Health Education Research, Vol. 17, No. 1, 19-26,
February 2002
© 2002 Oxford University Press
Factors that enable and inhibit transition from a weight management program: a qualitative study
School of Nursing, Family and Community Health (Building G10), College of Social and Health Sciences, University of Western Sydney, Hawkesbury Campus, Richmond, NSW 2753, Australia
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Abstract |
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 Top Abstract IntroductionMethodFindingsDiscussion and implicationsRecommendationsReferences |
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Failure of clients to initiate closure and move out of weight management programs after it is considered they should have reached the stage of maintenance in their health behavior change has implications for clients' self-management, provision of health promotion programs and their cost-effectiveness. This study aims to identify factors that enable and inhibit class attendees' transition from a weight management program. Six short-term attendees who had left the program after two terms and six long-term attendees who had attended four or more terms of the program volunteered to participate in in-depth interviews. Enabling factors were identified to be program knowledge and attainment of set goal weight, and inhibiting factors were the perceived need to come to classes, concern about keeping in control, recognition of the potential to lapse and being involved with a group. Recommendations are made for the program to include a component addressing relapse prevention training and to trial some form of follow-up support strategy. Additionally, further research is needed into transition from weight management programs.
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Introduction |
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TopAbstractIntroductionMethodFindingsDiscussion and implicationsRecommendationsReferences |
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Failure of clients to initiate closure and move out of weight management programs after it is considered they should have reached the stage of maintenance in their health behavior change has implications for clients' self-management, provision of health promotion programs and their cost-effectiveness. This study focuses on long- and short-term attendees' transition from weight management programs.
Obesity
Overweight and obesity are recognized as major health problems in Australia with almost one in five adults being obese (Australian Bureau of Statistics and Commonwealth Department of Health and Family Services, 1997
). The obese have an increased disposition to conditions such as coronary heart disease, hypercholesterolemia, hypertension, diabetes, cholethiasis, degenerative joint disease, social and psychological problems (Health Education Authority, 1995), and obstructive sleep apnea (Rossner et al., 1991). However, obese people can achieve substantial health benefits with modest weight loss (Goldstein, 1992). Hence, health programs in communities that aim to enable people to achieve and maintain weight losses are essential for health gain.
Community programs for obesity
A recent study in Australia showed the majority of adults in a rural community do believe weight loss is possible and worthwhile attempting. Most of the men and women who were surveyed held the view that weight was under their personal control (Crawford and Campbell, 1998). This finding is consistent with studies in other countries (O'Connell and Velicer, 1988; Stotland and Zuroff, 1990).
Behavioral, diet and exercise programs have been found to be effective in managing adult obesity, particularly when two or more of these approaches are used in combination (Glenny and O'Meara, 1997). Perri et al. tested the effectiveness of various weight loss maintenance strategies and found ongoing self-monitoring of eating and exercise behavior along with high frequency of client–therapist contact appear to be prerequisites for continued weight loss progress (Perri et al., 1992). Further, most clients required professional help to deal effectively with the many obstacles that impeded the maintenance of weight loss. Post-treatment contact seems to be helpful because the longer the client remains in contact with the healthcare professional, the longer they sustain the eating and exercise habits necessary to maintain weight loss (Perri et al., 1989). If clients were not provided with a post-treatment maintenance program they were found to most likely abandon the self-control strategies learned in treatment and to regain weight. Other studies have shown a noticeable trend in weight loss maintenance is achieved when contact continues after weight loss intervention (Ashby and Wilson, 1977; Hall et al., 1978; Perri et al., 1984, 1988; Baum et al., 1991). According to Glenny et al., long-term follow-up maintenance strategies should be an integral part of any weight loss program as weight regain is common in people who do successfully lose weight (Glenny et al., 1997).
The Transtheoretical Model (TM) of behavior change and weight loss
Prochaska and DiClemente's (1984) TM of health behavior change has been applied to weight loss (Cowan et al., 1995). The TM asserts that individuals change their behavior through a gradual dynamic process involving progress through a series of sequential stages: precontemplation, contemplation, preparation, action, maintenance and termination. Over these stages 12 processes of change that have two main process dimensions, experiential and behavioral, are employed to change behavior (Prochaska and Velicer, 1997). Experiential processes include internal experiences and behavioral include overt activities. Ten processes have received most empirical support (Proshaska and Velicer, 1997). They are the experiential processes (consciousness raising, dramatic relief, self-re-evaluation, environmental re-evaluation, social liberation) and the behavioral processes [counter conditioning, stimulus control, contingency management (reinforcement), helping relationships, self-liberation]. According to Cowan et al., interventions that are experientially oriented are appropriate in the earlier stages and in the later stages behaviorally oriented are more appropriate (Cowan et al., 1995).
Two other specific cognitions, self-efficacy integrated from Bandura's self-efficacy Theory Of Social Learning (Bandura, 1977) and decisional balance integrated from Janis and Mann's model of decision making (Janis and Mann, 1977), are also associated with movement from one stage to the next. Self-efficacy, the belief in one's ability to accomplish particular behaviors successfully, is a major determinant of activity choices, the amount of effort expended in those activities and the length of time the efforts persist (Dennis and Goldberg, 1996). Several studies have found positive associations between self-efficacy and weight loss during the intervention phase (Edell et al., 1987; Stotland and Zuroff, 1991) as well as at 1- and 2-year follow-ups (Jeffrey et al., 1984). The other determinant for motivational readiness to change behavior is decisional balance that represents the cognitive and motivational aspects individuals consider when changing their behavior (Allison, 1995). Pros, the positive elements associated with weight loss, need to outweigh the cons, the negative elements, for action to occur.
Stages of action and maintenance
In weight management programs, enrolment is considered to be entry into the action stage. The action stage involving engagement in the desired behavior normally takes 3–6 months to complete (DiClemente, 1991) and is followed by the maintenance stage with the desired behavior being practiced consistently for at least 6 months. In the stage of maintenance, habituation of the desired behavior into the individual's lifestyle occurs (Proshaska and Goldstein, 1991). Behavioral changes are stabilized and relapse avoided with four processes of change: counter-conditioning, stimulus control, contingency (reinforcement) management and helping relationships (Prochaska and Velicer, 1997). Progress in the maintenance stage also depends on the pros and cons of changing behavior (decisional balance) and self-efficacy. In maintenance, individuals have relatively high pros, lower cons, and higher decisional balance (pros minus cons) and self-efficacy scores (Marcus and Owens, 1992). Self-efficacy is an important predictor of progress in maintenance (Prochaska and Marcus, 1995). The stage of maintenance is followed by termination with low temptation and high self-efficacy being experienced. However, according to Prochaska and Velicer, movement from this maintenance stage to termination may not occur for individuals with weight management lifestyle changes (Prochaska and Velicer, 1997). This suggests a more realistic goal may be a lifetime of maintenance without termination being achieved.
Experiences of clients in action and maintenance stages
Clients who join programs view this as making a public commitment to action, seeking support, attempting to gain greater self-efficacy and creating artificial, external monitors of health behavior activity (DiClemente, 1991). On engaging in the action stage some clients demonstrate premature self-efficacy by believing they have gone far enough (Kent, 1991). Further in maintenance, clients often believe they can maintain their desired behavior change if the right mixture of encouragement, peer pressure, occasional reminder, threats, willpower and luck is available (Kent, 1991). Clients who have achieved a long time desired behavior have been found to appear superstitious in how they act: nothing must be altered, they believe lest it break the `spell' of their new behavior pattern (Prochaska and DiClemente, 1984; Kent, 1991). Hence, it is not unusual for clients to have a rigid structured way of thinking about their behavior. In fact some clients have been shown to enter a specific stage and not progress (Prochaska and DiClemente, 1984; Kent, 1991). This suggests clients could continue with program attendance and not progress to maintaining their health behavior change independent of a program. No literature was found about factors enabling and inhibiting transition from programs. This study aims to identify factors that enable and inhibit class attendees' transition from a weight management program that included behavioral, dietary and exercise strategies.
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Method |
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TopAbstractIntroductionMethodFindingsDiscussion and implicationsRecommendationsReferences |
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Design
A qualitative study explored experiences of long- and short-term clients in an area health service's weight management program. The focus of the study was factors that enabled and inhibited class attendees' transition from the program. The research question answered was: What are the enabling and inhibiting factors involved in long- and short-termers' transition from weight management programs?
Sample
Ethics approvals were obtained from Institutional Ethics Committees at both the university and the area health service. Attendees of a weight management program in the last 18 months received study information letters by mail asking for expressions of interest from potential clients to be lodged by telephoning the Healthy Lifestyle Unit. To be eligible to join the study clients needed to be maintaining weight management strategies and to either have completed two terms followed by termination of attendance (short-termer attendee) or to have four or more terms of participation in the weight management program (long-termer attendee). Only 18 expressions of interest were received. Each potential participant was then sent a study information sheet and consent form by mail, and followed-up with a telephone call 3 days later. Twelve class attendees, six long-term and six short-term, were recruited to the study and an interview time scheduled. As the class attendees were considered to be homogeneous regarding attendance patterns the sample was considered acceptable for Kuzel (Kuzel, 1992) indicates 6–8 data units are adequate when sample homogeneity is present. The long-term attendees, five females and a male, had all attended more than four terms of classes. Sixty-seven percent of long-termers were still in classes which was considered beneficial to the intent of the study to explore factors inhibiting transition. Short-term attendees were all females, none were enrolled in the program, and all had attended two terms of classes (20 weeks) and declared they were maintaining weight management as learned in classes.
Data collection procedure
An informed consent was obtained from each participant at the commencement of the scheduled interview session. The 12 participants were interviewed individually in the privacy of a quiet room for approximately 45 min. Each interview was audio-taped. An interview schedule with the topic areas: class experiences and leaving the program was used, and the interviewer asked each participant to talk about their experience of the program and decision to remain in or leave the classes. Interviews were concluded when participants considered they had nothing further to talk about. Participants were thanked for their time and contribution to the study and informed that a summary of findings would be mailed to them at the conclusion of the study.
Data analysis procedure
Transcripts were prepared from tapes, read in their entirety and then analyzed. The key ideas pertinent to the research question were identified and main categories developed by comparing and contrasting key ideas and using working categories that were modified and refined till they accommodated all the data. Relevant data extracts in a form most parsimonious for retaining contextual meaning were then used to support each category.
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Findings |
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Main findings identified the enabling and inhibiting factors involved in long- and short-term attendees' transition from a weight management program. Factors that enabled transition from classes were having program knowledge and set goal weight attainment. Long-term attendees indicated that once they had knew the program presented in the classes they found them repetitive and recognized they knew enough about these aspects.
I don't really want to go back to the program full time. Towards the end I did get bored with the program because you knew the program and there was a lot of repeating in it. [Long-termer 1]I feel that I knew enough about the food. I know when I am eating the wrong things. [Long-termer 6]
Short-term attendees suggested in many cases a preference for taking the knowledge of the program and applying it in their own lifestyle.
I thought the program was very comprehensive, quite good really. You could help each other. I wouldn't bother going again because I've got all the facts. I should be capable of carrying on myself. Just sticking to it and getting a bit of exercise. [Short-termer 6]
Reaching the set goal weight was considered by both long- and short-term attendees to be intrinsic to their decision to leave fully or partially.
I'd reached my goal weight that's the reason why I left. I found I had accomplished what I needed to accomplish. [Long-termer 3]I enjoyed the classes while I was there and it was necessary to get to my goal. When I got to my goal I didn't need them anymore. [Short-termer 2]
Factors that inhibited long-term attendees transition from classes were the perceived need to come to classes, concern about keeping in control, recognition of the potential to lapse and being involved with a group. The perceived need of long-termers to attend classes led them to continuously come to classes from one term to the next or a term of classes from time to time or to `pop in' to the classes to maintain a focus on weight management.
You really cannot do this by yourself you need someone to help you. If the classes weren't there I would feel like it was going to be a bit more of a struggle. I just feel in the back of my mind that I just really need a refresher to keep me on track. I need to get another boost. [Long-termer 1]
By comparing long- and short-term attendees, long-termers expressed more concern about keeping control of their weight management situation by returning to group/classes from time to time.
I feel I've got to come and do that once a month. It's sort of a challenge maintaining the same weight and not letting it gradually creeping up again. I wouldn't say I've got total control but quite good control. I feel like I'm fairly much in control. I want to maintain what I've achieved and not go back. [Long-termer 2]If I go to classes that helps me discipline myself. I suppose that's one of the reasons why I've been coming on and off over the years. [Long-termer 6]
Long-termers showed more recognition of their likelihood to `slip back' than short-termers.
I put on weight if I'm not careful I don't want to slip back. [Long-termer 2]They say once you get the hang of it that it should be automatic. It's not automatic. It can't be automatic. You've got to think about what you're eating. You've got to be sort of aware of it. You've got to sort of give it some kind of thought. [Long-termer 4]
A couple of long-termers associated this potential to `slip back' with fear, failure and disgust.
It's the fear primarily, the fear of losing control and going back and having to do it again, because you know it has to be done. It's sort of a problem that never goes away so you need that reinforcement. If you slip then you feel a certain degree of failure. You associate success and failure with it. There's a fear of failure. There is a definite fear that I won't be able to do it. There is that fear in the back of my mind and this is an area that I'm still feeling new to and so there is definitely that fear that I could still stuff up. I'm still not convinced I think keeping it off is more an issue than taking it off in the first place over a period of time. Sustaining it, is really the issue for me. [Long-termer 1]
Long-term more than short-term attendees indicated that group involvement was important to their weight management process. The group had a positive effect on clients, e.g. increasing confidence.
It is sort of a problem that never goes away so you need the group...that reinforcement. I think I gain confidence. In fact I find maintenance at times harder than actually getting it off. After a while the initial motivation sort of dissipates when you go back into the normal routine of everyday life. [Long-termer 1]I like being involved with the group in losing weight. Just the informality of it and the people, the socialness. It increases my ego I suppose, to a certain extent. I feel it can help, it has been a help I think to realize that it can be done. The group is important. It makes a big difference. [Long-termer 2]
I found being part of the group was comfortable. I felt there were other people that understood. I think that had an important part to play. [Long-termer 6]
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Discussion and implications |
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TopAbstractIntroductionMethodFindingsDiscussion and implicationsRecommendationsReferences |
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Transition from classes to independent weight management was dependent on the enabling factors, program knowledge and attainment of set goal weight. For long-term attendees knowing the program and the sameness of the classes pushed them to leave. However, though short-termers indicated knowing the program was essential they more readily considered they were capable of managing themselves by referring to material and sticking to the pattern established in class. The other factor active in instigating transition was the achievement of set goal weight.
The views of short-term attendees suggest they are more confident about applying what they have learned to their self-management. Transition from the program seemed to be associated with higher self-efficacy. Previous research has shown that self-efficacy is an important predictor of progress in maintenance with a positive association existing between self-efficacy and losing weight (Jeffrey et al., 1984; Edell et al., 1987; Stotland and Zuroff, 1991). Long-termers' confidence in their ability to weight manage independent of the program may influence their difficulties with transition.
Other factors that inhibited transition of long-termers from the program were perceptions that `you can't do it by yourself', there is a tendency to slip and lose control over actively managing your weight yourself and involvement with the group is intrinsic to the weight management endeavor. Though research findings concerning locus of control among obese people are contradictory. Findings from this study that are associated with inhibiting transition from classes suggest long-term attendees may have an external locus of control. Studies of obese people suggest that this external locus of control may only be in circumscribed areas (Thomason, 1983; Mills and Cullen, 1994). Hence, long-term attendees may exhibit internal loci of control with other aspects of their lives but in the area of weight status and food-related behaviors they experience feelings of being out of control so having an external control orientation. Further interpersonal dependency findings by Mills showed that obese people preferred to be with others rather than alone and their self-esteem was contingent on approval and acceptance from others (Mills, 1994). This may explain to some degree long-term attendees need for group involvement and for continued support. An external locus of control and the personality characteristic of interpersonal dependency may partially explain clients' not leaving the weight management program.
The tendency to slip that long-term attendees described has been noted in Marlatt and Gordon's work (Marlatt and Gordon, 1985) that stressed a lapse (or slip) might or might not develop into a full-blown relapse. Their highly influential theory of relapse has provided insight into the relapse process and some trialing of relapse prevention training (Perri et al., 1990). Active interventions in the form of relapse prevention training have been found to be effective for addressing the potential for lapse (Perri et al., 1990). Increased control by clients could be influenced by this type of strategy (Perri et al., 1990).
Long-termers considered they needed group involvement to maintain weight loss. This reflects findings that show weight loss is sustained when contact continues after the weight loss intervention (Ashby and Wilson, 1977; Hall et al., 1978; Perri et al., 1984, 1988; Baum et al., 1991). According to Perri et al., obesity is a chronic condition requiring continuous care and obese individuals must focus their efforts on controlling their condition through active self-management efforts for the rest of their lives (Perri et al., 1992). Most long-termers in the study showed they were acutely aware of the effort they needed to make to continue to actively self-manage their weight status.
According to Prochaska and Velicer, movement from the stage of maintenance to termination may not be achieved by individuals with weight management lifestyle changes (Prochaska and Velicer, 1997). Indeed, individuals with weight problems may require a similar type of self-help group to Alcoholics Anonymous (Prochaska and Velicer, 1997). Further, Glenny et al. indicated that long-term follow-up maintenance needs to be available after weight loss intervention as weight regain is common in people who successfully lose weight (Glenny et al., 1997). This has implications for the support that obese individuals need to sustain their weight loss maintenance. Hence, it is possible that transition from a weight management program could be facilitated by availability of follow-up support.
The small number of expressions of interest (n = 18) received in response to letters sent to all attendees of the program in the last 18 months may have been associated with obesity being a sensitive topic, as indicated in some interviews. Six of the 18 who expressed interest declined to enter the study as they were uncomfortable about taking part in interviews. This could be addressed by trialing the use of a small group approach, e.g. focus groups, which may be more acceptable to attendees in light of the meaning of the group experience for them.
The transferability of these findings to other long-term attendees of weight management programs is questionable. The small number of clients interviewed has provided some insight and understanding of factors that enable and inhibit transition. However, the findings are tentative and further investigation into the process of transition from weight management programs is indicated.
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Recommendations |
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Clients were inhibited by their perceived lack of control. Concerns about lapsing has the potential to result in relapse which could be addressed by extending the program to include relapse prevention training.
As obesity can be considered a chronic condition requiring continuous care and as clients indicate a need for continuous support, obese individuals must focus their efforts on controlling their condition through active self-management efforts for the rest of their lives. A multifaceted set of strategies needs to be developed to adequately support such individuals. In light of the financial constraints within the area of health, a support system that further develops client independence and confidence such as a self-help strategy may be appropriate, as the group effect seems to be a strong motivator. Hence, studies that determine the effect of follow-up strategies are required.
This small study has provided some insight and understanding of factors that enable and inhibit transition. However, further research that addresses the process of transition from weight management programs is required. A study of long-term attendees of weight management programs using a focus group approach may confirm findings from this study and identify other areas pertinent to the transition process. A qualitative study of this nature has the potential to identify areas from which items can be developed to design a questionnaire. This questionnaire could then be tested and used to examine associations between factors and long-term attendance in weight management programs. If findings from this additional work support a relationship between long-term attendance and interpersonal dependency and external control orientation with weight status and food -related behavior, then this hypothesis should be tested. The hypothesis would be that long-term attendees have greater interpersonal dependency and external control orientation with weight status and food-related behavior than short-term attendees of weight management programs.
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Acknowledgments |
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Acknowledgements to the University of Western Sydney Hawkesbury who funded the study, to Ms Jan Brooks and leaders of community groups for their support and cooperation with the study, to the participants who so willingly shared their experiences of the program and its effect on their lives, and to the research assistants (Ms Judi Powis and Ms Rachel Wolfenden).
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References |
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Received on December 13, 2000; accepted on April 27, 2001
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