Development of a tailored, 5a's-based weight management intervention for veterans within primary care

Abstract

BACKGROUND: Obesity affects 36 % of patients in the Veterans Health Administration. The United States Preventive Services Task Force endorses the use of the 5As framework (Assess, Advise, Agree, Assist, Arrange) to deliver obesity counseling in primary care (PC). This study used qualitative methods to inform the development of a 5As-based weight management intervention to improve obesity care at Veterans Affairs (VA) Medical Centers. METHODS: We conducted a secondary analysis of 6 focus group sessions with Veteran patients and 25 interviews with key VA staff in PC (physicians, nurses, and MOVE! staff) in order to guide intervention development. We asked Veterans and staff to provide feedback on a proposed 5As intervention initially conceived based on prior work and a systematic review of the literature. This proposed intervention would use an online tool to deliver the 5As by assessing health behaviors and barriers (“assess”), providing tailored advice (“advise”), and helping patients set goals (“agree”). Members of the healthcare team would then discuss goals further, focusing on addressing barriers (“assist”) and providing follow-up/referral to more intensive support (“arrange”). Participants were also asked about their experiences with goal setting, weight management, and technology. Focus group and interview sessions were audio-recorded, professionally transcribed, and coded using a rigorous process previously described. To guide intervention development, transcription segments originally coded as “goal-setting,” “proposed intervention,” and/or “technology” were analyzed. The “proposed intervention” code had not been previously analyzed. RESULTS: Both Veterans and VA staff held positive views toward the use of goal setting for healthy behavior change and stressed the importance of social support in achieving goals. Veterans particularly felt the need for someone to hold them accountable for their goals and give them consistent feedback on their progress. VA staff felt that the goals needed to come directly from the patient and that the providers' role was to support the process. Veterans and staff reported mixed attitudes toward technology, acknowledging that some patients were unfamiliar with or distrusting of technology. When asked to give feedback about the proposed intervention, Veterans and staff liked that it would provide individualized counseling and support from the healthcare team to achieve goals. However, some Veterans did not believe a computer could generate individualized advice and did not want technology to replace human support. Most healthcare team members felt that time constraints would be a barrier to implementation and indicated that they could not spend more than 3-5 min on weight management. As a result of these findings, our revised intervention includes the use of a health coach to provide in-person support while using the online tool. The health coach will also provide initial counseling about weight loss and lifestyle goals to allow the healthcare team to focus their time on performing brief counseling to address barriers and endorse the goals. CONCLUSIONS: This study informed the development of a 5As intervention to improve the treatment of obesity in the PC setting. Usability testing of the online tool is currently ongoing, and pilot testing of the intervention will begin soon.