Impact of the 5As Team study on clinical practice in primary care obesity management: a qualitative study
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* Jodie Asselin
* Eniola Salami
* Adedayo M. Osunlana
* Ayodele A. Ogunleye
* Andrew Cave
* Jeffrey A. Johnson
* Arya M. Sharma
* Denise L. Campbell-Scherer

## Abstract

**Background:** The 5As [Ask, Assess, Advise, Agree, Assist] of Obesity Management Team study was a randomized controlled trial of an intervention that was implemented and evaluated to help primary care providers improve clinical practice for obesity management. This paper presents health care provider perspectives of the impacts of the intervention on individual provider and team practices.

**Methods:** This study reports a thematic network analysis of qualitative data collected during the 5As Team study, which involved 24 chronic disease teams affiliated with family practices in a Primary Care Network in Alberta. Qualitative data from 28 primary care providers (registered nurses/nurse practitioners [*n* = 14], dietitians [*n* = 7] and mental health workers [*n* = 7]) in the intervention arm were collected through semistructured interviews, field notes, practice facilitator diaries and 2 evaluation workshop questionnaires.

**Results:** Providers internalized 5As Team intervention concepts, deepening self-evaluation and changing clinical reasoning around obesity. Providers perceived that this internalization changed the provider-patient relationship positively. The intervention changed relations between providers, increasing interdisciplinary understanding, collaboration and discovery of areas for improvement. This personal and interpersonal evolution effected change to the entire Primary Care Network.

**Interpretation:** The 5As Team intervention had multiple impacts on providers and teams to improve obesity management in primary care. Improved provider confidence and capability is a precondition of developing effective patient interventions. **Trial registration:** ClinicalTrials.gov, no.: [NCT01967797](http://www.cmajopen.ca/lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01967797&atom=%2Fcmajo%2F5%2F2%2FE322.atom).

Many primary care providers do not feel equipped to address obesity prevention and management with their patients.1-3 Interventions aimed at changing health care professionals' behaviour to support patients with obesity are lacking,4,5 and misinformation about the complexity and chronicity of obesity leads to unrealistic expectations on the part of health care providers and patients that hamper care.5

The 5As [Ask, Assess, Advise, Agree, Assist] of Obesity Management are a suite of resources for use in primary care.6-8 This approach stresses that the root causes of obesity are far more than diet and exercise; they include mental health, social situation and comorbid diseases. The 5As approach has been shown to improve practitioners' willingness and efficacy in providing obesity management and counselling and to support patient weight loss.9-12

The 5As Team study was a randomized controlled trial with mixed-methods evaluation, developed collaboratively with primary care practitioners.13 The aim was to increase the frequency and quality of obesity management in primary care through changing the behaviour of interdisciplinary health care providers, by identifying and addressing provider-identified needs and barriers to effective care. The objective of the qualitative component, presented here, was to understand interdisciplinary health care providers' perspectives of the intervention's impact on their clinical practices.

## Methods

### Study design

The 5As Team trial protocol, intervention structure, content, theoretical foundation and provider content evaluation have been described elsewhere.13,14

### Setting and participants

The trial was carried out in a large Primary Care Network in Edmonton serving ethnically and socially diverse patients, reflecting an urban/suburban Canadian setting. The embedded interdisciplinary teams, who are paid by the Primary Care Network, focus on improving the management of chronic diseases (e.g., diabetes, obesity, depression), prenatal care and care of elderly people. Eligible clinics had a primary care team (registered nurse/nurse practitioner, mental health worker and dietitian) embedded by April 2013. Twenty-four eligible clinics serving 157 470 patients were randomly assigned to either the intervention arm (*n* = 12) or the control arm (*n* = 12).13 All practitioners in the intervention arm (*n* = 29) were the subjects for this qualitative study and included registered nurses/nurse practitioners (*n* = 15), dietitians (*n* = 7) and mental health workers (*n* = 7); the last 2 groups were shared between intervention clinics. One registered nurse/nurse practitioner withdrew, and the data for this person were excluded.

### Intervention

The intervention has been described in detail elsewhere.14 It was created with front-line providers who self-assessed the skills and resources needed to improve their ability to support obesity management. The goal of the intervention was to educate health care providers on obesity management in primary care using the 5As framework and to facilitate change and innovation in the intervention clinics. The format of the intervention was 12 two-hour sessions held biweekly from November 2013 to April 2014, with a kick-off and wrap-up session. This was followed by a postintervention evaluation session in May 2014; and review session October 2014. The focus was on diverse aspects of obesity management, with a presentation by content expert(s) followed by facilitated discussion with clinic team groups. The intervention was supported by practice facilitation.

### Data collection

The core qualitative data were obtained from semistructured interviews (conducted by J.A.) with all participants, field notes taken during the 12 sessions, exit questionnaires and diaries of the practice facilitator, recorded throughout the study. Activity sheets from evaluation workshops at the end of the intervention and sustainability phases augmented this data set. The interviews and questionnaires are detailed in Appendix 1 (available at [www.cmajopen.ca/content/5/2/E322/suppl/DC1](http://www.cmajopen.ca/content/5/2/E322/suppl/DC1)). The methods and role of practice facilitators have been described elsewhere.13,14

Interviews were audiorecorded, transcribed and entered into NVivo 10 qualitative data software (QSR International). Field notes followed the method of Shaw and colleagues.15 Immediately after each session, team members synthesized field notes into summaries that were coded and organized with the use of NVivo 10. Questionnaire data were collected after the 6-month intervention and at 12 months. We used the coding method of Attride-Sterling16 to assess long-answer responses. Participant feedback was solicited in the evaluation sessions.

### Analysis

Our thematic analysis approach16 had 3 stages: familiarization, reduction and exploration. In familiarization, we reviewed materials multiple times to gain a broad understanding of the data. In reduction, we applied qualitative coding to organize the data by broad subject, assigning descriptors to units of text.16 A coding manual was derived from the data during early analysis and was vetted by 4 team members. A subset of interviews was then cross-coded by 5 team researchers, and an external qualitative researcher independently reviewed coding for consistency. Coding led to topic-specific text clusters. Finally, in exploration, we developed thematic maps that organized text from codes into themes. A theme was defined as integrations of disparate pieces of data that were consistently present, linked numerous codes and were latent or manifest.17 Three team members assessed all themes for agreement. The results were member-checked by participants at the evaluation sessions, with strong agreement.

### Ethics approval

This study was approved by the University of Alberta Research Ethics Board (Pro00036740).

## Results

### Participant internalization of 5As approach

The intervention affected how participants thought about, spoke about and managed obesity in their clinical practice (Table 1). Participants reported that the intervention revealed their intrinsic biases, with increased self-awareness leading many to reframe obesity as a chronic disease rather than a lifestyle choice. This resulted in self-reported improved sensitivity, moving scales for privacy and ordering bariatric equipment.

View this table:
[Table 1:](http://www.cmajopen.ca/content/5/2/E322/T1)

Table 1:   Provider-level impacts of the 5As Team intervention

Although changes to perceptions and moments of sudden insight appeared frequently in the data, the most widely reported personal perceived effect of the intervention was on participant confidence. Participants reported increased willingness to initiate conversations about obesity management with patients and specifically cited intervention content as the source of their confidence.

Related to all aspects of internalization is the concept of participant buy-in. Participants reported that they believed in and accepted core program messaging. Participants frequently reported that they loved the approach or thought it was valid and applicable to their practice.

### Provider-patient impacts

Increased participant willingness to ask their patients about obesity management was a dominant theme. Participants noted that asking permission to discuss obesity was among the easiest changes they made following the intervention. Providers perceived that their relations with patients improved through their increased willingness to initiate discussion of obesity management, increased patient focus and improved goal-setting (Table 2).

View this table:
[Table 2:](http://www.cmajopen.ca/content/5/2/E322/T2)

Table 2:   Provider-patient impacts of the 5As Team intervention

Another theme was that providers adopted a more patient-centred approach. Participants cited previous tendencies to focus on what they thought was best for patients and detailed how the intervention pushed them to fashion care plans around patient preferences. They noted greater attentiveness to patients' thoughts, feelings and motivations. This increased sensitivity to patients' needs manifested as simple concern and efforts to foster rapport. The intervention spurred participants to think about cultural sensitivity as a dimension of patient-centred care and to attempt to adapt obesity management to different cultural contexts.

### Provider-provider impacts

Increased interdisciplinary work among nurses, dietitians and mental health workers as a result of the 5As Team intervention was noted (Table 3). Participants adapted principles of interdisciplinary teamwork emphasized in sessions to their specific clinical environments. Examples ranged from quick debriefings and face-to-face patient referrals to complete interdisciplinary clinical interviews. Participants noted increased empowerment from partaking in the intervention together, which armed them with effective obesity management knowledge and supported them as change agents in their clinics. Many described increased willingness to challenge views of team members on obesity management and to actively educate and change colleagues' perceptions.

View this table:
[Table 3:](http://www.cmajopen.ca/content/5/2/E322/T3)

Table 3:   Provider-provider impacts of the 5As Team intervention

Interdisciplinary team care for obesity management can be challenging.18 Sensitive topics discussed during intervention sessions indicated that this was a safe space for participants to speak candidly about interprofessional teamwork. The data were roughly evenly split between positive and negative work environments. Some participants cited effective communication and strong rapport as assets, whereas others spoke pointedly about difficult working environments. For instance, many participants cited colleagues' different values and lack of willingness to change as major barriers to implementing the 5As approach. Dietitians and mental health workers who moved between intervention clinics added another dimension, with some citing variability in receptiveness. Participants also noted that a longer working relationship could improve the level of teamwork and interdisciplinary work.

The intervention had an uneven impact on the professions in this study. Although participants in all 3 professions reported changes to their practice as a result of the intervention, mental health workers consistently reported having less use for the 5As material. They felt that, although weight was interconnected with the psychological and emotional issues seen frequently in their clinics, obesity management was secondary to their goals and was infrequently the focus of clinical practice. Conversely, dietitians became more aware of mental health issues and the need to support patients with these as part of obesity management.

### Clinic-level impacts

Impacts on participants' clinics involved changes to the physical environment, including efforts to make the clinic space more inclusive (Table 4). Participants reported actions such as moving weight scales to more private areas and assuring availability of bariatric scales and furniture. Motivations for such changes were voiced as stemming from increased awareness of clinic practices that compromised patient dignity and comfort.

View this table:
[Table 4:](http://www.cmajopen.ca/content/5/2/E322/T4)

Table 4:   Clinic-level impacts of the 5As Team intervention

Participants further reported improvement to clinical visits with integration of the 5As approach. Not only did they feel better equipped to initiate discussions of obesity management, but they also improved visit organization, comprehensiveness and follow-up. In addition, participants mentioned changing their line of clinical questioning, asking about and considering patient history they would not have included before. Improved clinical practices were often linked to the 5As Team tools,19 which participants used as sources of information and organizational aids.

Last, participants reported adaptation of the 5As Team approach to their clinical environment and style, describing changes or improvements made as an extension of their usual routine.

### Impacts on Primary Care Network

The 5As Team intervention gave participants a forum to discuss strengths and weaknesses of the Primary Care Network in obesity management (Table 5): gaps in and access to existing programming, issues with scheduling, resource allocation and areas of identified need. Front-line staff often critically evaluated the network's existing plans to address obesity as a possible catalyst for change. De-identified feedback was shared with the Primary Care Network, which resulted in changes in patient programs and training of new staff.

View this table:
[Table 5:](http://www.cmajopen.ca/content/5/2/E322/T5)

Table 5:   Impacts of the 5As Team intervention on the Primary Care Network

## Interpretation

Changing clinical practice is a complex endeavour involving diverse actors with established ways of thinking and working together that need to shift to co-create new norms. Our findings show that provider internalization and adaptation of an intervention are key to this process. Ultimately, internalization of new ways of practising is achieved through increased self-awareness and reflection, improved knowledge and effective resources to reinforce the continued use of learned concepts. In our team-based sessions, members shared experiences through stories and by reporting personal goals. These interactions worked to externalize tacit knowledge and helped participants work through the integration of new information into collective practice. The uptake of knowledge and sustained change in practice is supported through the co-creation of tools, which serve as anchors for new information and its integration into practice.19 There was room for each participant to contextualize the new information to their own practice and adapt it to their patients, while revisiting their learning collaborative and benefiting from peer learning.

In situations in which sustained practice change requires a team approach, practitioners work together to integrate new information into their practice and to adjust the setting to support change. This concept is particularly important in obesity management, as it is not sufficient to change an individual provider's practice; rather, there is a need to co-create a new clinical paradigm for the entire team or, in the terminology of Gabbay and Le May,20 to co-create a "collective mindline." As our results show, individual providers shifted their personal approach to obesity management consultations, and participants reported changes in teamwork to develop new collective approaches. This is particularly important given the finding that obesity management is embedded within other reasons for clinical encounters in primary care.21

Literature focusing on improving providers' clinical practice in obesity management is scant,4,22 which makes comparison of our core findings difficult. The few studies that assessed provider-level interventions focused on patient outcomes, specifically the amount of weight loss achieved, rather than on the process of provider change.4 In their review of existing literature, Flodgren and colleagues4 found only 1 high-quality study that assessed change in providers' behaviour. Studies involved shorter interventions (several hours to several days), and randomized controlled trials rarely had qualitative accompaniment.4,22,23

The qualitative component of the 5As Team study is similarly unique compared to the existing qualitative literature on primary care providers and obesity management. Past studies focused on providers' self-reported barriers to obesity management,3,24,25 assessment of providers' existing obesity management ability,26,27 providers' views on the utility of obesity management interventions,28 and providers' biases regarding weight and attitudes toward obesity management.29 The current literature does not describe processes of provider change and development for supporting obesity management in response to an intervention.12

### Limitations

The data on the impact of the intervention are from the providers' perspective only; there are no data on the effects on other clinic team members such as reception staff, clinical assistants, clinical managers or patients. Our ongoing parallel 5As Team patient study is exploring patients' values, preferences, expectations of primary care providers, and evaluation of the 5As approach and tools to support their obesity management and health. Primary Care Network physicians were very supportive in agreeing to have their salaried team members released for this intensive intervention; however, we were unable to include the physicians owing to inability to provide monetary compensation for their time. We have developed and pilot-tested a shorter intervention, which is more manageable in terms of time. Although future research must assess the transferability of the effect of the 5As approach in different populations and settings, the findings of this initial study show how a provider-level intervention can create practice change.

### Conclusion

The 5As Team study shows that a multifaceted educational intervention for primary care providers can affect obesity management at multiple practice levels. This intervention changed participants' personal understanding of and clinical approach to obesity management and their interactions in collaborative practice. Participants reported internalization of the 5As Team concepts, which facilitated improved communication and teamwork in the clinic, as well as transfer of newly acquired skills to clinic colleagues. The intervention also brought participant-reported improvements in interactions with patients and insights into better organization of care in primary care clinics. The 5As Team intervention represents one model for training interventions that affect practice in a concrete manner.

### Supplemental information

For reviewer comments and the original submission of this manuscript, please see [www.cmajopen.ca/content/5/2/E322/suppl/DC1](http://www.cmajopen.ca/content/5/2/E322/suppl/DC1)

## Acknowledgements

The authors thank their community partner, the Edmonton Southside Primary Care Network, for their engagement and work on the 5As Team project. They also thank the front-line health care providers, administrative staff, management and patients for their support of the project. Christian Rueda-Clausen and Sheri Fielding assisted in writing the grant. Robin Anderson and Sheri Fielding oversaw the clinical operations. Thea Luig supported the writing of the manuscript.

## Footnotes

*   **Competing interests:** Denise Campbell-Scherer is an unpaid board chair for the Edmonton Southside Primary Care Network. Andrew Cave received a grant from Astra-Zeneca for an asthma study. Arya Sharma is a member of an advisory board for an antiobesity drug with Novo Nordisk and was a member of the Data Safety Monitoring Board for an antiobesity trial with Takeda. No other competing interests were declared.

*   **Contributors:** Denise Campbell-Scherer and Arya Sharma, supported by Jeffrey Johnson, conceived of the study and supervised the project. Denise Campbell-Scherer, Jodie Asselin and Adedayo Osunlana wrote the protocol. Jodie Asselin led the qualitative data collection, supported by Denise Campbell-Scherer, Eniola Salami, Adedayo Osunlana, Ayodele Ogunleye and Andrew Cave. Denise Campbell-Scherer, Eniola Salami and Jodie Asselin wrote the manuscript. All of the authors participated in data analysis and interpretation, reviewed the manuscript for important intellectual content, approved the final version to be published and agreed to act as guarantors of the work.

*   **Funding:** The 5As Team study is funded by Alberta Innovates - Health Solutions, with significant in-kind support from the Edmonton Southside Primary Care Network. The researchers are independent of the study funder. The funder had no access to study data, no involvement in the design or execution of the study, no involvement in analysis and no role in the decision to publish.

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