Are Providers Self-Efficacy and Outcome Expectations ... · Social Cognitive Theory ... Analysis...

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Are Providers’ Self-Efficacy and Outcome Expectations Related to Obesity Counseling Frequency?

Lisa M. Lowenstein, MPH, RD

Eliana Perrin, MD, MPH; Marci K Campbell PhD; Deborah Tate, PhD; Jianwen Cai, PhD, Alice Ammerman, DrPh, RD

Gillings School of Global Public Health, School of MedicineCenter for Health Promotion and Disease PreventionThe University of North Carolina at Chapel Hill

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Background

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Childhood Overweight and Obesity

NHANES Data (2003-2006)

BMI Category 2-5 year olds 6-11 year olds

Overweight (≥ 85th percentile) 26% 33%

Obese (≥ 95th percentile) 14% 18%

Ogden JAMA 2008

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Consequences of Childhood Overweight and Obesity

� Health Disparities� Physical

� Asthma � Sleep apnea� Diabetes� More likely to develop other chronic diseases

� Psychosocial� Low self-esteem � Decreased quality of life

� Economic� Increased health care costs� Increased lab requests

Daniels, SR Future child 2006; Dietz, W Pediatrics 1998; SchwimmerJAMA 2003; Magarey, AM Int J Obes Relat Metab Disord. 2003

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Points of Intervention

� One point of intervention is in primary care� May be the only option for low-income

populations� Multiple levels of intervention

� Provider-patient communication� Provider

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Obesity Prevention and Treatment in Primary Care� Primary care providers seen as a source of

health information� Clinic based interventions

� Weight loss� Improved health behaviors

� Few resources are available� USPSTF Guidelines

� 25 hours of contact

Epstein LH. Health Psychol 1994; Mellin LM J Am Diet Assoc. 1987; Sothern MS J Am Diet Assoc 2002; Patrick K Arch Pediatr Adolesc Med 2001; Savoye M JAMA 2007; Schwartz R Arch Pediatr Adolesc Med 2007

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Preventive Counseling Frequency

� Less than 50% of providers counsel on nutrition and physical activity

� Predictors of counseling� Female providers� > 10 patients/week� Spent >20 minutes/patient� Plotting BMI� Older children� Children with a BMI ≥ 95th percentile

Frank E Am J Clin Nutr 2002; Rattay K Obesity Res 2004; Cook S Pediatrics 2005

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Barriers to Preventive Counseling

� Lack of time� Lack of resources� Lack of reimbursement� Low parent motivation� Low perceived efficacy� Low self-efficacy

Story MT Pediatrics 2002; Douglas F BMC Public Health 2006; Perrin EM Ambul Pediatr2005

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Providers’ Attitudes and Beliefs

� What we know� Providers

� Believe overweight and obese children and adolescents need treatment

� Believe overweight and obesity during childhood and adolescence affects chronic disease risk

� Have low self-efficacy for obesity prevention counseling� Find obesity counseling unrewarding

Story MT Pediatrics 2002; van Gerwen M Obesity Reviews 2009

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Providers’ Attitudes and Beliefs

� What we don’t know� Outcome expectations

� One study assessed outcome expectations � "How much can you do to prevent these problems?“� Not outcome expectations

� Relationship of self-efficacy, outcome expectations, and counseling frequency

Cheng T Arch Pediatr Adolesc Med 1999

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Objectives

� Does obesity preventive counseling differ from other preventive counseling topics?

� Do providers with higher levels of self-efficacy or outcome expectations report they counsel on obesity related topics more often?

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Methods

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Kids Eating Smart and Moving More (KESMM) – Phase II

� Goal: Improve providers’ ability to identify and assess children who are at risk for or already overweight

� 5-year randomized pediatric obesity intervention trial funded by NICHD

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Participants - Providers

� Providers include:� Medical Doctors, Nurse Practitioners, and Physician

Assistants

� Can participate if their practice is enrolled into KESMM

� Provider champion lets other providers know about the study

� Consented at the first practice training � Receive continuing medical education credits at

second practice training

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Provider Baseline Survey

� Developed� Review of the literature � Refined from the pilot study

� Pre-tested the survey to assess � Amount of time to fill out� Clarity of questions

� Administration:� Delivered at the first practice training � Picked-up at the second practice training

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Social Cognitive Theory

Self Efficacy Goals

Sociostructural Factors

Facilitators

Barriers

Outcome Expectations

Physical

Social

Self-evaluative

Behavior

Bandura A Health Educ Behav 2004

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Self Efficacy Goals


Facilitators

Barriers


Physical

Social

Self-evaluative

Behavior


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Self Efficacy Goals


Facilitators

Barriers


Physical

Social

Self-evaluative

Behavior


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Provider Attitudes & Beliefs Linked to Patient Behavior

Provider Attitudes & Beliefs

•Self-Efficacy

•Outcome Expectations

Provider Behavior

Counseling on

•Nutrition

•Physical activity

•Achieving/maintaining a healthy weight

Patient Behavior

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Dependent Variables – Preventive Counseling Frequency� When you see children 3-8 for well child

check, how often do you discuss the following topics:� Healthy Eating� Physical Activity� Achieving/Maintaining a Healthy Weight

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Independent Variables – Self-Efficacy

� Please rate your confidence in your ability to effectively counsel families about � Increasing F&V� Decreasing sweetened beverage consumption� Decreasing juice consumption� Switching to lower fat milk� Decreasing junk food consumption� Reducing screen time � Increasing outdoor activity� Discuss children’s weight status

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Independent Variables – Outcome Expectations� Please rate your agreement with the following

statement: “I believe that my counseling families will result in actual change regarding …. � Increasing F&V� Decreasing sweetened beverage consumption� Decreasing juice consumption� Switching to lower fat milk� Decreasing junk food consumption� Reducing screen time � Increasing outdoor activity� Discuss children’s weight status

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Analysis

� STATA� Basic descriptive statistics� Proportional-Odds-Modeling

� Outcome variables are ordered and non-normal� Greater power than logistic regression� Random effect to account for clustering

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Results

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Participant CharacteristicsClinics (N=21)Providers (N=110)

8268Pediatrics/Med-Peds

1815Family Medicine

Provider Type/Residency

%nVariable

27

83

96

24Nurse Practitioner/Physician Assistant

75MD/DO

69Female

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Healthy Eating Counseling FrequencyAll of the time

0

10

20

30

40

50

60

Healthy eating

Physical activity

Age-specific injuryprevention

Maintaining andachieving a healthyweight General behaviorproblems

Preschool/schoolproblems

* Single test of proportions (p<0.05)

**

* * *

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Physical Activity Counseling FrequencyAll of the time

0

10

20

30

40

50

60Healthy eating

Physical activity





*

* * *

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Healthy Weight Counseling FrequencyAll of the time

0

10

20

30

40

50

60Healthy eating

Physical activity





*

* *

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Providers are confident but have low expectations

9 (8)

7 (6)

4 (4)

6 (5)

22 (20)

15 (14)

18 (16)

5 (5)

4 (4)

Outcome ExpectationsN (%)

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

p-value

44 (40)Weight status

Self-EfficacyN (%)

37 (34)Outdoor activity

35 (32)Screen time

16 (15)Behavior problems

42 (38)“Junk food”

52 (47)Lower fat milk

52 (47)Juice

50 (45)SSB

42 (38)Fruit & vegetables

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9 (8)

7 (6)

4 (4)

6 (5)

22 (20)

15 (14)

18 (16)

5 (5)

4 (4)


<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

<0.00001

p-value


Self-EfficacyN (%)


35 (32)Screen time




52 (47)Juice

50 (45)SSB


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9 (8)

7 (6)

4 (4)

6 (5)

22 (20)

15 (14)

18 (16)

5 (5)

4 (4)


<.001

<.001

<.001

<.001

<.001

<.001

<.001

<.001

<.001

p-value


Self-EfficacyN (%)


35 (32)Screen time




52 (47)Juice

50 (45)SSB


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Is Self-Efficacy Related to Counseling Frequency (CF)?

Physical Activity

1.4 (0.78, 2.7)2.3 (0.89, 5.8)Healthy weight

Healthy Eating

1.7 (1.0, 2.7)

1.5 (0.9, 2.3)

1.5 (0.9, 2.6)

1.7 (1.0, 2.9)

2.0 (1.2, 3.2)

2.3 (1.4, 3,7)

2.2 (1.3, 3.8)

Outcome ExpectationsOR (95% CI)

Self-EfficacyOR (95% CI)

2.6 (1.7, 3.9)Outdoor activity

1.8 (1.1, 2.8)Screen time

1.7 (1.0, 3.0)“Junk food”

2.5 (1.4, 4.3)Lower fat milk

2.0 (1.2, 3.4)Juice

2.2 (1.1, 4.3)SSB

1.8 (1.0, 3.1)Fruit & vegetables

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Is Self-Efficacy Associated with CF After Controlling for Outcome Expectations?

Physical Activity

1.1 (0.60, 1.9)2.2 (0.86, 5.7)Healthy weight

Healthy Eating

1.3 (0.73, 2.4)

1.2 (0.71, 2.0)

1.3 (0.74, 2.4)

1.4 (0.84, 2.3)

1.7 (1.0, 2.8)

1.9 (1.2, 3.1)

1.9 (1.1, 3.2)




1.7 (0.99, 2.8)Screen time

1.6 (0.93, 2.8)“Junk food”


1.7 (0.99, 2.9)Juice

1.7 (0.89, 3.4)SSB


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Is Outcome Expectations Related to CF?

Physical Activity

1.4 (0.78, 2.7)2.3 (0.89, 5.8)Healthy weight

Healthy Eating

1.7 (1.0, 2.7)

1.5 (0.9, 2.3)

1.5 (0.9, 2.6)

1.7 (1.0, 2.9)

2.0 (1.2, 3.2)

2.3 (1.4, 3,7)

2.2 (1.3, 3.8)




1.8 (1.1, 2.8)Screen time

1.7 (1.0, 3.0)“Junk food”


2.0 (1.2, 3.4)Juice

2.2 (1.1, 4.3)SSB


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Is Outcome Expectations Associated with CF After Controlling for Self-Efficacy?

Physical Activity

1.1 (0.60, 1.9)2.2 (0.86, 5.7)Healthy weight

Healthy Eating

1.3 (0.73, 2.4)

1.2 (0.71, 2.0)

1.3 (0.74, 2.4)

1.4 (0.84, 2.3)

1.7 (1.0, 2.8)

1.9 (1.2, 3.1)

1.9 (1.1, 3.2)




1.7 (0.99, 2.8)Screen time

1.6 (0.93, 2.8)“Junk food”


1.7 (0.99, 2.9)Juice

1.7 (0.89, 3.4)SSB


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Discussion

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Main Points

� Providers are confident in their counseling skills but do not have high expectations

� Self-efficacy and outcome expectations were associated with counseling frequency for dietary and exercise behaviors but not counseling about healthy weight

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Strength & Limitations

� Modeled the relationship of provider attitudes and beliefs with behavior

� Providers from clinics participating in an obesity prevention intervention

� Sample limited to mainly pediatricians� Counseling frequency was self-report

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Summary & Discussion

� Contributes to the emerging research on pediatric overweight and obesity prevention and assessment in primary care practices

� Future research could target provider outcome expectations in addition to self-efficacy

� May help the development of other interventions to train providers in the prevention, assessment, and treatment of childhood obesity

Questions?

Funded by NICHD

Acknowledgements: Ziya Gizlice, Larry Johnson, Lisa Pullen Davis, Maihan Vu, Cecelia Gonzales

Contact: [email protected]

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Psychometric Testing of Scales(Self-efficacy, Outcome Expectations, Counseling Frequency)

� Cronbach’s alpha was calculated � Items were equally weighted

Preventive counseling

Nutrition Physical Activity

Self-Efficacy 0.9334 0.9519 0.7785

Outcome expectations 0.9414 0.9206 0.8677

Counseling Frequency 0.8524 NA NA

Are Providers Self-Efficacy and Outcome Expectations ... · Social Cognitive Theory ... Analysis...

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