"It's not like a fat camp" - A focus group study of adolescents' experiences on group-based obesity treatment

Background: The health burden related to obesity is rising among children and adolescents along with the general population worldwide. For the individual as well as the society this trend is alarming. Several factors are driving the trend, and the solution seems to be multifaceted because long-lasting treatment alternatives are lacking. This study aims to explore adolescents’ and young adults’ motivation for attending group-based obesity treatment and social and environmental factors that can facilitate or hinder lifestyle change. Methods: In this study, we arranged three focus groups with 17 participants from different obesity treatment programs in the west and south of Norway. The content in these programs differed, but they all used Motivational Interviewing as a teaching method. We conducted a data-driven analysis using systematic text condensation. Self-determination theory has been used as an explanatory framework. Results: We identified four major themes: 1) motivation, 2) body experience and self-image, 3) relationships and sense of belonging, and 4) the road ahead. Many of the participants expressed external motivation to participate but experienced increasing inner motivation and enjoyment during the treatment. Several participants reported negative experiences related to being obese and appreciated group affiliation and sharing experiences with other participants. Conclusion: Motivation may shift during a lifestyle course. Facilitating factors include achieving and experiencing positive outcomes as well as gaining autonomy support from other course participants and friends. Obstacles to change were a widespread obesogenic environment as well as feelings of guilt, little trust in personal achievements and non-supporting friends.publishedVersio

Factors Predicting Physical Activity and Sports Participation in Adolescence

Physical activity is important for children’s health and wellbeing, yet participation declines across teenage years. It is important to understand the mechanisms that could support adolescents to maintain physical activity participation. The aim of this study was firstly to examine change in sports and nonsports activities over two years during adolescence. Secondly, we explored possible predictors of physical activity and sports participation after two years. Method. A longitudinal cohort study was conducted between 2011 and 2013. Our data were collected from 1225 Norwegian adolescents who were followed over a two-year period, from 6th to 8th grade (11 to 13 years) and from 8th to 10th grade (13 to 15 years). We examined the relations between physical activity and predictors such as peer support, parent support, socioeconomic status (SES), attitude towards physical education, active transportation to school, self-rated health, body image, and change of nonsports activities. We used linear regression analyses and binary logistic regression to explore possible predictors of physical activity and sports participation after two years. Results. We found a significant reduction in sports participation during early adolescence, most pronounced, from 8th to 10th grade (from 13 to 15 years). Factors which predicted physical activity after two years were a positive attitude towards physical education, perceived support from parents, if the student travelled to school in an active way (by walk or bicycle) and also how the student rated his/her own health. The last three factors also predicted improvements of physical activity during the two years. Possible predictors of persisting or starting doing sports were increasing levels of self-rated health, increasing socioeconomic status, whereas increasing engagement in nonsports activities predicted reduced participation in sports. Conclusion. Health promotive efforts aiming at increasing active school transportation, parental support, and subjective health seem important for maintenance of physical activity and sports participation during adolescence. Attitudes may improve by adapting physical education to individual needs and interests and can function as an additional promotive factor.publishedVersio

Getting Physically Active by E-Bike : An Active Commuting Intervention Study

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Patients want their doctors’ help to increase physical activity: a cross sectional study in general practice

Background Inactivity is prevalent in patients presenting in general practice, and the health benefits of increased physical activity (PA) are well known. Few studies have explored whether patients want their general practitioner’s (GPs) contribution in facilitating a lifestyle change. Objective To identify the characteristics of patients who expect help from their doctor in increasing levels of PA. Design We collected data via questionnaires for this cross-sectional study from general practices. Setting General practices in Norway, during Spring 2019. Subjects A total of 2104 consecutive patients (response rate 75%) participated. Main outcome measures The questionnaire included questions about self-rated health, level of physical activity, the desire to become more physically active, and questions about the role of the GP in increasing the level of physical activity in their patients. We analysed our data using Pearson chi-square and binary logistic regression. Results Female patients were less active, but their motivation to increase activity and their expectations of receiving help from their doctor were similar to males. Younger patients were more motivated for increased activity, and to manage without help from their doctors. Impaired self-rated health (SRH) was associated with inactivity and, at the same time, with the motivation to become more active with help from general practitioners. Conclusion Most patients in the GPs’ office are physically inactive. This study revealed an important message for GPs: in clinical work, emphasise physical activity for health gains, especially for patients with impaired SRH.publishedVersio

Healthy and unhealthy eating after a behaviour change intervention in primary care

Background: To prevent and reduce non-communicable diseases, the Norwegian Directorate of Health encourages Healthy Life Centres (HLCs) in all municipalities. Aims: This study investigates whether the behaviour change interventions at HLCs positively affected participants’ diet and to evaluate predictors for healthy and unhealthy eating. Our data are part of the Norwegian Healthy Life Centre Study, a 6-month, pragmatic randomised controlled trial (RCT). Methods: Totally, 118 participants ≥18 years old were randomised to an intervention group (n 57), or a waiting list (control group) (n 61). Eighty-six participants met at the 6 months follow-up visit. We merged the participants to one cohort for predictor analyses, using linear regressions. Findings: The RCT of the HLCs’ interventions had no effect on healthy and unhealthy eating 6 months after baseline compared with controls. A short, additional healthy eating education programme produced a modest, statistically significant improvement in healthy eating compared with controls. This did not, however, reduce unhealthy eating. Higher income predicted unhealthier eating over time. Increasing body mass index and impaired physical functioning also led to an increase in unhealthy eating. Healthy eating at 6 months was predicted by self-rated health (SRH), vitality and life satisfaction, and hampered by musculo-skeletal challenges and impaired self-esteem (SE). SRH impacted improvement in healthy eating during the 6 months. The effect of interventions on healthier eating may be improved by an emphasis on developing positive self-concepts like better SRH, vitality, life satisfaction, and SE.publishedVersio

How can we improve specialist health services for children with multi-referrals? Parent reported experience

Background Children with combined mental and somatic conditions pose a challenge to specialized health services. These cases are often characterized by multi-referrals, frequent use of health services, poor clinical and cost effectiveness, and a lack of coordination and consistency in the care. Reorganizing the health services offered to these children seems warranted. Patient reported experiences give important evidence for evaluating and developing health services. The aim of the present descriptive study was to explore how to improve specialist health services for children with multiple referrals for somatic and mental health conditions. Based on parent reported experiences of health services, we attempted to identify key areas of improvement. Methods As part of a larger, ongoing project; “Transitioning patients’ Trajectories”, we asked parents of children with multiple referrals to both somatic and mental health departments to provide their experiences with the services their children received. Parents/guardians of 250 children aged 6–12 years with multi-referrals to the Departments of Pediatrics and Child and Adolescent Mental Health at Haukeland University Hospital between 2013 and 2015 were invited. Their experience was collected through a 14 items questionnaire based on a generic questionnaire supplied with questions from parents and health personnel. Possible associations between overall experience and possible predictors were analyzed using bivariate regression. Results Of the 250 parents invited, 148 (59%) responded. Mean scores on single items ranged from 3.18 to 4.42 on a 1–5 scale, where five is the best possible experience. In the multiple regression model, perception of wait time (r = .56, CI = .44–.69 / β = 0.16, CI = .05–.28), accommodation of consultations (r = .71, CI = .62–.80 / β = 0.25, CI = .06–.45 / β = 0.27, CI = .09–.44), providing adequate information about the following treatment (r = .66, CI = .55–.77 / β = 0.26, CI = .09–.43), and collaboration between different departments at the hospital (r = .68, CI = .57–.78 / β = 0.20, CI = -.01–.40) were all statistically significantly associated with parents overall experience of care. Conclusions The study support tailored interdisciplinary innovations targeting wait time, accommodation of consultations, communication regarding the following treatment and collaboration within specialist health services for children with multi-referrals to somatic and mental specialist health care services.publishedVersio

Performance of primary care in different healthcare facilities: A cross-sectional study of patients' experiences in Southern Malawi

Objective In most African countries, primary care is delivered through a district health system. Many factors, including staffing levels, staff experience, availability of equipment and facility management, affect the quality of primary care between and within countries. The purpose of this study was to assess the quality of primary care in different types of public health facilities in Southern Malawi. Study design This was a cross-sectional quantitative study. Setting The study was conducted in 12 public primary care facilities in Neno, Blantyre and Thyolo districts in July 2018. Participants Patients aged ≥18 years, excluding the severely ill, were selected to participate in the study. Primary outcomes We used the Malawian primary care assessment tool to conduct face-to-face interviews. Analysis of variance at 0.05 significance level was performed to compare primary care dimension means and total primary care scores. Linear regression models at 95% CI were used to assess associations between primary care dimension scores, patients’ characteristics and healthcare setting. Results The final number of respondents was 962 representing 96.1% response rate. Patients in Neno hospitals scored 3.77 points higher than those in Thyolo health centres, and 2.87 higher than those in Blantyre health centres in total primary care performance. Primary care performance in health centres and in hospital clinics was similar in Neno (20.9 vs 19.0, p=0.608) while in Thyolo, it was higher at the hospital than at the health centres (19.9 vs 15.2, p<0.001). Urban and rural facilities showed a similar pattern of performance. Conclusion These results showed considerable variation in experiences among primary care users in the public health facilities in Malawi. Factors such as funding, policy and clinic-level interventions influence patients’ reports of primary care performance. These factors should be further examined in longitudinal and experimental settings.publishedVersio

Healthy and unhealthy eating after a behaviour change intervention in primary care

Background: To prevent and reduce non-communicable diseases, the Norwegian Directorate of Health encourages Healthy Life Centres (HLCs) in all municipalities. Aims: This study investigates whether the behaviour change interventions at HLCs positively affected participants’ diet and to evaluate predictors for healthy and unhealthy eating. Our data are part of the Norwegian Healthy Life Centre Study, a 6-month, pragmatic randomised controlled trial (RCT). Methods: Totally, 118 participants ≥18 years old were randomised to an intervention group (n 57), or a waiting list (control group) (n 61). Eighty-six participants met at the 6 months follow-up visit. We merged the participants to one cohort for predictor analyses, using linear regressions. Findings: The RCT of the HLCs’ interventions had no effect on healthy and unhealthy eating 6 months after baseline compared with controls. A short, additional healthy eating education programme produced a modest, statistically significant improvement in healthy eating compared with controls. This did not, however, reduce unhealthy eating. Higher income predicted unhealthier eating over time. Increasing body mass index and impaired physical functioning also led to an increase in unhealthy eating. Healthy eating at 6 months was predicted by self-rated health (SRH), vitality and life satisfaction, and hampered by musculo-skeletal challenges and impaired self-esteem (SE). SRH impacted improvement in healthy eating during the 6 months. The effect of interventions on healthier eating may be improved by an emphasis on developing positive self-concepts like better SRH, vitality, life satisfaction, and SE.publishedVersio

Motivating cardiac rehabilitation patients to maintain lifestyle changes

Background: In Western societies, the single greatest opportunity to improve health and reduce premature death lies in personal behaviour. Personal behaviour is, however, embedded in social contexts. Therefore, we may question whether behavioural interventions are ethically justifiable. Those who are socioeconomically disadvantaged and people with emotional problems have a poorer prognosis for cardiovascular disease. Cardiac rehabilitation aims at improving lifestyle, but lifestyle changes are hard to achieve and even harder to maintain. Moreover, we want to develop interventions that do not leave some groups, and especially the disadvantaged, behind. Research is required to present and evaluate new and improved interventions. It is as important to describe why an intervention works (or does not work) as to present its efficacy. In this thesis, we wanted to present a newly developed intervention aimed at improving and maintaining lifestyle changes in a cardiac rehabilitation setting. We also wanted to explore whether lifestyle changes were harder to achieve among the socioeconomically disadvantaged and people with emotional problems. The intervention was based on elements from social cognitive theory and self-determination theory. Aims: The main aim was to evaluate whether the intervention was superior to standard cardiac rehabilitation. We also examined important predictors derived from our theoretical basis. In a separate analysis, we wanted to analyse the effect of providing personal choice. The first paper examines how socioeconomic factors, disease severity and risk status affect the ability of individuals to make dietary and exercise improvements after heart disease. We also wanted to evaluate whether unfavourable lifestyle outcomes among disadvantaged people were mediated by motivational problems. Methods: This is a randomised controlled trial and a longitudinal study of predictor variables in a four week heart rehabilitation setting with two years of follow-up. During a two-year period starting in August 2000, 217 patients were recruited and randomised to either intervention or standard, multifaceted cardiac rehabilitation. At 24 months, 41 patients were lost to follow up, leaving 176 patients eligible for two-year analysis. The intervention was based on a cognitive theory and autonomy support from self-determination theory. It aimed at helping the patient to prioritise between different lifestyle achievements during two individual counselling sessions. They also received a telephone follow-up at six and 24 months, focusing on their prioritised goals. Their level of exercise, smoking and present dietary habits were measured on inclusion and after six and 24 months. Different motivational factors and emotional distress were measured at baseline. Their predictive power was tested in the three dietary and exercise outcomes. Motivational factors were measured by task-specific self-efficacy questionnaires, General Expectancy and Treatment Self-Regulation Questionnaire. An Anxiety-Depression-Irritability questionnaire measured emotional status, while household income was chosen as the socioeconomic status predictor. Autonomy support was measured by the Health Care Climate Questionnaire. Results: We found no statistically significant between-group differences. Both groups showed an improvement in their dietary and exercise measures. Self-efficacy predicted an increased frequency of eating fish dinners, more daily units of fruit and vegetables and increased physical capacity. Autonomous motivation was significantly associated with a lower saturated fat diet, exercise and exercise intensity. General expectancy was a significant predictor of increased exercise and physical capacity. Controlled motivation hampered improvement in physical capacity. Autonomous self-regulation was lowest among smokers and female participants. Participants with high scores for emotional distress predicted lower motivation for all the measures. We found no association between socioeconomic status (household income) and the ability to achieve lifestyle changes. Current smoking status predicted lower ability to obtain lifestyle changes on all measures. Emotional distress was related to lower ability to increase physical activity at six months but not at 24-month follow-up. The mediating effects of motivational factors were insignificant. Conclusion: We found no effect of adding autonomy supportive, individual counselling to group-based interventions. Enhancing choice in a cardiac rehabilitation setting is not sufficient if the goal is to stimulate long-term lifestyle changes. Based on longitudinal documentation, this cardiac rehabilitation programme possibly improves long-term maintenance of dietary changes and exercise measures. Maintenance of these lifestyle achievements is related to autonomous motivation and self-efficacy. The results of this study do not support the suspicion that preventive efforts accentuate the socioeconomic differences in cardiovascular health. We need to target our rehabilitation efforts at special groups like smokers and the emotionally distressed