Structure and theoretical underpinnings for the development of a general practitioner delivered weight management program
4. IMPLEMENTATION
NHMRC Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia (2013)
National Heart Foundation’s Physical activity and energy balance (2007)
RACGP’s Guidelines for preventive activities in general practice (‘Redbook’) (2012)
RACGP’s National guide to a preventive health assessment for Aboriginal and Torres Strait Islander People (2012)
RACGP and Diabetes Australia’s General practice management of type 2 diabetes – 2014– 15
RACGP – Royal Australian College of General Practitioners; NHRMC - National Health and Medical Research Council
In developing the intervention, we used theory to guide knowledge translation, as well as theory related to behaviour change.
Knowledge to Action framework
The Knowledge to Action (KTA) framework was developed to improve the translation of evidence into best clinical practice.7 The framework was developed in Canada in 2006 and was informed by
31 planned action theories from interdisciplinary and nursing fields.8 The framework is not
intended to be a “recipe” for knowledge translation, but as a guide with suggestions for improving implementation practice. As shown in Figure 2, the framework has a central Knowledge Creation funnel, surrounded by a cyclical Action Cycle.7 Each part of the framework can be used iteratively,
informed by feedback from the participants as the cycle continues. The KTA framework was used to guide the intervention development study that is reported in Chapter 4.
Figure 2 - Knowledge To Action diagram. This diagram depicts the phases of the KTA framework with
components of the “ActionCycle” in rectangles surrounding the “KnowledgeCreation” funnel in a triangle.
Adapted from Graham, I.D., et al.7
5As for behaviour change
The “5As” of behaviour change is a mid-level theory that is based on the transtheoretical model of behaviour change.9 The original theory from Prochaska and Diclemente describes the different
stages of motivation that individuals can pass through when thinking about behaviour change and it has been applied extensively to health behaviours like smoking.9 Using the Transtheoretical
model, the 5As was developed by the United States Preventative Task Force Agency as a framework for practitioners to work with patients on smoking cessation.10 It is presented as a
stepwise process from Ask, Assess, Advise, Assist/Agree, Arrange, with some differences in the verbs that are applied in Australia and North America.
The 5As model has been applied to obesity management and is used extensively to both develop models of care, and to evaluate consultations in the primary care setting.11-13 The 5As was used to
inform the development of the weight intervention as described in Chapter 4. It was also used to evaluate the GPs’ experiences of using the weight management program in a quantitative survey with results described in Chapter 6. A possible adaptation of the 5As for behaviour change is
care, and the therapeutic alliance between a family doctor and patient.
2. Assessing feasibility
The acceptability and feasibility of the weight management program were explored in a mixed methods feasibility study. This is described in detail in Chapter 5.
The MRC guideline for complex intervention development2 encourage the consideration of how
and why change occurs in the intervention. Using a theoretically informed approach, this doctoral work considered a number of processes that influenced whether the weight management
program was effective for patients in the feasibility trial. Normalisation Process Theory
Normalisation Process Theory (NPT) is a mid-level theory that was developed by a sociologist working with an interdisciplinary team in the UK.14 NPT is based on the premise that a successful
intervention is one that can be implemented and embedded into everyday practice.14 The four
components described by NPT for successful implementation are:
1. Coherence – the ability of the individual practitioner to understand the new way of working. It is composed of four different subsections: differentiation, communal specification, individual specification, internalisation.
2. Cognitive Participation – the way the individual practitioner integrates the new practice into their everyday work for sustainability. The subsections here are: initiation, enrolment, legitimation, activation.
3. Collective Action – the way the individual practitioner operationalises the new way of working, and in particular, the processes that they use. The subsections here are: interactional
workability, relational integration, skill set workability, contextual integration.
4. Reflexive monitoring – the way the individual practitioner understands the new work’s impact on themselves and those around them. The subsections here are: systematisation, communal appraisal, individual appraisal, reconfiguration.14
NPT is used in Chapter 5 as a tool for assessing the implementation of a new weight management program in a feasibility study in Australian general practice.
Therapeutic alliance
In 1979 the contemporary psychologist Bordin published his seminal paper on what he termed the “working alliance”.15 According to this theory, there are three components of the therapeutic
alliance, that is:
1. Bond – the warm and respectful partnership between a practitioner and client; 2. Goals – the ability of the dyad to collaborate on goal setting; and,
3. Tasks – the mutual understanding of what needs to occur to reach the goals.15
Each of these three factors has to be strong for a good working alliance. Bordin’s paper highlighted the alliance between a psychologist and their client, but he also described the alliance as essential to any helping relationship, be it a “student and teacher, between community action group and leader, and, with only slight extension, between child and parent”.15Bordin’s theory was used to
develop a tool to measure the working alliance in psychological practice – the Working Alliance Inventory.16 In Chapter 8, Bordin’s conceptualisation of the therapeutic alliance is applied to the
feasibility study using the Working Alliance Inventory.
Self-efficacy theory
Self-efficacy was described by Bandura to be “anindividual’s belief in his or her capacity to
execute behaviours necessary to produce specific performance attainments”.17 It forms part of his
overarching Social Cognitive Theory which seeks to describe the factors that influence a person’s motivation and behaviours.18 In Bandura’s theory, a person’s self-efficacy is shaped by four
factors:
1. Vicarious experiences – if an individual sees someone that they feel they can relate to performing a task well, this influences their self-efficacy in a positive way;
2. Physiological feedback – an individual’s bodily reaction to a situation can influence their self-efficacy. For example, the bodily experience of adrenaline release from the
autonomous nervous system includes heart palpitations and feeling sweaty, and this experience can have a negative impact on sense of self-efficacy for the task they were undertaking at the time;
3. Verbal persuasion – when a person is verbally encouraged in their performance of a task, this can have a positive effect on their self-efficacy;
outcome they were aiming for, this has a positive impact on their self-efficacy.
Performance mastery is the most influential factor in a person’s self-efficacy for a task.17
Bandura’s self-efficacy theory is frequently applied to situations where a patient is trying to change their lifestyle or health related behaviours. In Chapter 6 we describe how this theory helped to inform the analysis of GP self-efficacy in relation to obesity management in primary care.
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