Nutritionists and the comprehensive care of overweight individuals in primary care

MOURA, Ana Luisa Souza de Paiva; RECINE, Elisabetta

doi:10.1590/1678-9865201932e190008

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Sumário

Original • Rev Nutr 32 • 2019 • https://doi.org/10.1590/1678-9865201932e190008 copy

Nutritionists and the comprehensive care of overweight individuals in primary care

O nutricionista e o cuidado integral do indivíduo com excesso de peso na atenção básica

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

This study sought to highlight the different types of challenges for the integral care of overweight individuals in primary care based on the perception of nutritionists.

Methods

This is a qualitative study with primary care professionals from the Federal District, Brazil. Semi-structured interviews were conducted to understand the perceptions regarding the organization of integral care. The analysis of the data was based on the theoretical framework Theoretical Domains Framework.

Results

Challenges related to 10 of the 12 different domains proposed by the theoretical framework were identifi ed. These challenges are related to the capability, opportunity and motivation of workers to act to offer moreeffective care.

Conclusion

The different nature of the barriers identifi ed were overlapped, which reveal the need for professional qualifi cation along with the consolidation of an appropriate care model for chronic noncommunicable diseases such as obesity.

Keywords
Delivery of health care; Integrality in health; Nutritionist; Obesity; Primary health care

Domain	Constructs	Definition	Use in research
Knowledge	Knowledge; procedural knowledge; knowledge of task environment.	Knowledge of the existence of some-thing, an evaluation based on the expression of having or not knowing about procedures or certain behaviors.	Knowledge of the guidelines or protocols that organize care as given as well as knowledge of how to carry out each of the actions in care.
Abilities	Skills; Skill development; Competence; Aptitude; Interpersonal Skills; Practice; Skill assessment.	Aptitude or proficiency acquired through practice, which is identified from expressions that describe techniques and skills used in carrying out the actions.	Interpersonal skills (empathy, practice, sensitivity, non-judgmental, patient approach, etc.) as well as skills adopted as an alternative due to the lack of adequate training.
Social or professional role and identity	Professional identity; Role of the professional; Social identity; Identity; Professional limits; Professional trust; Group identity; Leadership; Organizational commitment.	How professionals perceive them selves, to what extent they understand that carrying out those actions is their professional or social responsibility, how much their personal identity influences performance of that action or behavior.	The degree to which professionals feel that their performance of actions is their attribution, and the influence of perception of their identity for the development of actions.
Beliefs about abilities	Self-efficacy; Perceived skills; Self-confidence; Beliefs; Empowerment; Self-esteem; Perceived behavioral control; Professional trust.	Associated with acceptance of truth and validity about a skill or talent that professionals have and use for something.	Perceived capacity of professionals to perform actions.
Optimism	Optimism; Pessimism; Unreal optimism; Identity.	Confidence that actions will be considered good and desired goals will be achieved, or the opposite (associated with the pessimism con-struct).	Expressions that identify if the actions performed are something positive or even the opposite.
Beliefs about consequences	Beliefs; Expectation of results; Charac-teristics of outcome expectations; Early repentance; Consequences.	Acceptance of truthfulness and validity about the consequences or results of a behavior in a given situation.	Expressions indicating that profes-sionals believe that performing or not the given set of actions will have consequences for themselves, the team or the individual.
Reinforcement	Rewards (proximal/distal; valued/not valued; probable/unlikely); Incentives; Punishment; Results/effects; Reinforcement; uncertainty; sanctions.	Increased probability of a response from the relationship between the existence of a given stimulus and the occurrence of that response. Related to associative learning.	Expressions indicating that carrying out the proposed set of actions is associated with some reward or punishment, e.g. from unit management, team members, etc.
Intentions	Stability of intentions; Behavior change models; Transtheoretical model and stages of change.	It is a conscious decision to perform a behavior or the decision to act in a particular direction. It is more related to willingness to start or end a behavior.	How much the professional is willing to perform the actions provided for the care of the overweight individual and how much these actions are prioritized.
Objectives	Objectives (distal and proximal); Objective priorities; Establishment of objectives/goals; Objectives (autonomous or controlled)Action planning; Implementation of intention.	It is related to a future scenario toward which individuals focus on their actions, i.e. the purpose of the activities or efforts used.	Expressions that indicate possible goals that will be achieved in comprehensive care for overweight individuals.
Memory, attention and decision processes	Memory; Attention; Attention control; Decision making; Cognitive exhaustion/tiredness.	The ability to retain information, selectively focus on aspects of the environment, and choose between two or more behavioral alternatives.	Assertiveness about situations in which professionals remember or forget to perform the planned actions; Cognitive approaches to performing a behavior or making a quick decision; Cognitive limitations such as forgetting or not being able to make a particular decision regarding integral care.
Environmental context and resources	Material resources/resources; Envi-ronmental stressors; Culture; Organ-izational environment; Salient events/critical incidents; Person x environmental interaction; Barriers and facilitators.	Any circumstance associated with a situation or environment that encourages or discourages the development of skills, independence, social competence or adaptive behavior.	The statement of absence or presence, or even the expression of the desire for presence, equipments, resources, services organizational structure that facilitates or prevents care to individuals are environmental context factors and resources that influence the professional's behavior.
Social influence	Social pressure; Social norms; Group compliance; Social comparisons; Group norms; Group support; Power; Intergroup conflicts; Alienation; Group identity; Modeling.	Interpersonal processes that influence the change of thoughts, feelings or behaviors of individuals. Interactions that influence behavior may be associated, for example, with individuals, patients, staff, managers, or hierarchical relationships.	Assertiveness that shows that a relationship risks the development of actions or even that the form of interaction with the patient may condition the completion or not of care in an integral way.
Emotions	Affection; Stress; Depression; Fear; Burn out; Positive/negative affect; Anxiety.	Patterns of complex reactions that involve behavioral, psychological and experiential elements by which the individual deals with a relevant issue or event.	Expressions of emotional reactions or emotional states in view of the actions.
Behavior regulation	Self-monitoring; Breaking habits; Action planning.	Anything aimed to organize, manage or objectively change certain actions.	Assertiveness in which professionals want assessment or feedback of behavior, or when referring to necessary or ongoing processes to monitor the performance of action, i.e. conscious efforts that regulate behavior.

Component of “COM-B”	Behavior domain	Challenge/Barrier
Capability	Knowledge	Unawareness of actions defined for primary care in the context of integral care, both as a whole and isolated actions.
		Recognition of the proposal by similarity with the work done.
		Unawareness of the flow in the Health Care Network to achieve comprehensive care.

	Skills	Difficulty working as a team.
		Difficulties in approaching the patient.
		Inability to manage individuals who have undergone bariatric surgery.

	Behavioral Regulation	Lack of team planning.
		No protocol for health care.
		Lack of personal organization.
		Failure to demand from the chief.

Opportunity	Social Influences	Work misalignment among the team.
		Devaluation of the nutritionist by the team.
		Relational criticism and conflict.
		Low compromise of management.

	Environmental Context and Resources	Inadequate and insufficient physical space to perform actions.
		Lack of resources and materials.
		Health care network and non-consolidated care model.
		Shortage of professionals.
		Imbalance between demands and available workload.

Motivation	Beliefs about Consequences/Optimism	Perception of possible inequities in care.
		Disbelief in the model and its implementation.
		Optimism regarding the proposal subjected to team involvement.
		Optimism regarding the proposal subjected to the approach to care.
		Optimism about the proposal subjected to the individual’s interest in changing.
		Perception that the proposal makes work processes bureaucratic.

	Beliefs about abilities	Need for training.
		Need for team support to implement actions.
		Not feeling fit to perform certain actions.
		Competition with productivity goals and administrative processes.

	Social/Professional Role and Identity	Conflict between the nutritionists’ roles and team’s role.
		Conflict over duties that they believe are the responsibility of another aspect of care.
		Non-identification of care for bariatric individuals such as primary care responsibility.
		Demand for skills and abilities that go beyond the core of the profession.

	Reinforcement	Lack of team support.
		Team demotivation.
		Imposition of actions by management.

	Emotions	Frustration in view of results.
		Anxiety and powerlessness to change behavior.
		Anger and indignation.
		Guilt.

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[1] Correspondence to: E RECINE. E-mail: recine@unb.br.