Beneficial self‐management support and user involvement in Healthy Life Centres—A qualitative interview study in persons afflicted by overweight or obesity

Abstract Background Relapse is high in lifestyle interventions involving behavioural change and weight loss maintenance. The purpose of lifestyle self‐management interventions offered at Healthy Life Centres (HLCs) is to empower the participants, leading to self‐management and improved health. Exploring beneficial self‐management support and user involvement in HLCs is critical for quality, improving effectiveness and guiding approaches to lifestyle change support in overweight and obesity. Objective The aim of this study was to explore how persons afflicted by overweight or obesity attending lifestyle interventions in Norwegian HLCs experience beneficial self‐management support and user involvement. Method Semi‐structured in‐depth interviews were conducted with 13 service users (5 men and 8 women). Data were analysed using qualitative content analysis. Results One main theme was identified: regaining self‐esteem and dignity through active involvement and long‐term self‐worth support in partnership with others. This main theme comprised four themes: (a) self‐efficacy through active involvement and better perceived health, (b) valued through health‐care professionals (HPs) acknowledgement, equality and individualized support, (c) increased motivation and self‐belief through fellowship and peer support; and (d) maintenance of lifestyle change through accessibility and long‐term support. Conclusion Service users’ active involvement, acknowledgement and long‐term self‐worth support from HPs and peers seem to support self‐management and user involvement and may be some of the successful ingredients to lifestyle change. However, prolonged follow‐up support is needed. A collectivistic and long‐term perspective can integrate the importance of significant others and shared responsibility.


| BACKG ROU N D
Overweight and obesity are considered some of the primary drivers of chronic non-communicable diseases (NCDs), such as cardiovascular diseases, cancer, diabetes type 2 and chronic respiratory conditions. 1 Worldwide, more than 1.9 billion adults are afflicted by overweight, of whom 650 million present with obesity. 2 Due to this high prevalence, overweight and obesity have become a significant national and international health concern and place an extensive burden on health-care services worldwide. [1][2][3] The vast burden on health-care services has led to the increased development of educational self-management interventions. [4][5][6] These behavioural interventions aim to help patients and service users better manage their own conditions (self-care) and health-care needs. 3,4,6 Self-management may be one means of bridging the gap between patients' needs and the capacity of health-care services to meet those needs. 5 An individual's ability to detect and manage symptoms, treatment, physical and psychosocial consequences, and the lifestyle changes (such as exercise and diet) inherent in living with a chronic condition is the core of self-management. 5 In this study, self-management support is understood as interventions or educational approaches supporting self-management. 4,6 The desired outcome of self-management support is behavioural change. 7 There has been a growing interest in national and international health policies to more actively involve and empower patients in their health care. [8][9][10] Individual empowerment is a process through which people gain greater control over decisions and actions affecting their health. 11 The literature highlights patient and user involvement as a means of ensuring the quality of care and health services. 12,13 In this study, user involvement is understood as a clinical partnership between the service user and health-care professionals (HPs). 13 According to Greenhalgh, structured self-management programmes focusing on building patients' self-efficacy can be seen as synonymous with patient or user involvement in managing chronic diseases. 13 The literature on lifestyle change and self-management interventions in chronic conditions or NCDs is extensive. Systematic reviews and meta-analysis demonstrate that both individual and groupbased interventions designed to target dietary and physical activity behaviours are recommended strategies for lifestyle change 14,15 and weight loss maintenance. 16,17 The literature in the field of obesity is scarce regarding patient education and self-management interventions, while self-management terminology is rarely used in the context of overweight and obesity.
One review and one meta-analysis found in the literature on patient education about obesity suggest that patient health outcomes, including self-management skills and quality of life, could be improved. 18,19 However, these analyses are based on the literature related to specific NCD diagnoses such as diabetes and not on generic programmes targeting educational interventions for overweight and obesity per se.
The main challenge of overweight and obesity treatment is not merely weight loss, but long-term weight loss maintenance. 17,[20][21][22] Most efforts to change behaviours have limited success. 23,24 Findings provide initial evidence that overlooking psychosocial factors, such as weight stigma, may hinder weight loss maintenance and hamper help-seeking. [25][26][27] The Norwegian Directorate of Health recommends the establishment of Healthy Life Centres (HLCs) in primary health care to meet the challenge of overweigh, obesity and NCDs. HLCs offer lifestyle self-management interventions for persons in need of support for lifestyle change who already have or are at risk of NCDs. The purpose of the intervention is to empower the participants, leading to self-management and improved health. 28 HLCs are a novelty in primary health care and health service research; thus, the knowledge of their efficacy is sparse. One study shows that less physically active persons became more physically active after attending a HLC. 29 Both physical fitness and health-related quality of life improved significantly in the short and the long term, 30 and at the 24-month follow-up, no one had developed type 2 diabetes. 31 One qualitative study from a HLC found that having a trustful relationship with the HPs being respected and experiencing continuity in the care were essential for service user involvement. 32 Another qualitative study highlighted social support and pointed out the need for more research on how HPs in HLCs can help with and promote lasting lifestyle changes and whether HLCs can help participants who want and need such changes. 33 However, no studies exploring what the participants really find beneficial when they seek help to change their lifestyle at a HLC have been found, and little is known about the significance of user involvement for lifestyle change in overweight and obesity care. Knowledge about the service users' experiences of self-management support as well as how aspects of user involvement affect participation in interventions could be helpful in understanding the overall process of lifestyle change, and how HLCs may provide beneficial support and a qualitative good health-care service. Such knowledge is highly relevant for the future development of lifestyle interventions in HLCs. Thus, the aim of this study was to explore how persons afflicted by overweight or obesity attending lifestyle interventions in Norwegian HLCs experience beneficial self-management support and user involvement.

| Design
A qualitative, interpretative interview study, grounded in hermeneutic tradition, was designed to explore beneficial self-management support and user involvement for the service users in HLCs.

K E Y W O R D S
dignity, empowerment, lifestyle change, long-term individualized support, obesity, overweight, self-efficacy, self-management support, user involvement

| Study context
HLCs offer individual and group-based lifestyle interventions focusing on the promotion of healthy dietary and physical activity habits. This interdisciplinary primary health-care service provides educational self-management interventions aimed at empowering people to manage their condition or health behaviour change. The HLC emphasizes the strengthening of physical, mental and social resources for health and self-management based on a health promoting, preventive and salutogenic foundation. User involvement is a key principle that is enshrined in the legislation, and the interventions are based on a person-centred approach, adjusted to service users' needs, individual resources and self-management skills. 28 HPs, including physiotherapists, public health nurses, psychiatric nurses, nutritionists and bachelors in public health, provide the interventions. HLCs are easily accessible through direct contact or by referrals from general practitioners. The initial health conversation is based on each service user's needs and desire for help, after which a group-based healthy diet course and/or physical activity sessions is offered. The healthy diet course consists of four to five two-hour sessions with practical tasks and theory. Physical activity in the form of group-based indoor and outdoor activities is offered two to three times a week. If desired, individual counselling is also available. An intervention lasts for three months with the possibility to extend it on two occasions.

| Recruitments
The participants in this study were recruited from five different small and medium-sized HLCs in Norway. The first author (ES) contacted HLC administrators and asked them to send an information letter about the study with an invitation to take part to both women and men who had participated in lifestyle courses. The inclusion criteria were persons aged 18 to 80 years who had contacted the HLC to obtain help to change their dietary and activity habits, afflicted by overweight or obesity and who were able to speak and understand the Norwegian language. Purposive sampling 34 was used to identify participants for interview to ensure that the sample included individuals of various ages and both sexes from small (rural) and mediumsized (urban) municipalities. The first author contacted all the service users who consented to participate. Before the individual interviews, precautions had been taken by reflecting on how to take care of the participants if the interview situation became unpleasant or challenging. The ethical guidelines in the Helsinki Declaration were followed. This study was registered and approved at the Norwegian Centre for Research Data (NSD) project number 48025.

| Analysis
Data were analysed by the analytical steps in Qualitative Content Analysis suggested by Graneheim & Lundman 36 and Graneheim, Lindgren & Lundman. 37 According to these authors, categories present the manifest, descriptive content of the text, while a theme presents the latent content, a thread of an underlying meaning on an interpretative level. 36 ES was responsible for the analysis with input from all the co-authors (GF, BSH, ALH). Table 2 shows the steps in the analytical process. To capture complete ideas and something important in relation to the research question, the main theme and themes have been labelled with a phrase or a sentence. 38,39

| RE SULTS
A total of 13 service users, five men and eight women, were included in this study (Table 3). Some had been recommended lifestyle changes such as regular moderately intensive physical activity, healthy diet and weight reduction by their general practitioners.

TA B L E 1 Thematic guide for individual interviews
Self-management support: • Can you describe what you have experienced as beneficial support in the lifestyle interventions in HLCs?
• What do you perceive as helpful for lifestyle change?
• How was the information and support in the intervention adjusted to your needs?
• What have given you strength to start or continue lifestyle change?
• Can you describe your need for follow-up in the future?
User involvement: • What do you understand by user involvement at the HLCs lifestyle interventions?
• What is important for you regarding user involvement?
• How did you get involved?
• What give you a sense of being involved?
• How were your opinions met?
• Can you describe your own role in the involvement?
However, the majority had contacted the HLC on their own initiative because they wanted to lose weight and needed help to change their lifestyle habits. Several of the participants had contact with HLC and/or participated in physical activity group sessions for more than a year, and they still had this contact. The participants were either overweight (Body-Mass Index [BMI] ≥ 25) or obese (BMI ≥ 30) and had additional diagnoses that put them at risk ( Table 4).
The analysis resulted in one main theme and four themes compromising several sub-themes related to the service users' experience of beneficial self-management support and user involvement when attending to lifestyle interventions in the HLC (Table 5).

| Regaining self-esteem and dignity through active involvement and long-term self-worth support in partnership with others
Overall, the participants were taking personal responsibility for active involvement. They described help as supporting self-worth and increasing their belief in self-management. They perceived being strengthened and regaining self-esteem and dignity by being invited to become involved in an equal partnership, built on a trustful relationship with competent HPs. User involvement was described as acknowledgement. Thus, acknowledgement can be the HPs' ability to personalize and tailor selfmanagement support and lifestyle intervention to service users' needs and everyday life. Participation in supervised groups and emotional support from peers increased motivation and self-belief. Several of the participants expressed a need for long-term support, and accessibility and long-term support was critical to maintenance of lifestyle change.

| Self-efficacy through active involvement and better perceived health
The participants described taking responsibility for the initiative to engage in the lifestyle interventions in the HLC. They described

TA B L E 2
Steps of analytical process 1. Open reading The transcripts were read repeatedly to obtain an overall impression and discussed at group meeting between the authors

Identifying meaning units
The text was divided into meaning units by first author

Condensing meaning units
These meaning units were condensed into a more written style

Creating codes and categories
The condensed meaning units were further abstracted and labelled with a code by the first author (e.g., listening, understanding needs, modifying, tailoring, adjusting support, flexibility, openness)

Sorted codes and categories abstracted into sub-themes
The codes were abstracted into tentative sub-themes and continuously regrouped and discussed between the authors (e.g., the importance of flexibility and individualized support)

Formulating into latent theme
The sub-themes were discussed, and the latent content was labelled with a sentence to capture context, complete ideas and reasoning

Interpretation into one main theme
In accordance with the hermeneutical methodological approach, the themes were interpreted into a main theme answering the aim of the study

| Valued through HPs acknowledgement, equality and individualized support
The participants experienced the first meeting at the HLC, the in- The participants experienced being met, listened to and receiving emotional support in terms of a coherent and holistic approach.
Feedback, encouragement and emotional support were very important for all the participants. They described this as 'they build you up', meaning giving them belief in own ability to manage, self-respect and worth. This can be exemplified by one of the participants: The way they do it…they encourage you to perform, everything is good enough, they build you up and you TA B L E 4 Self-reported challenges, strains and additional diagnoses (number of participants in brackets) One or several of somatic diagnosis: Type 2 diabetes (3), cardiovascular disease (CVD) (4), chronic obstructive pulmonary disease (COPD) (2), coeliac disease (1), multi sclerosis (MS) (1), sleep apnoea (1), various chronic pain conditions (8), fibromyalgia (3), cancer (2) One or several of psychosocial strains and challenges: Anxiety (3), depression (4), loss and grief (1), identity reactions (12), eating disorders (2), suicidal thoughts (2), alcohol abuse (1), isolation (6), financial difficulties (2) TA B L E 5 Main theme, themes and sub-themes describing service users' experiences of beneficial self-management support and user involvement in the HLCs

| Increased motivation and self-belief through peer support and fellowship
When starting at the HLC, several of the participants experienced a sense of being unsafe and feeling uncomfortable in group sessions, and the thought of working out with others and exposing their big body and bad shape was frightening. After some time, most of the participants experienced the group as a safe place. They experienced inclusion, an atmosphere of humour, respect and acknowledgement, as well as a safe place to express personal views.
Getting inspiration from, sharing experiences and being supported and encouraged by the other participants were essential for endurance and motivation:

| Maintenance of lifestyle change through accessibility and long-term support
The service users described a need for someone to contact when they experience adversity and relapse. They considered that the HCL was a locally situated and easily accessible (low threshold) healthcare service that was easy to contact if they needed something, which created a sense of safety. The participation period for these service users, ranged from 3 to 42 months (Table 3)

| D ISCUSS I ON
HLCs offer self-management interventions for persons in need of support for lifestyle change, with the intention of empowering the participants to achieve self-management and improved health. The aim of this study was to explore beneficial self-management support and user involvement for persons afflicted by overweight or obesity attending lifestyle interventions in HLCs. In the following, we will discuss the results in relation to previous research within this field and in the context of HLC and primary care. The main theme and themes will guide the discussion.

| Regaining self-esteem and dignity through active involvement and long-term self-worth support in partnership with others
Service user's active involvement and long-term self-worth support in partnership with HPs and fellow participants seem to be an overall means to achieve individual empowerment, user involvement and self-management. We suggest that acknowledgement and individualized support from competent HPs promote selfworth and participation, which are a prerequisite for user involvement and again for self-management. These findings support the connection between self-management support and user involvement and that these may be considered synonyms and overlapping in chronic diseases. 13 Over time, acknowledgement, equality and self-worth support may contribute to a feeling of dignity. Previous studies on HLC participants' perceptions of seeking help for lifestyle change show that persons afflicted by overweight or obesity experience emotional distress and search for change and dignity. 33,40 How one looks at her/himself is an existential question of identity. Self-worth support may lead to an increased feeling of being a valuable person, and belief in oneself.
The service users experience self-efficacy through active involvement and better perceived health. This indicates that individual elements influencing user involvement and self-management were related to the service users' motivation. Perceived control and self-efficacy are important elements in individual empowerment, 41,42 and an important goal of the interventions in HLCs. 28 We suggest that taking the initiative to change and to participate in HLC shows autonomous motivation. Previous research confirms that a participant whose motivation was more autonomous would attend intervention programmes more regularly. 43  person, by phone or internet. 65 On the other hand, prolonged follow-up involves a cost. It is reasonable to believe that HLC participants need further support and motivation to continue regularly monitoring their food intake and physical activity in order to maintain their lifestyle change and self-management. Our findings demonstrate that several of the participants continued to take part, especially in activity group sessions, after the conclusion of their three assigned periods (Table 3). We believe that some HPs recognize the need for long-term follow-up and in some way are 'gaming the system' by letting the participants continue to attend in group sessions. By so doing, they recognize each service user's need for continued support, which can be seen as adjusted and individualized health-care support, as well as a shared responsibility of partnership. Given the chronic nature of obesity, extended care may be necessary to achieve long-term health benefits, 52,61 but first and foremost, obesity should be recognized as a chronic condition that requires lifelong support. 21,22 The considerable amount of literature on self-management in chronic conditions like type 2 diabetes and cardiovascular diseases, in contrast to the sparse literature on overweight and obesity may be explained as a lack of recognition of overweight and obesity as a chronic disease. The World Obesity Federation considers obesity to be a chronic relapsing disease. 2,66 However, recognition of obesity as a disease is by no means universal. 67 HPs play a critical role in facilitating longterm changes and follow-up after lifestyle interventions. 65 We suggest that cost-effective follow-up programmes, maybe over years, should be developed, including long-term self-care strategies with a supportive design and practice to promote self-esteem and dignity. Further studies should also focus on methods to improve these programmes regarding social support, for example recruitment of participants with friends or family to safeguard the necessary long-term support. There is a need to investigate HPs' role and understanding of these matters to fully understand how self-management support and user involvement are beneficial for self-management and lifestyle change in HLCs.

| ME THODOLOG IC AL CONS IDER ATIONS
The trustworthiness of the findings is related to confidence in the analysis 68 and to the researchers' preunderstanding and interpretation of the statements made by the service users. 69 We argue that the trustworthiness of our findings was strengthened by systematically analysing the data using inductive coding and categorization. 70 The The strengths of the present study include the richness of each semi-structured in-depth interview. The variation in age, gender, background and current situation, in addition to the collection of data from five different HLCs in both rural and urban municipalities, reflects multiple realities and practices, which might increase the transferability to other settings.
However, some methodological limitations should be addressed.
HPs' recruitment of participants could be influenced by their knowledge of service users who were especially satisfied. The self-selection of volunteers to participate and the service users' opportunity to participate in HLC interventions in the daytime (due to their employment situation) may have influenced their descriptions of user involvement and satisfaction (structure and social support). We have no data on those who declined to take part in the study, or those who were prevented from participating for various reasons. However, as the aim of the study concerned experience of beneficial self-management support and user involvement (and not useless support and barriers to participation), the participants recruited were therefore suitable.

| CON CLUS ION
Our findings suggest that service user's active involvement and longterm self-worth support in partnership with others seem to promote self-management and user involvement. Acknowledgement from HPs in HLCs, self-management support tailored to service users' needs, and peer support in supervised group sessions seems to be important mechanisms for increasing user involvement, self-efficacy and self-esteem, leading to dignity and individual empowerment. We believe that lifestyle change is not simply a question of individual autonomous motivation and willpower, but primarily concerns relational, emotional and social support. Long-term self-worth support from significant others seems to be some of the successful ingredients to lifestyle change. A collectivist perspective can integrate the importance of significant others, involvement and shared responsibility. Motivating participants to participate in HLC interventions together with a friend or a partner may lead to more independence, 'self'-management and lasting lifestyle changes. Recognizing overweight and obesity as a chronic condition in line with diabetes type 2 etc and providing long-term support, maybe over many years for those in need, will strengthen the ability of HLCs to provide beneficial 'self'management support to persons afflicted by overweight or obesity.

ACK N OWLED G EM ENTS
The authors would like to thank health personnel at Healthy Life Centres for recruiting participants for the study and for facilitating interviews at local HLCs. We are grateful to the participants for sharing their time and experience. We also thank Monique Federsel for reviewing the English language.

CO N FLI C T S O F I NTE R E S T
The authors declare that they have no competing interests.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data set used and analysed during the current study is available from the corresponding author on reasonable request.