Low-Income African American Women's Perceptions of Primary Care Physician Weight Loss Counseling: A Positive Deviance Study

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Thomas Jefferson University Jefferson Digital Commons Master of Public Health Thesis and Capstone Presentations Jefferson College of Population Health 6-25-2015 Low-Income African American Women's

1 Thomas Jefferson University Jefferson Digital Commons Master of Public Health Thesis and Capstone Presentations Jefferson College of Population Health Low-Income African American Women's Perceptions of Primary Care Physician Weight Loss Counseling: A Positive Deviance Study Elaine Seaton Banerjee, MD Jefferson College of Population Health, Thomas Jefferson University, Elaine.Banerjee@jefferson.edu Let us know how access to this document benefits you Follow this and additional works at: Part of the Community Health and Preventive Medicine Commons Recommended Citation Seaton Banerjee, MD, Elaine, "Low-Income African American Women's Perceptions of Primary Care Physician Weight Loss Counseling: A Positive Deviance Study" (2015). Master of Public Health Thesis and Capstone Presentations. Presentation This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Master of Public Health Thesis and Capstone Presentations by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu.

2 LOW-INCOME AFRICAN AMERICAN WOMEN S PERCEPTIONS OF PRIMARY CARE PHYSICIAN WEIGHT LOSS COUNSELING: A POSITIVE DEVIANCE STUDY Elaine Seaton Banerjee, MD CAPSTONE PRESENTATION 6/25/2015

3 BACKGROUND: OBESITY They both have like hypertension, diabetes, and strokes and stuff, and it comes from them being heavy.

4 BACKGROUND: WEIGHT-LOSS I cut my medications almost nothing. I was on three different types of medications, now I m down to one pill.

5 BACKGROUND: WEIGHT-LOSS 5-10% weight loss improves: Blood sugar and A1c Blood pressure Lipids

6 BACKGROUND: POPULATION High risk of obesity: African Americans Women Low-Income

7 BACKGROUND: POSITIVE DEVIANCE Positive deviants deviate from the norm in a good way Finding behaviors that lead to improved outcomes Population specific

8 BACKGROUND: OBESITY IN PRIMARY CARE Primary care physicians are expected to counsel patients on obesity Appropriate treatment for obesity may depend on patient factors

9 BACKGROUND: POPULATION Studies with African Americans identified the importance of: Physician manner Word choice Type of advice given Recognition Great job increasing your exercise! Obese

10 STUDY DESIGN This capstone is a part of a larger study Focus on medical interactions

11 AIM 1 Identify positive deviants in weight loss in a population of low-income, African-American women

12 AIM 2

13 AIM 2: EMR DATA Predict positive-deviant group membership based on EMR documentation of: Physician counseling regarding weight Having at least one weight-related medical problem Having obesity listed on their problem list

14 AIM 3

15 AIM 3: SURVEY DATA Predict positive-deviant group membership based on participant selfreport of: Having a weight-related medical problem Receiving physician counseling

16 AIM4: QUALITATIVE RESEARCH How do positive deviants characterize their interactions with the healthcare system?

17 METHODS: PARTICIPANTS Inclusion Criteria: years old Female African-American Patients from the Jefferson Family Medicine Associates (JFMA) practice Receive Medicaid Insurance Live within Philadelphia Were ever obese (BMI 30 kg/m 2 )

18 METHODS: PARTICIPANTS

19 Demographics METHODS: MATERIALS EMR VARIABLES Documentation of dietary counseling Documentation of obesity, overweight, or morbid obesity on the problem list Documentation of a weight related medical problem

20 METHOD: PROCEDURE

21 Demographics METHODS: MATERIALS SURVEY VARIABLES Have you ever received advice from a doctor or another health professional to lose weight? Have you ever had a medical problem that is caused or worsened by your weight?

22 METHOD: PROCEDURE

23 METHODS: MATERIALS QUALITATIVE DATA COLLECTION Has a doctor or another health professional ever talked with you about your weight? How did they go about it and what did they tell you? What effect did this have on you? What could have been done better?

24 Data collected and analyzed using SPSS Demographic Differences Predictors of positive deviant group membership Power METHODS: PROCEDURE QUANTITATIVE ANALYSIS EMR: 99% Power for 20% difference with α=0.05 Survey: 57% Power for 20% difference with α=0.1

25 Convened a coding panel Used a modified grounded theory Developed coding framework METHODS: PROCEDURE QUALITATIVE ANALYSIS Coded all 20 interviews Organized and analyzed using nvivo software

26 RESULTS: EMR DESCRIPTION OF POSITIVE DEVIANTS Mean (SD) Amount of Weight Lost (lbs) 42 (19) Percent of Weight Lost 19% (6%) Amount of Weight Regained (lbs) 8 (12) Percent of Weight Maintained 15% (5%)

27 RESULTS: EMR DEMOGRAPHICS Case (N=161) N (%) or Mean (SD) Control (N=602) N (%) or Mean (SD) Sex - Female 161 (100%) 602 (100%) N/A Age 40.1 (11.6) 37.3 (11.8) Race African American 161 (100%) 602 (100%) N/A Maximum Weight (lbs) (43.9) (48.7) Maximum BMI p

28 RESULTS: EMR PREDICTIVE ANALYSIS Predictor of weight loss Odds Ratio r 2 x 2 p Documentation of dietary counseling <0.001 Documentation of a weight-related diagnosis <0.001 Documentation of obesity on problem list

29 RESULTS: EMR ANALYSIS POST-HOC EMR PREDICTIVE ANALYSIS FOR DIETARY COUNSELING Predictor of Dietary Counseling Odds Ratio r 2 x 2 p Documentation of obesity on problem list <0.001

30 RESULTS: SURVEY DEMOGRAPHICS Case (N=35) N (%) or Mean (SD) Contol (N=36) N (%) or Mean (SD) Sex - Female 35 (100%) 36 (100%) N/A Age 44.9 (10.4) 43.0 (11.6) Race African American 35 (100%) 34 (94%) Ethnicity Non-Hispanic 35 (100%) 36 (100%) N/A Maximum Weight (43.9) (48.7) Marital Status Married or Living with Partner 11 (31%) 5 (15%) Education Did not complete High School 12 (34%) 3 (8%) Employment Currently Employed 12 (34%) 24 (67%) Housing Type Own Home 7 (20%) 7 (19%) Length of Time at Current Residence (y) 8.8 (8.4) 9.2 (11.1) Number of People 3.3 (1.5) 4.2 (2.9) Household Income $24,848 ($27,406) $26,613 ($28,394) % Federal Poverty Level 122% (123%) 110% (92%) p

31 RESULTS: SURVEY PREDICTIVE ANALYSIS FOR POSITIVE DEVIANT CASE GROUP MEMBERSHIP Predictor Odds Ratio r 2 x 2 p Participant-reported weight-related diagnosis Participant-reported discussion of weight

32 RESULTS: QUALITATIVE THEME 1 Framing the problem of obesity in the context of other health problems provided motivation.

33 RESULTS: QUALITATIVE when I walked out of his office, I said, You know what? I m just gonna do this because he sayin my blood pressure was really out of control, and the medication that they had me on was really too much.

34 RESULTS: QUALITATIVE THEME 1 If they already knowed that I was overweight at the time, instead of hitting me with the diabetes then they should have been working on my weight loss with me then I would have made a life change earlier, and then, and then, avoid the diabetes, try to.

35 RESULTS: QUALITATIVE THEME 2 Having a discussion around weight management was important.

36 RESULTS: QUALITATIVE I m glad that she showed me a calendar, how to eat portions of food, and what to eat, and stuff. I started eating more vegetables and more fruits, and took all of the cakes and sugars out.

37 RESULTS: QUALITATIVE THEME 2 They could have geared me to the information, instead of just telling me the problem, and sending me on my way. Cause they told me, You got an atomic bomb here. Now you go figure it out.

38 RESULTS: QUALITATIVE THEME 3 An ongoing conversation and relationship was helpful.

39 RESULTS: QUALITATIVE SUBTHEME 3A Celebrating small successes was helpful in ongoing motivation.

40 RESULTS: QUALITATIVE It s more encouraging when you have a doctor tellin you you re doing good, keep up the good work.

41 RESULTS: QUALITATIVE THEME 4 Advice is helpful but only up to a point. Participants reported that they must be ready to make a change in order for advice and information to be helpful.

42 RESULTS: QUALITATIVE You know, I had to really want to do it for myself And, and, in order to stick to it as well.

43 DISCUSSION: COMPARISON Our results are similar to those of previous studies: Wanted their physician to raise the topic of obesity. Discussed the importance of specific advice for how to lose weight and referrals to programs Discussed the importance of a caring and ongoing relationship with their PCP Discussed the importance of recognition of small successes.

44 DISCUSSION: STRENGTHS Positive deviance approach High risk population Traditional methods are not working Solutions are accessible to population Mixed methods study

45 DISCUSSION: LIMITATIONS Limited Population Small N Generalizability Use of the EMR

46 DISCUSSION: FUTURE DIRECTIONS Qualitative evaluation with controls Testing the hypotheses generated by the qualitative evaluation

47 DISCUSSION: CONCLUSION Positive Deviants exist and are beating the odds

48 DISCUSSION: CONCLUSION Physician counseling is predictive of successful weight loss Patients want: More physician counseling More specific guidance or referrals

49 DISCUSSION: CONCLUSION Having a weight related diagnosis was predictive of weight loss Framing obesity in the context of diagnoses was motivating Physicians must draw connections between weight and health problems

50 CONCLUSION Once I started reading about it and it was like this wake-up call, you know. You have to do what you gotta do, before you don t be here.

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52 QUESTIONS & COMMENTS

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