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Obesity is a public health issue of epidemic proportions with costly health and social consequences (Finkelstein, Trogdon, Cohen, & Dietz, 2009; Ogden, Carroll, Kit, & Flegal, 2012; United States Centers for Disease Control and Prevention, 2013a). Worldwide, the prevalence of obesity has nearly doubled since 1980 (World Health Organization, 2014). Related health disparities are well documented: minority and socially disadvantaged populations suffer disproportionately from obesity (Lee, Harris, & Lee, 2013; United States Department of Health and Human Services Office of Minority Health, 2014).
Global health leadership organizations have responded by recommending a multifaceted approach to decrease obesity using a public health approach. The World Health Organization (WHO) calls all stakeholders to take action at global, regional, and local levels to improve diet and physical activity patterns of populations and community at the system level (Flodgren et al., 2010; World Health Organization, 2014). In the United States, the Center for Disease Control and Prevention (CDC) designated obesity as a public health priority with large-scale impact on health and urges the adoption of known, effective strategies to address the underlying causes of obesity in child care, schools, hospitals, and workplaces (United States Centers for Disease Control and Prevention, 2014). Collaboration of multiple sectors is needed to address the obesity issue. The Institute of Medicine, Affordable Care Act, and National Public Health Performance Standards advocate for cooperation between public health and clinical partners to promote population health (Institute of Medicine [IOM], 2012; National Public Health Performance Standards Program, 2013; United States Department of Health and Human Services, 2010). Clinician practice is central to the obesity management effort, given that clinicians impact obesity-related health behaviors through clinical obesity management and prevention interventions (Farran, Ellis, & Lee Barron, 2013; Fitch et al., 2013).
Obesity stigma contributes to health disparities and poor health outcomes (Puhl & Heuer, 2010). The stigma and blame associated with being obese is a serious ethical and emotional issue for clinicians as well as patients. The global call to address obesity as a public health threat may thus marginalize individuals and bias practice within health care settings (Warin & Gunson, 2013). For example, diet, exercise, and weight-related counseling declined between 1995 and 2008, especially among patients with obesity and related comorbidities (Kraschnewski et al., 2013). Nonoverweight physicians and nurses are more likely to engage in obesity management and prevention than overweight physicians and nurses (Bleich, Bennett, Gudzune, & Cooper, 2011; Zhu, Norman, & While, 2012). Furthermore, numerous evidence-based clinical obesity guidelines have been developed, but not consistently translated into practice (Fitch et al., 2013; Strategies to Overcome and Prevent Obesity (STOP) Alliance, 2010).
In the Midwest United States, a voluntary, interprofessional partnership formed as a community response to these urgent obesity-related social and health issues. This partnership developed between local public health departments and clinical health care organizations in a four-county region with racially diverse populations characterized by a high prevalence of poverty and obesity. Their collaborative project addressed clinical practice deficiencies among health care systems, particularly those serving disadvantaged populations, by translating the Institute for Clinical Systems Improvement (ICSI) Prevention and Management of Adult Obesity Guideline into clinical practice. The ICSI Guideline promotes routine assessment of Body Mass Index (BMI); comprehensive assessment of comorbid conditions; and use of motivational interviewing techniques to assess readiness for change to assist in finding reasons for change, and build confidence in the ability to change (Fitch et al., 2013). An evaluation of project outcomes was completed after 3 years of intervention, and findings are detailed in a separate publication (Erickson, Attleson, Monsen, Radosevich, Neely, Oftedahl, & Thorson, in review).
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Participants from diverse health care organizations serving disadvantaged clients from areas with a high prevalence of obesity shared their experiences of translating obesity practice guidelines. Four themes emerged from the analysis: (1) a shift from powerlessness to positive motivation, (2) heightened awareness coupled with improved capacity to respond, (3) personal ownership and use of creativity, and (4) a sense of the importance of increased interprofessional collaboration. These themes describe the personal and collective emotional investment of participants as they changed health system practice related to this serious health problem and ethical issue over a 3-year period. Feelings of self-respect and self-efficacy were overarching concepts that were repeated across the themes, as participants described shifting from feeling powerless to having resources and skills to co-creating a new norm of evidence-based, interprofessional obesity management practice.
Participants had prior knowledge of global obesity trends; however, this knowledge was not sufficiently motivating to catalyze practice change. Instead, participants felt powerless, possibly related to the sensitive ethical and emotional concerns that relate to obesity. The project's collaborative response to these issues overcame perceived barriers to addressing obesity with clients, and created shared motivation to improve obesity management. The project became the vehicle by which powerless was transformed to self-respect and self-efficacy. It brought the issue to the forefront, and provided tools, methods, and training. Participants responded positively to the project, feeling respected and feeling self-respect. This created a collective experience of pride, confidence, dignity, and honor versus stigma, judgment, and blame.
Administrators and clinicians engaged in the creative design of guideline implementation within their organizations. Participant comments indicated a sense of ownership that developed from specifically tailoring the system's support for the guideline and how it was incorporated within the system and workflow. This engagement in the change effort resulted in a feeling of self-efficacy, a belief in their ability to achieve guideline translation in their organizations.
The project fostered interprofessional collaboration and connections around the goal of guideline translation. Participant comments demonstrated that the project transcended silos in practice within and among organizations through collective effort and increased interprofessional connection. This created a shift in responsibility from clinicians as sole actors to the coordinated professional response of the organization. Clinicians were energized and expressed a desire for even more interdisciplinary interaction and communication beyond the project. The project also fostered a wider awareness of community resources to address obesity, and of personal experiences and goals for healthy weight, nutrition, and physical activity. These findings suggest that the PHN facilitator role may be key to supporting the implementation of obesity guidelines in clinical settings as well as within their own public health agencies.
Blame and stigma associated with obesity extended to health care clinicians as they described a sense of helplessness in managing population obesity. In the special case of clinician participants with obesity, the clinicians adapted and used the nonjudgmental approaches that they were learning to use with clients in their own lives. Personal health changes such as weight reduction and increased physical activity were key to their feeling of success in counseling others. Further research is needed to understand the perspectives of obese clinicians regarding relationships between blame, stigma, and powerlessness and the transformation to self-efficacy and self-respect.
The collaborative guideline translation project and the 10 participating organizations created a novel and diverse context for this qualitative research. The findings suggest that there may be generalizable concepts that should be further explored in other health systems to promote the ideals of interprofessional collaboration and to support clinicians charged with improving obesity management and population health. This transformation may be needed within an organization to support the same transformation in individual clinicians so they in turn can support the same transformation in their obese patients.
To successfully address the obesity epidemic and improve population health, public health agencies must be seen as a valued resource and respected partner in the community. Local public health agencies should create and nurture interprofessional collaboratives for the mutual benefit of all partners and their patients. Further research is needed to develop methods for linking system-level PHN interventions to population health outcomes.