A Community Jury on initiating weight management conversations in primary care

Abstract Background Current guidelines recommend that patients attending general practice should be screened for excess weight, and provided with weight management advice. Objective This study sought to elicit the views of people with overweight and obesity about the role of GPs in initiating conversations about weight management. Methods Participants with a body mass index ≥25 were recruited from a region in Australia to take part in a Community Jury. Over 2 days, participants (n = 11) deliberated on two interconnected questions: ‘Should GPs initiate discussions about weight management?’ And ‘if so, when: (a) opportunistically, (b) in the context of disease prevention, (c) in the context of disease management or (d) other?’ The jury deliberations were analysed qualitatively to elicit their views and recommendations. Results The jury concluded GPs should be discussing weight management, but within the broader context of general health. The jury were divided about the utility of screening. Jurors felt GPs should initiate the conversation if directly relevant for disease prevention or management, otherwise GPs should provide opportunities for patients to consent to the issue being raised. Conclusion The jury's verdict suggests informed people affected by overweight and obesity believe GPs should discuss weight management with their patients. GPs should feel reassured that discussions are likely to be welcomed by patients, particularly if embedded within a more holistic focus on person‐centred care. Public contribution Members of the public took part in the conduct of this study as jurors, but were not involved in the design, analysis or write‐up.

there are increasing calls for primary care to screen for overweight and obesity. 5 However, initiating weight management conversations in primary care is a controversial issue for general practitioners (GPs). Despite current guidelines, previous studies suggest few patients attending general practice in Australia are weighed, and few at-risk patients are given advice or referred to other services. 6 Identified barriers include insufficient time, concerns about upsetting patients, lack of training/confidence in this clinical area and perceptions that effective interventions are lacking. [7][8][9] A recent systematic review and thematic synthesis of 29 qualitative studies exploring GPs' and nurses' perspectives on discussing weight with patients with overweight and obesity in primary care highlighted that discussing weight is not perceived to be a priority for GPs. 10 GPs' perceptions that effective weight management options are lacking, are not entirely unsupported. Although there is some evidence that GP referrals to programmes outside of the primary care setting can be effective, the effects are generally modest.  11 More recently, a UK-based trial of an opportunistic primary care referral to a behavioural weight-management programme supported a similar weight loss difference of 1.43 kg (95% CI 0.89-1.97) over 12 months. 12 While these effects are not negligible at the population level, individual patients may be disappointed.
Exploring the views of those directly affected by overweight and obesity provides GPs and policymakers with an important perspective on this issue. Data from the UK-based trial of an opportunistic primary care referral suggested <1% of patients felt it was inappropriate. 12 Furthermore, cross-sectional data suggest that receiving advice from a GP may be an important motivator for patients; people who report receiving advice from a healthcare professional to lose weight are more likely to be trying to lose weight than people who do not recall receiving advice. 13 Two qualitative studies conducted in the United States and Canada also suggest patients want and expect their GP to discuss weight management, but do perceive there to be limitations within current models of care. 14,15 More research is needed to gain a clearer understanding of patients' views around GPs initiating these discussions, and whether patients perceive it to be appropriate in all circumstances.
Community Juries (CJs) are a deliberative democracy technique that provides a group of community members affected by an issue with expert information and an opportunity to question the experts.
The jury then deliberate, to form a 'verdict' on the issue, which can influence health policy decision making. 16 In contrast to other qualitative approaches, a CJ therefore asks those affected by the issue to reflect on more than just their own experiences. The expert information places the issue within a wider context, and participants are asked to consider the issue with the community interest in mind. 17 Obtaining the views of individuals both affected by the issue, and informed of the context and implications of different approaches via the CJ method, may be more likely to influence GPs and policymakers than views obtained via interviews or focus groups alone.
The aim of this CJ was therefore to elicit the views of people with overweight and obesity about the role of GPs in initiating conversations about weight management. CJ participants deliberated on two questions: 'Should GPs initiate discussions about weight management?' And 'if so, when: (a) opportunistically, (b) in the context of disease prevention, (c) in the context of disease management or (d) other?' 2 | ME THODS

| Participants & recruitment
Recommendations for the composition of CJs suggest a sample size between 12 and 25 is appropriate. 18 We were therefore aiming to recruit 15 participants to allow for some dropout and ensure there were sufficient people to encourage a wide ranging, but manageable, discussion, where all voices would be heard. 19 We were seeking to obtain the views of 'consumers' (the affected public), 17 as these would be most relevant to GPs considering this issue. Therefore, we recruited participants over 18 years with a body mass index ≥25 (calculated from self-reported height and weight). We excluded anyone unable to provide informed consent due to mental incapacity, or unable to speak or understand English.
We recruited participants from a region in Australia through Taverner Research using a random-generated landline and location known mobile sample drawn from SamplePages. This sample frame had the potential to cover 80% or more of the population in the region. Compared with an online panel or market research database, recruits were therefore less likely to have been exposed to research and people without internet could be included. We requested roughly equal numbers of men and women, and where possible, a range of education levels and ages.
Using the random generated and location known telephone numbers, Taverner Research contacted potential participants and, without coercion or pressure, asked respondents whether they would be willing to receive more information about the study. Interested participants were checked by Taverner Research for eligibility, and given further details about the study, including an explanatory statement containing details about the nature and purpose of the CJ alongside contact details for the research team in case they had any queries, and a consent form. If potential participants agreed to take part after reading this sheet, and having had the opportunity to contact the research team with any queries, then they were asked to sign a consent form. Participants were asked to either send the consent form in advance, or bring a hardcopy on the day of jury. Written consent was obtained from all participants before commencing the CJ.
CJ participants received two $100 gift cards as reimbursement for their time. Ethics approval was provided by the University's Human Research Ethics Committee (#16213).

| Procedure
The CJ was conducted over a weekend (10)(11) March 2018) (see Table 1 for schedule). All sessions except for the final deliberation were facilitated by an experienced facilitator and researcher, who had conducted work in the field of obesity/weight management. The facilitator ensured equal participation, recorded questions and noted participant concerns. Two observers took notes on participant comments, affect and participation, except during the final confidential deliberation. To not lead or bias the jurors towards a specific recommendation, only jury group members were present during private deliberations.
On Day 1, following written consent, participants completed a brief survey to assess their comprehension of the topic and attitudes prior to receiving information. Four experts with clinical, research and public health expertise, each presented 20-minute voice over PowerPoint presentations followed by a telephone question-and-answer session with the jurors. As background, the first expert provided a scientific overview of obesity; the second presented on the available resources and services for weight management in the local region. The third and fourth experts presented opposing views on whether GPs should initiate conversations with patients about weight management. Participants were provided with hand-outs of the presentations and the experts' biographies.
Participants commenced facilitated discussions after the presentations and broke for the day. On Day 2, participants shared overnight reflections and, where needed, re-questioned the experts by telephone. Participants then deliberated in private until a consensus or impasse was reached and presented their decisions on the two questions to the facilitator and other researchers. Postsurveys were administered to participants prior to CJ completion. 9.00-9. 30 Overview of Community Jury To capture jurors' decisions, participants were asked whether they would want GPs to initiate a conversation with them and whether they thought GPs should initiate conversations in general using a 7-point scale ranging from 1 (definitely not) to 7 (definitely would/should). Responses of 5-7 were classified as positive and scores of 1-4 as negative. As per other CJ studies, to explore the time and information provision required to achieve consistent responses, we asked participants these questions on nine occasions. 24 An informed decision was defined as adequate comprehension (>50%) and a consistency between attitudes and decisions. 21,22

| Analyses
CJ proceedings were audiotaped and transcribed. Reasons for the jury recommendation were analysed by two researchers using thematic analysis. 25 Changes to participant survey responses pre-to post-CJ were assessed using Wilcoxon signed-rank tests. All quantitative data were analysed in SPSS Statistics 23.

| RE SULTS
Of the 13 participants recruited, 11 (5 males and 6 females) attended the CJ weekend. No explanations were provided for nonattendance. Mean age of attendees was 47 years (SD 20); median BMI was 29.1 (IQR 26.6-31.6). All jurors had completed high school and a majority had some post-high school education (9/11; See Table 2).

| Community Jury decision, GP initiating conversation on weight management
The jury found the original first question problematic and opted to change it to 'Should GPs discuss lifestyle, health, and weight management, with their patients?' All 11 jury members voted yes to the amended question.
In what contexts should GPs discuss weight management? (a) Patient-initiated (e.g. when a patient brings the topic up for discussion or if the patient has completed a questionnaire that asks if they would like to discuss specific issues with their GP, and lifestyle, weight management or health is one of these topics), (b) In the context of prevention and management of a health condition, and / or (c) Screening (discussed with everyone who comes in, regardless of context/reason for visit).
While all jury members agreed with options (a) and (b), option (c) was more divisive, with five members agreeing and six disagreeing that GPs should screen all patients for overweight/obesity.

| Jury's rationale for changing the question
The jury felt it was important that weight management be considered as just one aspect of overall health as part of a holistic approach to care.
In terms of screening, the jury did not reach a unanimous decision.
There was a lack of clarity about the appropriate timing of any potential weight screening, or evidence for this approach.
'the screening is just a mechanism, and how it's applied and when, is not answered' 'That's fine and dandy to screen every human being, everybody who walks through their door, but we don't. We don't know what works.' Around half felt this would be appropriate as they believed GPs should be able to discuss weight in all contexts.
'I just think that when the opportunity arises on anything, that they should be able to confront you.
They're your GP.' (5F) Those in support of screening felt that screening could be normalized, or made routine, in line with other regular checks, and that weighing everyone would avoid discrimination.

| Comprehension, attitudes and individual decisions
There were no changes pre-to post-CJ in participants' comprehension, attitudes or interest in GPs initiating conversations about weight management with either themselves or other patients (Table 3)

| D ISCUSS I ON
A CJ of individuals affected by overweight and obesity concluded unanimously that GPs should be discussing weight management in Knowledge total (/10) Framing any questionnaire or discussion around well-being and general health was perceived by the jury to be more acceptable than a sole focus on weight. All jury members were positive about weight management being raised in the context of disease, but discussed this in relation to clear indicators (such as high blood pressure). This is in contrast to some research, which suggests attempts to link weight management discussions to health may be more likely to cause resistance. 26 However, the jury was more divided about BMI alone as a risk factor and screening tool, and emphasized the importance of considering all aspects of an individual's health and well-being. On the other hand, routine screening for all patients was discussed as a way of avoiding reliance on a GP's visual assessment alone, which can be inaccurate, 30 and could cause patients to feel stigmatized.
Another common barrier for GPs discussing weight is the perception that interventions are ineffective, particularly over the longer term. 7 However, while some members of the jury acknowledged that weight management is difficult and outcomes variable, no jury members voiced that they felt this should be a deterrent. Some members of the jury highlighted that GPs are perceived as both trustworthy and objective. Patients may be open to discussions about weight management options presented alongside the available evidence.
Additionally, highlighting the independent value of increasing physical activity for health, 31 for example, may be well-received. In this context, it may be important to incorporate measurements of success beyond weight loss and to assess the impact of any changes on overall well-being. 32 It is important to note that this jury chose to change the question provided to them. Previous public deliberation studies have permitted participating publics to frame the questions, 17 but it is not a common outcome. Involving members of the public with lived experience in the design of future CJ research could ensure the development of questions that a jury feels are appropriate. In the context of the current study, the change could reflect the complexity of the issue, and sensitivity around the language used when discussing weight management. 33 The jury felt that asking about weight management alone was insufficient, and potentially stigmatizing. Community juries are not intended to be representative of the wider population but we sought to include a balance of men and women, and a variety of ages and levels of education. However, a limitation of this study is that the majority of our sample were educated to a post-high school level and those with lower levels of education were under-represented. Due to low recruitment and 2 non-attenders on the day, our sample was below the recommended composition of 12-25. It was still within the range reported within a scoping review of public deliberation, which identified 20 community juries, most of which were 1-2 day events involving a single jury of 9-16 people. 17 However, the low recruitment may suggest a lack of interest from individuals affected by overweight and obesity in this issue or that our approach was not appropriate. In line with the recruitment processes for most CJs, 17 we used an external recruitment company. This company did not hold information on our eligibility criteria, including BMI, and so we do not have data on eligibility rates nor on the number eligible that were approached but declined.
The median BMI for our sample was within the overweight category, and we may not have captured the views of those affected by higher levels of excess weight. People with severe obesity are more likely to experience stigma, including in health care, 35 and so may have been less willing to discuss their experiences. Future research should seek to engage those with higher BMIs, to explore whether they would make similar decisions. All participants in this jury also had high levels of knowledge about overweight and obesity at baseline. Their views provide insight into the informed attitudes of people affected by overweight and obesity. However, other, less-engaged groups may reach different conclusions. Similarly, the views expressed were based on engagement with primary care in Australia, and it will be important to repeat this process in countries where experiences of primary care may differ. This jury also focussed on GPs discussing weight management within primary care and did not explore views on other health-care professionals engaging patients in these discussions.
The present study suggests that informed people affected by overweight and obesity in Australia believe GPs should discuss weight management with their patients. The views of this jury are in line with the NHMRC clinical practice guidelines for the management of overweight and obesity in Australia, which recommend GPs Ask, Assess, Advise, Agree and Assist. 4 GPs should feel reassured that this approach is likely to be welcomed by patients, particularly if embedded within a more holistic focus on personcentred care.

ACK N OWLED G EM ENTS
The authors would like to thank Professor Chris Del Mar and Professor Mark Harris for their contributions to the jury process and Professor Chris Del Mar for his thoughtful comments on a draft of this manuscript.

CO N FLI C T O F I NTE R E S T
None declared.

AUTH O R CO NTR I B UTI O N S
RB, AS, RT and PG designed the study. RB, AS, RT, GC, RS and HC contributed to the running of the study. RB, AS and RT analysed and interpreted the data. RB wrote the manuscript. All authors provided critical comment, edited the manuscript and approved its final version.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.