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BMC Health Services Research
Published in: BMC Health Services Research 1/2018

Open Access 01-12-2018 | Research article

Development of a 5As-based technology-assisted weight management intervention for veterans in primary care

Authors: Katrina F. Mateo, Natalie B. Berner, Natalie L. Ricci, Pich Seekaew, Sandeep Sikerwar, Craig Tenner, Joanna Dognin, Scott E. Sherman, Adina Kalet, Melanie Jay

Published in: BMC Health Services Research | Issue 1/2018

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Abstract

Background

Obesity is a worldwide epidemic, and its prevalence is higher among Veterans in the United States. Based on our prior research, primary care teams at a Veterans Affairs (VA) hospital do not feel well-equipped to deliver effective weight management counseling and often lack sufficient time. Further, effective and intensive lifestyle-based weight management programs (e.g. VA MOVE! program) are underutilized despite implementation of systematic screening and referral at all VA sites. The 5As behavior change model (Assess, Advise, Agree, Assist, Arrange) is endorsed by the United States Preventive Service Task Force for use in counseling patients about weight management in primary care and reimbursed by Medicare. In this paper, we describe the iterative development of a technology-assisted intervention designed to provide primary care-based 5As counseling within Patient-Centered Medical Homes without overburdening providers/healthcare teams.

Methods

Thematic analyses of prior formative work (focus groups with patients [n = 54] and key informant interviews with staff [n = 25]) helped to create a technology-assisted, health coaching intervention called Goals for Eating and Moving (GEM). To further develop the intervention, we then conducted two rounds of testing with previous formative study participants (n = 5 for Round 1, n = 5 for Round 2). Each session included usability testing of prototypes of the online GEM tool, pilot testing of 5As counseling by a Health Coach, and a post-session open-ended interview.

Results

Three main themes emerged from usability data analyses: participants’ emotional responses, tool language, and health literacy. Findings from both rounds of usability testing, pilot testing, as well as the open-ended interview data, were used to finalize protocols for the full intervention in the clinic setting to be conducted with Version 3 of the GEM tool.

Conclusions

The use of qualitative research methods and user-centered design approaches enabled timely detection of salient issues to make iterative improvements to the intervention. Future studies will determine whether this intervention can increase enrollment in intensive weight management programs and promote clinically meaningful weight loss in both Veterans and in other patient populations and health systems.
Literature
1.
2.
Das SR, Kinsinger LS, Yancy WS, Wang A, Ciesco E, Burdick M, et al. Obesity prevalence among veterans at veterans affairs medical facilities. Am J Prev Med. 2005;28:291–4.CrossRefPubMed
3.
Noël PH, Copeland LA, Pugh MJ, Kahwati L, Tsevat J, Nelson K, et al. Obesity diagnosis and care practices in the veterans health administration. J Gen Intern Med. 2010;25:510–6.CrossRefPubMedPubMedCentral
4.
Moyer VA. Screening for and management of obesity in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2012;157:373–8.PubMed
5.
Rosland A-M, Nelson K, Sun H, Dolan ED, Maynard C, Bryson C, et al. The patient-centered medical home in the veterans health administration. Am J Manag Care. 2013;19:e263–72.PubMed
6.
Bidassie B, Davies ML, Stark R, Boushon B. VA experience in implementing patient-centered medical home using a breakthrough series collaborative. J Gen Intern Med. 2014;29(Suppl 2):S563–71.CrossRefPubMed
7.
Jackson GL, Powers BJ, Chatterjee R, Prvu Bettger J, Kemper AR, Hasselblad V, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158:169.CrossRefPubMed
8.
9.
Del Re AC, Maciejewski ML, Harris AHS. MOVE: weight management program across the veterans health administration: patient- and facility-level predictors of utilization. BMC Health Serv Res. 2013;13:511.CrossRefPubMedPubMedCentral
10.
Arigo D, Funderburk J, Hooker S, Dundon M, Evans-Hudnall G, Dubbert P, et al. Veterans health Administration’s MOVE! Weight management program: primary care clinicians’ perceptions of program implementation. Mil Med. 2015;180:1027–33.CrossRefPubMed
11.
Kahwati LC, Lewis MA, Kane H, Williams PA, Nerz P, Jones KR, et al. Best practices in the veterans health Administration’s MOVE! Weight management program. Am J Prev Med. 2011;41:457–64.CrossRefPubMed
12.
Littman AJ, Boyko EJ, McDonell MB, Fihn SD. Evaluation of a weight management program for veterans. Prev Chronic Dis. 2012;9:E99. PubMedPubMedCentral
13.
Romanova M, Liang L-J, Deng ML, Li Z, Heber D. Effectiveness of the MOVE! Multidisciplinary weight loss program for veterans in Los Angeles. Prev Chronic Dis. 2013;10:E112.CrossRefPubMedPubMedCentral
14.
Dahn JR, Fitzpatrick SL, Llabre MM, Apterbach GS, Helms RL, Cugnetto ML, et al. Weight management for veterans: examining change in weight before and after MOVE. Obesity (Silver Spring). 2011;19:977–81.CrossRef
15.
U.S. Department of Veteran Affairs, National Center for Health Promotion and Disease Prevention. MOVE! Implementation best practices: evaluation results, final report 2010.
16.
Kahwati LC, Lance TX, Jones KR, Kinsinger LS. RE-AIM evaluation of the veterans health Administration’s MOVE! Weight management program. Transl Behav Med. 2011;1:551–60.CrossRefPubMedPubMedCentral
17.
VHA National Center for Health Promotion and Disease Prevention. MOVE! Weight management program for veterans fiscal year 2013 evaluation report: narrative summary 2013.
18.
Maciejewski ML, Perkins M, Li Y-F, Chapko M, Fortney JC, Liu C-F. Utilization and expenditures of veterans obtaining primary care in community clinics and VA medical centers: an observational cohort study. BMC Health Serv Res. 2007;7:56.CrossRefPubMedPubMedCentral
19.
Whitlock E. Evaluating primary care behavioral counseling interventions an evidence-based approach. Am J Prev Med. 2002;22:267–84.CrossRefPubMed
20.
Jacques L, Jensen T, Schafer J, McClain S, Chin J. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). 2011.
21.
Campbell-Scherer DL, Asselin J, Osunlana AM, Fielding S, Anderson R, Rueda-Clausen CF, et al. Implementation and evaluation of the 5As framework of obesity management in primary care: design of the 5As team (5AsT) randomized control trial. Implement Sci. 2014;9:78.CrossRefPubMedPubMedCentral
22.
Goldstein MG, Whitlock EP, DePue J. Multiple behavioral risk factor interventions in primary care. Summary of research evidence. Am J Prev Med. 2004;27(2 Suppl):61–79.CrossRefPubMed
23.
Glasgow RE, Goldstein MG, Ockene JK, Pronk NP. Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care. Am J Prev Med. 2004;27(2 Suppl):88–101.CrossRefPubMed
24.
Ajzen I. Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. J Appl Soc Psychol. 2002;32:665–83.CrossRef
25.
Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation: a 35-year odyssey. Am Psychol. 2002;57:705–17.CrossRefPubMed
26.
Webb TL, Sniehotta FF, Michie S. Using theories of behaviour change to inform interventions for addictive behaviours. Addiction. 2010;105:1879–92. CrossRefPubMed
27.
Shilts MK, Horowitz M, Townsend MS. Goal setting as a strategy for dietary and physical activity behavior change: a review of the literature. Am J Health Promot. 2004;19:81–93.CrossRefPubMed
28.
Nothwehr F, Yang J. Goal setting frequency and the use of behavioral strategies related to diet and physical activity. Health Educ Res. 2007;22:532–8.CrossRefPubMed
29.
Glasgow RE, Emont S, Miller DC. Assessing delivery of the five “as” for patient-centered counseling. Health Promot Int. 2006;21:245–55.CrossRefPubMed
30.
Schlair S, Moore S, Mcmacken M, Jay M. How to deliver high quality obesity counseling using the 5As framework. J Clin Outcomes Manag. 2012;19:221–9.
31.
Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical review: modified 5 as: minimal intervention for obesity counseling in primary care. Can Fam Physician. 2013;59:27–31.PubMedPubMedCentral
32.
Jay M, Gillespie C, Schlair S, Sherman S, Kalet A. Physicians’ use of the 5As in counseling obese patients: is the quality of counseling associated with patients’ motivation and intention to lose weight? BMC Health Serv Res. 2010;10:159.CrossRefPubMedPubMedCentral
33.
34.
Jay MR, Gillespie CC, Schlair SL, Savarimuthu SM, Sherman SE, Zabar SR, et al. The impact of primary care resident physician training on patient weight loss at 12 months. Obesity (Silver Spring). 2013;21:45–50.CrossRef
35.
KSH Y, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41.CrossRef
36.
Levine DM, Savarimuthu S, Squires A, Nicholson J, Jay M. Technology-assisted weight loss interventions in primary care: a systematic review. J Gen Intern Med. 2015;30:107–17.CrossRefPubMed
37.
Jay M, Gillespie C, Ark T, Richter R, McMacken M, Zabar S, et al. Do internists, pediatricians, and psychiatrists feel competent in obesity care? Using a needs assessment to drive curriculum design. J Gen Intern Med. 2008;23:1066–70.CrossRefPubMedPubMedCentral
38.
Ajzen I. The theory of planned behaviour: reactions and reflections. Psychol Health. 2011;26:1113–27.CrossRefPubMed
39.
Bodenheimer T, Handley MA. Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns. 2009;76:174–80.CrossRefPubMed
40.
Damschroder LJ, Lutes LD, Goodrich DE, Gillon L, Lowery JC. A small-change approach delivered via telephone promotes weight loss in veterans: results from the ASPIRE-VA pilot study. Patient Educ Couns. 2010;79:262–6.CrossRefPubMed
41.
Czajkowski S, Powell L, Adler N, Naar-King S, Reynolds K, Hunter C, et al. From ideas to efficacy: the ORBIT model for developing behavioral treatments for chronic disease. Health Psychol. 2015; Epub
42.
Jay M, Chintapalli S, Squires A, Mateo KF, Sherman SE, Kalet AL. Barriers and facilitators to providing primary care-based weight management services in a patient centered medical home for veterans: a qualitative study. BMC Fam Pract. 2015;16:167.CrossRefPubMedPubMedCentral
43.
Jay M, Mateo KF, Squires A, Kalet A, Sherman SE. Military service and other socioecological factors influencing weight and health behavior change in overweight and obese Veterans: a qualitative study to inform intervention development within primary care at the United States Veterans Health Administration. BMC Obes. 2016;3:5.
44.
Jaspers MWM. A comparison of usability methods for testing interactive health technologies: methodological aspects and empirical evidence. Int J Med Inform. 2009;78:340–53.CrossRefPubMed
45.
46.
Wayne N, Ritvo P. Smartphone-enabled health coach intervention for people with diabetes from a modest socioeconomic strata community: single-arm longitudinal feasibility study. J Med Internet Res. 2014;16:e149.CrossRefPubMedPubMedCentral
47.
48.
Perez HR, Nick MW, Mateo KF, Squires A, Sherman SE, Kalet A, Jay M. Adapting a weight management tool for Latina women: a usability study of the veteran health Administration’s MOVE!23 tool. BMC Med Inform Decis Mak. 2016;16:128.CrossRefPubMedPubMedCentral
49.
Tsai H-YS, Shillair R, Cotten SR, Winstead V, Yost E. Getting grandma online: are tablets the answer for increasing digital inclusion for older adults in the U.S.? Educ Gerontol. 2015;41:695–709.CrossRefPubMedPubMedCentral
50.
Smith PH, Homish GG, Barrick C, Grier NL. Using touch-screen technology to Assess smoking in a low-income primary care clinic: a pilot study. Subst Use Misuse. 2011;46:1750–4.CrossRefPubMed
51.
52.
Faulkner L. Beyond the five-user assumption: benefits of increased sample sizes in usability testing. Behav Res Methods Instrum Comput. 2003;35:379–83.CrossRefPubMed
53.
JMCMC B. Usability testing: a review of some methodological and technical aspects of the method. Int J Med Inform. 2010;79:e18–23.CrossRef
54.
Fonteyn ME, Kuipers B, Grobe SJ. A description of think aloud method and protocol analysis. Qual Health Res. 1993;3:430–41.CrossRef
55.
Olmsted-Hawala EL, Murphy ED, Hawala S, Ashenfelter KT. Think-aloud protocols: a comparison of three think-aloud protocols for use in testing data-dissemination web sites for usability. In: Proceedings of the 28th international conference on human factors in computing systems. ACM; 2010. p. 2381–90.
56.
Patel VL, Kaufman DR. Cognitive Science and Biomedical Informatics. In: Shortliffe EH, Cimino JJ. (eds) Biomedical Informatics. Health Informatics. New York: Springer; 2006.
57.
Lewis JR. Usability testing. In: Salvendy G, editor. Handbook of human factors and ergonomics. 4th ed. New York: John Wiley & Sons; 2012. p. 1267–312.CrossRef
58.
Ericsson KA, Simon HA. Protocol analysis: verbal reports as data. Cambridge: The MIT Press; 1993.
59.
60.
Doran GT. There’s a S.M.a.R.T. Way to write management’s goals and objectives. Manag Rev. 1981;70 11(AMA Forum):35–6.
61.
62.
Kok G, Gottlieb NH, Peters G-JY, Mullen PD, Parcel GS, Ruiter RAC, et al. A taxonomy of behaviour change methods: an intervention mapping approach. Health Psychol Rev. 2016;10:297–312.CrossRefPubMed
63.
64.
Dalum P, Brandt CL, Skov-Ettrup L, Tolstrup J, Kok G. The systematic development of an internet-based smoking cessation intervention for adults. Health Promot Pract. 2016;17:490–500.CrossRefPubMed
65.
Lin P-H, Intille S, Bennett G, Bosworth HB, Corsino L, Voils C, et al. Adaptive intervention design in mobile health: intervention design and development in the cell phone intervention for you trial. Clin Trials. 2015;12:634–45.CrossRefPubMedPubMedCentral
66.
Yardley L, Williams S, Bradbury K, Garip G, Renouf S, Ware L, et al. Integrating user perspectives into the development of a web-based weight management intervention. Clin Obes. 2012;2:132–41.CrossRefPubMed
67.
Cafazzo JA, Leonard K, Easty AC, Rossos PG, Chan CT. The user-centered approach in the development of a complex hospital-at-home intervention. Stud Health Technol Inform. 2009;143:328–33.PubMed
68.
Schnall R, Rojas M, Bakken S, Brown W, Carballo-Dieguez A, Carry M, et al. A user-centered model for designing consumer mobile health (mHealth) applications (apps). J Biomed Inform. 2016;60:243–51.CrossRefPubMedPubMedCentral
69.
Yardley L, Morrison L, Bradbury K, Muller I. The person-based approach to intervention development: application to digital health-related behavior change interventions. J Med Internet Res. 2015;17:e30.CrossRefPubMedPubMedCentral
70.
Van Velsen L, Wentzel J, Van Gemert-Pijnen JE. Designing eHealth that matters via a multidisciplinary requirements development approach. JMIR Res Protoc. 2013;2:e21.CrossRefPubMedPubMedCentral
71.
Webb J, Foster J, Poulter E, Research WCRFI for C, Parkin DM, Davies NJ, et al. Increasing the frequency of physical activity very brief advice for cancer patients. Development of an intervention using the behaviour change wheel. Public Health. 2016;133:45–56.CrossRefPubMed
72.
Kremers S, Reubsaet A, Martens M, Gerards S, Jonkers R, Candel M, et al. Systematic prevention of overweight and obesity in adults: a qualitative and quantitative literature analysis. Obes Rev. 2010;11:371–9.CrossRefPubMed
73.
Bradbury K, Dennison L, Little P, Yardley L. Using mixed methods to develop and evaluate an online weight management intervention. Br J Health Psychol. 2015;20:45–55.CrossRefPubMed
74.
Sutton S. The contribution of behavioural science to primary care research: development and evaluation of behaviour change interventions. Prim Health Care Res Dev. 2011;12:284–92.CrossRefPubMed
75.
Khaylis A, Yiaslas T, Bergstrom J, Gore-Felton C. A review of efficacious technology-based weight-loss interventions: five key components. Telemed J E Health. 2010;16:931–8.CrossRefPubMedPubMedCentral
76.
Cherrington AL, Willig AL, Agne AA, Fowler MC, Dutton GR, Scarinci IC. Development of a theory-based, peer support intervention to promote weight loss among Latina immigrants. BMC Obes. 2015;2:17.CrossRefPubMedPubMedCentral
77.
Peterson JC, Czajkowski S, Charlson ME, Link AR, Wells MT, Isen AM, et al. Translating basic behavioral and social science research to clinical application: the EVOLVE mixed methods approach. Special Issue: Behavioral Medicine and Clinical Health Psychology. 2013;81:217–30.
78.
Unrod M, Smith M, Spring B, DePue J, Redd W, Winkel G. Randomized controlled trial of a computer-based, tailored intervention to increase smoking cessation counseling by primary care physicians. J Gen Intern Med. 2007;22:478–84.CrossRefPubMedPubMedCentral
79.
Bennett GG, Warner ET, Glasgow RE, Askew S, Goldman J, Ritzwoller DP, et al. Obesity treatment for socioeconomically disadvantaged patients in primary care practice. Arch Intern Med. 2012;172:565–74.CrossRefPubMedPubMedCentral
80.
Wadden TA, Volger S, Sarwer DB, Vetter ML, Tsai AG, Berkowitz RI, et al. A two-year randomized trial of obesity treatment in primary care practice. N Engl J Med. 2011;365:1969–79.CrossRefPubMedPubMedCentral
81.
Appel LJ, Clark JM, Yeh H-C, Wang N-Y, Coughlin JW, Daumit G, et al. Comparative effectiveness of weight-loss interventions in clinical practice. N Engl J Med. 2011;365:1959–68.CrossRefPubMedPubMedCentral
82.
83.
Gray NM, Allan JL, Murchie P, Browne S, Hall S, Hubbard G, et al. Developing a community-based intervention to improve quality of life in people with colorectal cancer: a complex intervention development study. BMJ Open. 2013;3:e002596.CrossRefPubMedPubMedCentral
84.
Iribarren SJ, Beck SL, Pearce PF, Chirico C, Etchevarria M, Rubinstein F. mHealth intervention development to support patients with tuberculosis. J Mob Technol Med. 2014;3:16–27.CrossRefPubMedPubMedCentral
Metadata
Title
Development of a 5As-based technology-assisted weight management intervention for veterans in primary care
Authors
Katrina F. Mateo
Natalie B. Berner
Natalie L. Ricci
Pich Seekaew
Sandeep Sikerwar
Craig Tenner
Joanna Dognin
Scott E. Sherman
Adina Kalet
Melanie Jay
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2018
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-018-2834-2

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