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Thursday 8 May 2008

Management of obesity in primary care: nurses' practices, beliefs and attitudes

Journal of Advanced Nursing
Management of obesity in primary care: nurses' practices, beliefs and attitudes
ISSN: 0309-2402
Accession: 00004471-200708040-00002
Author(s):

Brown, Ian; Stride, Chris; Psarou, Aikaterini; Brewins, Louise; Thompson, Joanne

Issue:
Volume 59(4), August 2007, p 329–341
Publication Type:
[RESEARCH PAPER: Original Research]
Publisher:
Copyright © 2007 Blackwell Publishing Ltd.
Institution(s):
Ian Brown BSc PhD RN SCPHN Senior Lecturer Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
Chris Stride BSc PhD Statistician Institute of Work Psychology, University of Sheffield, Sheffield, UK
Aikaterini Psarou BSc Community Dietician Sheffield Primary Care Trust, Sheffield, UK
Louise Brewins BA MA Deputy Director Public Health Sheffield West Primary Care Trust, Sheffield, UK
Joanne Thompson BA MSc Research Fellow Institute of General Practice, University of Sheffield, Sheffield, UK
Correspondence to Ian Brown: e-mail: ian.brown@shu.ac.uk
Accepted for publication 12 February 2007
Keywords: attitudes, empirical research report, nursing, obesity, primary health care, survey
Abstract

Title: Management of obesity in primary care: nurses' practices, beliefs and attitudes

Aim: This paper is a report of a study to investigate patterns of clinical practice, beliefs and attitudes of primary care nurses with respect to obesity management.

Background: Nurses in primary care potentially play a key role in managing obesity, which has become a priority issue. There have been few studies of either the extent of clinical practice of nurses, or their attitudes and beliefs in this setting.

Methods: A correlational survey design was employed. Structured questionnaires were posted to 564 nurses and health visitors in primary care organizations in England. The response rate was 72·3%. The survey was conducted in April and May 2006.

Findings: Very few respondents reported training in obesity management, and most did not believe that organizational support was in place. Only practice nurses reported substantial clinical activity in obesity management, accounting for almost 5% of their contracted hours. This activity, comprised of assessment, lifestyle change support and referral, occurred in one-to-one consultations. Other nurses and health visitors reported much less activity, although they believed obesity to be an important health issue and its management an appropriate part of their role. Whilst outright negative stereotypes were rare, there were nevertheless a range of potentially negative beliefs and attitudes relating to obesity and obese patients. These views were related to the respondent's own body mass index but not to gender, age, experience and occupation.

Conclusion: Training and organizational support for obesity management are required by primary care nurses. Training should also address beliefs and attitudes about obesity and obese persons.



Introduction

Obesity is a condition of excess body fat associated with increased risks of diabetes, cardiovascular and other common diseases (Campbell & Haslam 2005). Its prevalence has increased over a short period in many parts of the world (WHO 2000), with obesity prevention and management becoming leading public health issues (Kumanyika et al. 2002). Among a range of responses, attention has focused on how to develop health services for the increasing numbers of patients who are already obese and need support in managing their weight (US Department of Health and Human Services 2001, Australian Institute of Health and Welfare 2004, Wanless 2004). Evidence-based guidelines in several countries recommend various interventions, including those that help patients with changes to lifestyle (SIGN 1996, NHS Centre for Reviews and Dissemination 1997, National Heart Lung and Blood Institute 1998). It is in this area that nurses are seen to have a key role, particularly those nurses working in primary care (Chambers & Wakley 2002, National Obesity Forum 2004).

Internationally, the contexts and roles for nurses undertaking lifestyle interventions vary considerably (McGee 2003). However, international health policy encourages the development of generalist first-level nurses in primary care for health promotion and support of patients with long-term conditions (Salvage & Heijinen 1997, World Health Organization 2000, 2005). The United Kingdom (UK) has a well-developed system of primary care nursing within which the issue of obesity has been increasingly prioritized over the last two decades (Department of Health 1992, HM Government 2004). It is estimated that a fifth of adults in the UK are obese (Zaninotto et al. 2006), and hence it provides a useful setting for research into the development of nursing practice in tackling obesity.

Background

In the UK there are three types of nurse who work in primary care in a generalist role with an adult client group (Sines et al. 2005). District or community nurses usually work with an older population requiring care at home. Typically, a district nursing team comprises a range of grades of nursing staff led by a sister or charge nurse with specialist community training. Practice nurses have a prevention and disease management role within the general practice (family practice) setting. Finally, health visitors (public health nurses) tend to focus on families with children in a primary prevention role. These are broad generalizations and it should be noted that there is increasing blurring of boundaries between nursing occupations. All three types of nurse have a health promotion role with adults.

Since the early 1990s health policy in the UK has identified obesity prevention and management as priorities for primary care nursing development (Department of Health 1992), and a number of developments in primary care and particularly practice nursing can be traced to this time (Saunders & Selvey 2005). Public health policy later focused on disease prevention, with obesity identified among priorities for management of cardiovascular diseases (Department of Health 2000). Around the same time, evidence-based guidelines were published for obesity management (SIGN 1996, NHS Centre for Reviews and Dissemination 1997). The latest public health policy explicitly discusses obesity, and any nurse working in primary care in the UK would recognize this as a current priority (HM Government 2004). However, concerns about the resources to tackle obesity in primary care have been raised (dr foster 2003, 2005).

The empirical research on nursing practice, attitudes and beliefs in relation to obesity management in primary care is limited, and is almost entirely focused on practice nurses in the UK, with only two studies outside the UK identified. First, a very small study of 17 nurses in Texas, USA, described a range of assessment and intervention activities that were undertaken, including body mass index (BMI) and waist measurement, and dietary and physical activity advice (Timmerman et al. 2000). Second, a clinical trial by Ashley et al. (2001) indicated that nurses had a role in providing support and advice in consultations lasting about 20 minutes.

In the UK, studies by Kyle (1993), Cadman and Wiles (1996) and Green et al. (2000) were very small in scale. They focused mainly on practice nurses' knowledge about nutrition, not only finding an improving general knowledge base in this group but also a lack of specific knowledge about obesity management. A larger survey by Hankey et al. (2003) suggested that this general knowledge base had improved further but was again weaker in relation to obesity.

Hoppe and Ogden (1997) argue that it is more useful to focus on measuring actual practices and beliefs than knowledge. In their large survey in England they found that most practice nurses typically provided general nutrition advice to obese patients within 10-minute consultations. More specific obesity management activities, such as advice about restricted calorie diets, were less common. A very similar picture was found in the large surveys by the National Audit Office (2001) and the Counterweight Project Team (2004) that also focused just on practice nurses; these clarified the range of referral options for practice nurses and suggested that practice was somewhat underdeveloped in terms of evidence-based protocols and audit.

These latter surveys did not examine nurses' beliefs and attitudes in relation to obesity yet this is an important issue for developing nursing practice, given the evidence of both negative attitudes towards obese patients (Brown 2006), and effects on patients' health care experiences and quality of life (Brown et al. 2006). Again, there has been very little research about primary care nurses; a small qualitative study by Mercer and Tessier (2001) indicated that practice nurses felt ambivalent about this area of work, expressing some frustrations at perceived poor outcomes and lack of patient motivation. Hoppe and Ogden (1997) found that practice nurses believed that obesity was preventable, was caused by lifestyle factors, and that obese patients lacked motivation. In addition, they identified that the nurses' own BMI had an effect on their attitudes towards obesity management.

Whilst this previous research is helpful, it has limitations and further study is justified. Hoppe and Ogden's (1997) study is particularly useful but it is now well over a decade since their data were collected. Like almost all the others, they focused only on practice nurses; it would be useful to compare the more recent activity of all primary care nurses. Furthermore, most other studies have aimed only to describe the extent of practice using nominal or ordinal level measurement tools. Whilst such single item measures are important, it would be useful to refine data collection tools for this area of clinical practice and to examine the relationships with attitudes and beliefs. Finally, none of the previous studies explicitly drew upon patients' perspectives of the relative importance of particular attitudes. It would be useful to involve patients with experience of obesity management in the research process, specifically including their input to the design of data collection tools.

The study
Aim

The aim of the study was to investigate the patterns of clinical practice, beliefs and attitudes of primary care nurses with respect to obesity management.

Design

A correlational survey design was adopted, using a self-completion postal questionnaire.

Participants

The survey took place in April and May 2006 within four neighbouring primary care trusts (PCTs) in the north of England selected for their typicality with respect to initiatives to tackle obesity and levels of obesity. The four PCTs were typical in that no additional special initiatives to tackle obesity were present (dr foster 2005) and levels of adult obesity matched the national picture very closely. A survey 3 years earlier had estimated that 60,000 adults (20% of the population) were obese within the four PCTs (Price & Skinner 2003).

All nurses and health visitors working within the four PCTs were included in the study. The sample comprised of all grades and specialists employed in primary care settings as well as a small proportion of unqualified staff within nursing teams whose role involved face-to-face care of patients or clients. In all, 564 staff were surveyed; 298 district nursing team staff (52·8%), 119 health visitors (21·1%), and 147 practice nurses (26·1%).

Questionnaire

We designed a short questionnaire drawing on both previous research of nurses' practice and attitudes in relation to obesity and its management, and on qualitative studies of patients' experiences of obesity and health services (Brown et al. 2006). We also benefited from the input of two advisory groups: one comprised of nurses and health visitors; the other made up of 10 people with experience of obesity as patients. These groups met several times over 2 months. The patient group provided useful input to the range of attitudes covered in the survey, particularly issues of empathy and motivation.

The questionnaire was tested with nurses and health visitors and a number of minor amendments made to the wording and order of questions. A pilot study with a sample of 32 nurses also enabled power calculations. Our primary consideration was to ensure an adequate sample for exploratory factor analyses; we concluded that a sample of 300 cases would be adequate and estimated that this would also give us a power of >90% of detecting medium effect sizes in our key areas of investigation. A follow-up of participants in the testing and pilot study phases did not indicate any obvious reliability problems with the questionnaire.

The questionnaire comprised a number of sections asking about:

* age, gender, height and weight, academic and professional qualifications, occupational group, contract hours, and experience (years since qualification)
* clinical practice activities of assessment, advice, support, and referral
* beliefs about causes and consequences of obesity
* attitudes to obese patients or clients
* views on obesity-related practice development, organizational support and training

To measure clinical practice, respondents were asked to indicate whether they had ever undertaken each of seven obesity management activities within their current post, and whether these activities were undertaken in a typical week. They were also asked about the number of individuals they had assessed and supported with weight management in the previous 4 weeks and the time spent on this. Referral activity was measured by asking whether any individuals had been referred to each of a range of different options. Tables 1 and 2 list the specific activities and referral options. The overall level of clinical activity was measured by a formative index, derived by summing the number of positive responses to ‘typical week’ activities (positively skewed, with median = 1, IQR = 3). As this was not a reflective scale, exploratory factor analysis and reliability analysis were not appropriate (Bollen & Lennox 1991).


Graphic
Table 2 Referral activities

Graphic
Table 1 Clinical practice activities

The questions (items) used to measure beliefs, attitudes and views asked for responses to a number of statements. These are given in Tables 3 and 4, with their sectioning and the 5-point Likert scale used for responses.


Graphic
Table 4 Beliefs about practice and organizational support

Graphic
Table 3 Beliefs and attitudes about obesity

Exploratory factor analyses (using Principal Axis Factoring) were used to identify subsets of items that could appropriately be combined into scales representing a smaller number of underlying concepts. Both the standard criteria of extracting factors until the next eigenvalue was less than 1, and the alternative using a scree plot indicated a 5-factor solution was most appropriate, accounting for 52% of variance. An oblique rotation gave the clearest solution; after discarding several items that did not load heavily on any single factor, the best grouping was as shown in Table 5, with the factors interpretable as Personal effectiveness, Importance of obesity, External causes, Negative views and Organizational support. The factor correlation matrix showed a small to medium correlation (r = 0·20) between Personal effectiveness and Organizational support. Internal consistency (Cronbach's [alpha]) was calculated for each of these potential scales (Table 5); although for two of these it was weak, they were judged to be adequate for the purposes of exploratory study. For each scale, mean scores were calculated across the items; all were approximately Normally distributed, with a potential minimum score of 1 and maximum score of 5.


Graphic
Table 5 Scale construction
Ethical considerations

The study was approved by an NHS Local Research Ethics Committee and the research governance leads at each PCT. Return of a completed questionnaire was taken as consent to participate.

Data analysis

First, we examined the basic sample properties in terms of demographic and occupational characteristics. Second, we evaluated the extent of practice activity, reporting the levels of individual practices and referrals, using appropriate non-parametric analyses to examine the zero-order relationships with potential demographic and background variables, followed by a generalized linear model analysis to investigate whether the index of total activity was related to occupation having controlled for possible identified confounding factors. Lastly, we looked into the beliefs and attitudes measures, initially reporting the scores on the individual items. For a more detailed analysis of the mean scores representing beliefs and attitudes scales, we examined their zero-order inter-correlations, before using a series of multiple regression analyses to assess the effect on them of a respondent's occupation, training and own BMI whilst controlling for potentially confounding demographic and background variables.

Results
Response and sample description

Of 564 questionnaires posted, 544 were actually delivered and, following two reminders, 398 were returned completed within 8 weeks, giving a high response rate of 72·3%. There was no indication of response bias in relation to occupational and demographic characteristics (gender, occupation, PCT).

The largest occupational group was district nurses (44·2% of the sample), followed by practice nurses (25·4%) and health visitors (21·6%). The remaining 8·8% of respondents were nursing assistants, almost all of these working within district nurse teams. Registered Nurses had been qualified for a mean of 22·8 years (SD = 9·7 years) indicating an experienced workforce. Three-quarters had completed some form of higher education. The average number of contracted hours each week within the sample was 29·0 hours (SD = 7·8 hours). Only a small minority (8·7%) reported any training or updates about obesity in the previous 5 years.

Almost all (96%) respondents were female. The mean age of the sample was 46 years (SD = 8·5 years). The mean BMI of respondents was 25·5 kg/m2 (SD = 4·8 kg/m2); with 14·1% of the sample ‘obese’ (BMI greater than 30 kg/m2) and a further 28·6% ‘overweight’ (BMI 25–30 kg/m2). A further 56·2% were a ‘normal’ weight (BMI 18·5–25 kg/m2); only 1·1% would be classified as ‘underweight’ (BMI <18·5 class="fulltext-SP">2).

Clinical practice activities

The reported levels of different clinical activities are summarized in Table 1, with Figure 1 illustrating the principal differences between occupations. Giving general advice was seen by majorities of all occupations as part of their role and many undertook this within a typical week, but more specific obesity management activities were largely confined to practice nurses.


Graphic
Figure 1 Example activities to illustrate patterns of practice.

Overall, 2138 individuals had been assessed or supported by the respondents through consultations with a median length of 13 minutes (IQR = 10 minutes). Most (1759 individuals, 82·3%) were seen by practice nurses; far fewer were seen by district nurses (268 individuals) and health visitors (111). As expected, the proportion of contracted hours spent on obesity management was statistically significantly greater for practice nurses than other occupations, although still relatively small (PN = 4·45% of time; DN = 0·35% and HV = 0·43% of time; Chi-square = 163·8, d.f. = 2, P <>

A substantial majority of referrals were undertaken by practice nurses (Table 2); for example, despite only accounting for a quarter of respondents, practice nurses made 79·2% of the referrals to dieticians and 87·0% of those to the local exercise prescription scheme.

Only nine respondents (2·3%) had ever provided input to a group intervention for obesity management, only two providing input to such groups in the preceding 4 weeks.

Zero-order relationships between the index of ‘typical week’ activity and the demographic and background variables were assessed using a series of non-parametric tests. Respondents were statistically significantly more likely to undertake a higher level of activity if they were a qualified nurse (Mann–Whitney U-test: Z = -4·08, P < class="fulltext-SP">2 = 15·36, d.f. = 5, P = 0·009); and had undertaken specific training with reference to obesity-related work (Mann–Whitney U-test: Z = -4·80, P < class="fulltext-IT">P = 0·012), but no significant relationship with either gender or a respondent's own BMI.

Finally, given the skewed nature of the distribution and discrete form of our index of clinical activity, a generalized linear model with a log link function and Poisson distribution was used to model its relationship with occupation, controlling for potentially confounding variables identified in the previous analyses. Occupation was found to have a very strong effect; when added the improvement in model fit was highly statistically significant ([chi]2 = 308 on 2 d.f., P <>

Beliefs, attitudes and perceptions

Responses to individual belief and attitude items are shown in Tables 3 and 4. Table 3 shows that respondents strongly believed that obesity is a serious issue for health and most agreed with statements about the cancer and cardiovascular disease risks. A large majority (88%) either disagree or strongly disagreed that the importance of obesity is now being overstated. A majority (58·5%) agreed that most health problems for an obese person are due to obesity.

Regarding beliefs about causes, very few respondents agree with either the idea that there is a specific medical cause (4·6%); or that environmental factors account for obesity (8·7%); however, a majority (57·4%) agreed that family history is important. Respondents were generally neutral about hormonal changes as cause of obesity in middle age. On the other hand, a majority agreed (68·9%) with the statement about personal choices about food and physical activity as a cause of obesity. There was also a slight tendency towards beliefs about lack of will power around food as a cause: overall 34·7% agreed with this statement whilst only 25·4% disagreed.

Table 3 also shows the responses to questions about attitudes to obese patients or clients. Very few respondents (8·2%) appeared to agree that patients are motivated to change; and approaching half (45·2%) disagreed that they are motivated. However, about half disagreed (51·9%) that obesity is due to lack of personal control. A majority also disagreed (60·7%) that obese patients are more lazy than other patients. On the positive side, very few agreed to feeling disgust (4·3%) and about half agreed with statements that this is rewarding work and to feeling empathy with obese clients.

Table 4 indicates that most respondents saw weight management as part of their role (82·2% disagreed with the statement that it is not their business) and as an important area for developing services (89·1% agree). Most did not find it an awkward or sensitive issue to discuss with patients. However, only 21·6% agreed that they felt effective in this work. Respondents generally did not feel there was well-developed organizational support.

Examining the mean scores of the scales indicates that our sample: leant slightly towards a positive rating of their Personal effectiveness (mean = 3·30, SD = 0·69); rated the Importance of obesity highly (mean = 4·04, SD = 0·47); tended not to agree that External causes are relevant (mean = 2·53, SD = 0·50); leant slightly towards less Negative views about obesity (mean = 2·89, SD = 0·47); and tended to perceive low levels of Organizational support (mean = 2·53, SD = 0·75).

The zero-order correlations between the beliefs and attitudes scale mean scores and other variables are given in Table 6. Personal effectiveness was positively related to Organizational support (Pearson r = 0·26, P < class="fulltext-IT">External causes was negatively related to Importance of obesity (Pearson r = -0·20, P <>
Graphic
Table 6 Summary statistics and correlations between main variables


We examined whether respondent occupation, previous training in obesity management, or own BMI (in kg/m2) affected any beliefs and attitudes, whilst controlling for any potentially confounding demographic and background variables. [The relationship with the index of clinical activity was not examined in these analyses due its extremely strong correlation with being a practice nurse (r > 0·8), invoking multicollinearity.] The zero-order correlations with potential background variables (Table 6) indicate that: educational qualifications had a small effect on each of the beliefs and attitudes; professional qualifications were statistically significantly associated with all but Negative views; and age, experience and gender were related to personal effectiveness.

Separate multiple regression analyses were used for each of the beliefs and attitudes scales; we chose to control for the same background factors in each analyses for comparability purposes (specifically age, gender, educational qualifications and whether the respondent was a qualified nurse), although not all of these factors had a direct effect on each scale.

Nursing qualifications had a statistically significant negative relationship with External causes and a significant positive one with Personal effectiveness and Importance of obesity. Otherwise, the only statistically significant background effects were those of age (positive) and gender (men perceived lower levels) on Personal effectiveness. Occupation was related to both Personal effectiveness and Importance of obesity: practice nurses perceived higher levels of the former compared with health visitors and district nurses, and both practice nurses and health visitors perceived higher levels of the latter compared with district nurses. Training was positively related to both perceptions of Personal effectiveness and Organization support. Finally, own BMI was statistically significantly related to views about obesity; nurses with higher BMI being less likely to have a negative perception of obesity. The final models for each outcome are summarized in Table 7.


Graphic
Table 7 Relationships between beliefs and attitudes scales and demographic and background factors
Discussion

The data collection tools reported here were successful in distinguishing types and levels of practice, attitudes and beliefs, and a good response rate was achieved with these tools. The content validity of the questionnaire was good with respect to patients' concerns and nursing practice because of the careful involvement of patients and clinicians in questionnaire design. However, two of the attitudinal scales should be treated with caution because of low internal reliability. Furthermore, although a case for the typicality of the setting has been made, this was not a nationally representative sample.

Clinical practice and roles of nurses

Our findings show that, whilst most primary care nurses may feel they can and should give general advice about obesity, it is only really practice nurses who have developed an extensive role in obesity management. This is not a surprise, given that various contractual changes have encouraged general practice nurses into a health promotion role in relation to management of long-term conditions (Health Departments of Great Britain 1989, NHS Confederation 2003). Other studies clearly show this group of nurses extending their role and knowledge base in relation to obesity management (Hankey et al. 2003, Counterweight Project Team 2004).

There has not been the same level of development in this respect for district nurses and health visitors and much less is known of their obesity practice activity – a gap which our study addresses. In some respects these two occupations stand at a similar point to that of practice nurses a decade ago. Kyle (1993) and Cadman and Wiles (1996) found that clinical practice at that time involved very general lifestyle advice rather than more specific obesity management. However, this kind of ‘general advice’ approach is not really evidence-based (Mulvihill & Quigley 2003).

Our findings indicate a lower level of group work than that found in the National Audit Office (2001) and Counterweight Project Team (2004) national surveys. This may reflect a bias in the two larger studies towards more active areas and active respondents.

Among clinical activities, waist circumference was rarely measured in comparison with BMI, although some clinicians advocate this as a more appropriate measure for identifying those at greater health risks through central obesity (Lean et al. 1998, Little & Byrne 2001).

The resources being put into obesity management by primary care nurses in the four PCTs can be estimated. Within an area with about 60,000 obese adults, there were about 2700 (4·5%) individuals being assessed and supported within any 4 weeks by primary care (mainly practice) nurses. This indicates the level of activity and also the scale of the problem (dr foster 2005).

Attitudes and beliefs

There is little recent literature about primary care nurses' attitudes with respect to obesity; hence our study also makes a useful contribution here. Public health policy-makers should be encouraged that an overwhelming majority of nurses think obesity an important health issue and see supporting patients with weight management as part of their role. On the other hand, very few appear to have had specific training and most do not perceive organizational support to be in place. Also, there may be potential problems in nurses overstating the importance of obesity for health. Some patients may be put off accessing health services if they believe that every problem is being attributed to obesity (Drury & Louis 2002, Brown et al. 2006).

Beliefs about causes of obesity are important because of the effects they can have on opinions about individual responsibility and hence on attitudes to obese clients (Puhl & Brownell 2003). We investigated perceptions of causes and individual responsibility, the mixed picture found being consistent with previous research (Brown 2006). As other studies of healthcare professionals have found, nurses lean towards obesity being an issue of lifestyle choice and personal responsibility (Hoppe & Ogden 1997, Epstein & Ogden 2005). However, whilst medical causes are set aside, nurses do go along with family history as an important cause.

It is likely that nurses' beliefs differ from those of patients. A number of studies indicate that patients may put more emphasis on factors that are outside personal control (Ogden et al. 2001, Brown et al. 2006). This may be a facet of the stigma associated with obesity (Puhl & Brownell 2003). Another potential difference is in perceptions of comfort when discussing obesity. Brown et al. (2006) showed that patients perceive that healthcare professionals are awkward about discussing obesity.

Only very small proportions of our respondents agreed with the more negative stereotypical statements about obese patients. This is encouraging, although the limitations of a ‘halo effect’ should be borne in mind. Other studies of nurses have shown somewhat larger proportions agreeing with such negative stereotypes; Bagley et al. (1989), Maroney and Golub (1992), Garner and Nicol (1998) and Culbertson and Smolen (1999) suggested that around a fifth of respondents agreed with negative statements about obese patients. However, these studies were undertaken in North America some years ago among hospital-based staff without a direct role in supporting patients with lifestyle change.

If outright negative stereotypes were unusual, there was nevertheless a spread of attitudes in the scale of Negative views about obesity. This, coupled with the finding that most nurses do not believe patients are motivated to change, gives cause for concern. The measure was made up of concern about health consequences, disgust, stereotypes about laziness, weaker will power and personality, and beliefs about causes being a matter of personal responsibility. This is a mix consistent with other work in a variety of contexts examining attitudes to obesity in Western societies and among healthcare professionals (Crandall 1994, Puhl & Brownell 2003, Brown 2006). Our findings showed these negative attitudes were only related to respondents' own BMI, but not to clinical practice experience, occupational group, age or gender, suggesting that personal experience of obesity softens negative attitudes.

Conclusion

In the UK, a number of policy and service development initiatives are under way (Department of Health 2006) to coincide with new guidance on obesity management from the National Institute for Health and Clinical Excellence (2006). Our findings indicate that considerable development and training will be needed if effective programmes are to be put in place. Training also needs to address beliefs and attitudes among all nurses; there is a danger of overstating the health risks of obesity (Monaghan 2005). It is necessary to challenge beliefs about personal responsibility and perceptions of poor motivation (Kolotkin et al. 2001); evidence suggests tackling beliefs about causes (Weise et al. 1992) and improving empathy for and appreciation of the experience of obesity (Lewis et al. 1997, Teachman et al. 2003).

Finally, further research would be useful to clarify nurses' attitudes and to refine methods of brief and reliable measurement enabling evaluation as obesity management policies are implemented.

It can be concluded that obesity management is an area where training and development are still required by primary care nurses. This is a pressing matter in the face of a rising level of obesity in many parts of the world.

Author contributions

IB and CS were responsible for the study conception and design and IB was responsible the drafting of the manuscript. IB, CS, AP, LB, JT performed the data collection and IB, CS and AP performed the data analysis. IB obtained funding and AP, LB and JT provided administrative support. IB, CS, AP, LB and JT made critical revisions to the paper. CS provided statistical expertise.

Acknowledgements

We are very grateful for the input at every stage of the project of two lay representatives: Annette Setterfield and Margaret Fisher. We thank the patient and clinician advisory groups for their input to questionnaire design. The study was funded by a NHS Health and Social Research Consortium grant.

What is already known about this topic
* Concerns about obesity are apparent in many countries and its management is an international public health priority.
* Primary care nurses have a role in providing lifestyle interventions for obesity management.
* Little is known about the clinical practice activities, beliefs and attitudes of primary care nurses with regard to obesity.
What this paper adds
* General practice nurses in England undertake a range of obesity management clinical activities with adults.
* Health visitors and district nurses, the other principal branches of primary care nursing in England, undertake very little obesity management work.
* The training beliefs and attitudes of nurses with respect to obesity and obese patients give rise to some concerns.
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Keywords: attitudes; empirical research report; nursing; obesity; primary health care; survey



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