice nurses' beliefs about obesity and their current weight management practices and to examine the role of both the
Table 3 Means for involvement in giving advice and type of intervention offered, broken down into subgroups by clinic and BMI No weight loss clinic Weight loss clinic Univariate f-values Low BMI n ˆ 201 High BMI n ˆ 207 Low BMI n ˆ 91 High BMI n ˆ 87 BMI Clinic 145 Involvement in giving weight loss advice Frequency of giving weight loss advice 2.48 2.50 2.69 2.77 0.86 18.24** (0.67) (0.64) (0.55) (0.48) Duration of consultations 2.35 2.37 2.59 2.55 0.06 13.58** (0.62) (0.62) (0.65) (0.71) Type of intervention usually offered Generalized nutritional advice 6.67 6.65 6.79 6.75 0.37 2.43 (0.77) (0.77) (0.66) (0.63) Exercise 4.85 4.74 5.03 4.69 0.82 0.42 (1.68) (1.91) (1.78) (1.99) Eat less in general 4.68 4.68 5.22 4.61 5.70* 1.08 (1.96) (2.05) (1.63) (1.93) Referral to self-help group 3.56 3.76 3.22 3.37 2.71 5.57* (1.61) (1.68) (1.40) (1.58) Calorie controlled diet 2.81 3.27 3.26 3.67 6.63* 6.33* (1.81) (2.01) (1.85) (2.11) * Main effects, P < 0.01. ** Main effects, P < 0.001. weight management context and the practice nurse's own BMI on these factors. As a professional group practice nurses rated lifestyle as the main cause and cardiovascular prob-lems as the main consequences of obesity. They regarded obesity as serious but both preventable and treatable and held a positive attitude towards the health bene ts of weight loss. Further, they were con dent that they had the necessary skills to give weight loss advice and reported mainly offering generalized nutritional advice and advising patients to undertake exercise. However, the practice nurses were pessimistic about the outcome of giving weight loss advice: ratings of patient adherence to advice, likelihood of actual weight loss and perceptions of success over the previous six months were low. This indicates that practice nurses regard obesity as a problem worthy of intervention and management both for its health consequences if untreated and health bene ts if treatment is successful and feel that they have the necessary skills to offer advice. However, this con dence in their skills does not appear to be translated into high expectations of success. Perhaps practice nurses maintain their high level of con dence regardless of the observation of the outcomes of their interventions. This result is consistent with research which has reported a difference between con dence and competence. 19 It is possible that the exposure to poor outcomes in primary care results in the practice nurses appraising their own advice skills as independent to patient weight loss; advice is evaluated as not being contingent upon the consequences of this advice; the advice is good but the outcome is poor. Further, the practice nurses appear to maintain this discrepancy between advice giving and outcomes by understanding failed weight loss in terms of patient not personal factors, with the practice nurses favouring patient noncompliance with advice and patient poor motivation as their preferred explanations of failed weight loss attempts. The present study also aimed to place practice nurses' beliefs and behaviour within a broader context. The results indicate that practice nurses who gave advice within a weight management clinic reported giving more frequently, spending longer counselling patients, reported higher con dence in their skills and higher outcome expectancies than those who offered advice within a surgery. Further, practice nurses working within a speci ed weight loss clinic were more likely to advise patients to eat less in general but less likely to refer patients to self-help groups. This suggests that these practice nurses showed greater involvement in weight management and supports previous research indicating a role for past behaviour and routines in beliefs and current practices. 17 The results also showed an impact of practice nurses' BMI on their beliefs and behaviours with subjects with higher BMIs rating obesity as less preventable and reporting being less likely to advise eating less in general and more likely to offer calorie controlled diets. This provides support for previous research which suggests that a relationship exists between health professional's own personal health status and their professional health promotion practices. 18 In addition, the effects of both the location of the advice and the practice nurse's BMI indicate variability in practice nurses's beliefs and behaviours and suggest a role for the broader context when examining the determinants of this variability. Conclusions Practicing nurses are responsible for the majority of weight related interventions in primary care and the
146 results provide some insights into their beliefs about obesity. However, the outcome of these interventions are poor. 6,7 This indicates a role for skills training for this professional group. 4 However, the results from the present study indicate that practice nurses rate their advice giving skills as good but as higher and apparently independent to the outcomes of this advice. Further the results suggest that practice nurses may maintain this high rating of their own behaviour by explaining the poor outcomes in terms of patient and not their own failures. In addition, the results suggest that variation exists within practice nurses and that this variation is related to the location of the consultation and the nurse's own weight status. Accordingly, these results have implications for education programmes targeting obesity management by practice nurses. The results indicate that such programmes should not only involve skills training but highlight both the complex factors involved in the advicegiving process and the need for self appraisal. The programmes should emphasise that such appraisal should include a role for both the practice nurse's and the patient's own behaviour which may help reduce this `the operation was a success but the patient died' approach to obesity management in primary care. Acknowledgements The authors would like to acknowledge the Primary Care Development Fund, South Thames Regional Health Authority for funding this project. References 1 HSMO. The Health of the Nation. HMSO: London, 1992. 2 Bray GA. Effects of obesity on health and happiness. In: KD Brownell and JP Foreyt (eds). Handbook of Eating Disorders: Physiology, Psychology and Treatment of Obesity, Anorexia and Bulimia. Basic books: New York, 1986. 3 Ross F, Bower P, Sibbald B. Practice nurses characteristics, workload and training needs. Br J General Practice 1994; 44: 15±18. 4 Hibble A. Practice nurse workload before and after the introduction of the 1990 contract for general practitioners. Br J General Practice 1975; 45: 35±37. 5 Robinson G, Beaton S, White P. Attitudes towards practice nursesðsurvey of a sample of general practitioners in England and Wales. Br J General Practice 1993; 43: 25±29. 6 Imperial Cancer Research Fund OXCHECK study group. Effectiveness of health checks conducted by nurses in primary care. Results of OXCHECK study after one year. BMJ 1994; 308: 308±312. 7 Family Heart Study. Randomized controlled trial evaluating cardiovascular screening and intervention in general practice. Principal results of British family heart study. BMJ 1994; 308: 313±320. 8 Francis J et al. Would primary health care workers give appropriate dietary advice after cholesterol screening. BMJ 1989; 306: 1652±1656. 9 Cade J, O'Connell J. Management of weight problems and obesity: knowledge, attitudes and current practices of general practitioners. Br J General Practice 1991; 41: 147±150. 10 Murray S, Narayan V, Mitchell M, Witte H. Study of dietetic knowledge among members of the primary health care team. Br J General Practice 1993; 43: 229±231. 11 Bandura A. Self-ef cacy: toward a unifying theory of behavioural change. Psychol Rev 1977; 84: 191±215. 12 Janz N, Becker M. The health belief model: a decade later. Health Educ Quart 1984; 11: 1±47. 13 Mullen PD, Holcomb JD. Selected predictors of health promotion counselling by three groups of allied health professionals. Am J Prevent Med 1990; 6: 153±160. 14 Thompson SC, Schwankovsky L, Pitts J. Counselling patients to make lifestyle changes: the role of physician self-ef cacy, training and beliefs about causes. Family Practice 1993; 10: 70±75. 15 Johnston M, Marteau TM16 The health beliefs of the health professionals. In: Dent H (ed). Clinical Psychology Research and Developments. Croom Helm: London 1987. 17 Marteau TM, Johnston M. Health professionals: A source of variance in health outcomes. Psychol and Health 1990; 5: 47± 58. 18 Sutton SR. The past predicts the future: interpreting behaviour-behaviour relationships in social psychological models of health behaviour. In: Rutter DR, Quine L (eds). Social Psychology and Health: European Perspectives. Avebury: Aldershot, 1994. 19 Stokes J, Rigotti N. The health consequences of cigarette smoking and the internist's role in smoking cessation. Ann Inter Med 1988; 33: 431±460. 20 Groeger JA, Grande GE. Self-preserving assessments of skill?. Br J Psychol 1996; 87: 61±79.