Danish University Colleges
Evidence-based practice framing an occupational therapy-based weight loss programme for the Danish municipalities
Jessen-Winge, Christina
Publication date:
2021
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Citation for pulished version (APA):
Jessen-Winge, C. (2021). Evidence-based practice framing an occupational therapy-based weight loss programme for the Danish municipalities.
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1 Evidence-based practice framing an occupational therapy-based
weight loss programme for the Danish municipalities
Christina Jessen-Winge
Thesis for doctoral degree (PhD) Research Unit of General Practice and
Research Unit User Perspectives Institute of Public Health University of Southern Denmark
2020
2 Supervisors
Principal supervisor
Jeanette Reffstrup Christensen Associated professor, OT, PhD
Research Unit of General Practice and Research Unit of User Perspectives Department of Public Health
University of Southern Denmark Denmark
Co supervisors Kim Lee
Post Doc, OT, PhD
Research Unit of General Practice and Research Unit of User Perspectives Department of Public Health
University of Southern Denmark Denmark
Heather Fritz
Assistant professor, OT, PhD
Occupational Therapy and Gerontology
Eugene Applebaum College of Pharmacy and Health Sciences & Institute of Gerontology Wayne State University
USA
Hans Jonsson
Associated professor, OT, PhD
Department of Neurodiology, Care Sciences and Society Karolinska Institute
Sweden
3
Table of content
Acknowledgement ... 5
Abstract ... 7
Dansk resumé ... 9
Preface ... 11
List of publications ... 13
Background ... 14
The challenge for adults living with obesity ... 14
Weight loss programmes in the Danish health care system ... 15
Knowledge about weight loss treatment and maintenance ... 16
The acceptance of obesity treatment from an occupational therapy perspective ... 17
Changing obesity from an occupational science perspective ... 18
Doing, being, belonging and becoming ... 18
Occupational balance ... 20
Occupational injustice ... 20
Evidence-based practice ... 21
Summary ... 22
Research objectives ... 23
Approach for understanding ... 23
Specific aim corresponding to the four studies ... 24
Study I ... 25
Materials and methods ... 25
Establish hypothesis or hypotheses ... 26
Identify appropriate data ... 26
Sample ... 26
Coding ... 27
Analysis ... 28
Results ... 29
Study II and III ... 30
Methodology ... 30
Design of Study II and study III ... 31
Participants ... 32
Data collecting ... 33
Interview ... 33
4
Transcription ... 34
Analysing ... 35
Results ... 37
Participants ... 37
Findings Study II ... 38
Findings study III ... 38
Synthesized empirical findings ... 39
Study IV ... 40
Methodology ... 41
Design of Study IV ... 41
Participants ... 42
The procedure for the meetings ... 43
Transcription ... 46
Analyses ... 46
Results ... 46
Discussion of main findings ... 48
Study I – The evidence from weight loss programmes in Danish municipalities seems reductionistic ... 48
Study II and Study III – Focusing on self-efficacy and wellbeing in the weight loss transition supported by an occupational perspective... 50
Study IV – Sustainable weight loss through co-occupations ... 53
Methodological considerations ... 55
Study I ... 56
Study II and Study III ... 56
Credibility of data ... 57
Credibility of analysis ... 58
Study IV ... 59
Credibility of data ... 59
Credibility of analysis ... 60
Transferability of the overall study ... 61
Conclusion ... 61
Implications for research ... 62
References ... 64
List of appendices ... 75
5
Acknowledgement
A great number of people have made this thesis possible and I am grateful for all the support, interest and engagement from all of you!
First of all, I want to thank my principal supervisor Jeanette Reffstrup Christensen for your believe in me, for your honesty, for your advice and for all our discussions during the last three years. It has been a privilege to learn from one of the most skilled persons within this subject. Further, I want to thank my co- supervisor Kim Lee for opening my eyes for alternative perspectives, your engagement and your continuing advices to keep me on the right track during the studies. My co-supervisor Heather Fritz for your incredible knowledge and for your constructive critic in the production of all four articles and my co-supervisor Professor Hans Jonsson for sharing your enormous knowledge within occupational science. All of you have a great responsibility for making this possible.
I would like to thank all the participants in the studies who were willing to use their time and engagement.
Thank you to the postgraduates who helped me collect data during all the four studies. I have experiences so many positive responses from all of you about this project. I am privileged to have been together with people sharing my believe in the importance of this project.
A special thank you to my colleagues Anette Enemark Larsen and Anne-Le Morville with whom I have shared professional discussions and frustration during the years. Pia Ilvig and Signe Surrow I have enjoyed discussing and learning from you based on your knowledge as Master of Occupational therapists. And all the professional and private discussions with my fellow PhD students Svetlana Solgaard Nielsen, Ann Nielsen, Christina Tvede Madsen and Julie Karstensen.
Thank you to all my fantastic colleagues at the Department of Occupational Therapy at University College Copenhagen. This has been a long process and I am grateful for your thoughts, discussions, interest and patience. Further thank you to three of the heads of the department Gitte Mathiasson, Mette Andreasen and Helle Mousing for making this a reality.
Thank you to all my colleagues at the Research Unit of General Practice at the University of Southern Denmark. This research unit has made it possible for me to get feedback from both engaged and skilled occupational therapists and lifting the perspective to an interdisciplinary perspective. Thank you for your constructive feedback of my work.
This thesis and the studies within it have been funded by the Danish Occupational Therapist Association, University College of Copenhagen and University of Southern Denmark.
6 Thank you!
Last, but not least thank you to my friends thank you for being there and waiting for me. And my family, my mother, father, parents-in-law and sister-in-law for the support, for the concern and encouragement. My husband Kasper and my children Malte, Askild, and Silje I love you from here to the stars.
7
Abstract
Introduction
Obesity seems to increase all over the world, and it has therefore been labelled ‘the greatest public health challenge in our century’ as obesity is associated with a number of severe diseases. Besides becoming ill, citizens with obesity experience challenges engaging in occupations and experience fear of prejudiced.
In Denmark weight loss programmes are conducted in the municipalities as the municipalities holds the responsibility of health promotion and prevention. These programmes are developed and conducted differently in every municipalities in Denmark. Weight loss programmes placed in municipalities worldwide seem heterogenic which might be the same in Denmark. There is strong evidence for including the
components diet, physical activity and behavioral therapy in weight loss programmes. However, weight loss maintenance is still a problem as citizens who lose weight seems to regain it after one to five years maybe partly because of a reductionistic approach. Occupational therapists are recommended to be part of weight loss programmes in the Danish municipalities and a recent scoping review has shown potential for
occupational therapists in weight loss programmes because of a more holistic and occupational perspective. Weight loss within occupational therapy is still sparsely described and need to be further evolved. One way is by taking an occupational science perspective based on occupational engagement and health.
There seems to be a potential to develop an occupational therapy weight loss programme for the municipality context.
Objective
The overarching aim of this thesis was to develop knowledge about “best practice” to develop an
occupational therapy weight loss programme for the Danish municipalities. “Best practice” was understood through the concepts of evidence-based practice: evidence, experiences from clinics and clients and context.
Design
To answer the overarching aim, four studies were made based on evidence-based practice. The concepts in evidence-based practice point at different epistemological understandings as it holds the ideas about evidence and perspectives. To integrate these differences in understanding a pragmatic eclectic approach situated this thesis. The benefit of this approach is that it provides possibilities of combining
understandings and methods best suited for every specific aim with each study and thereby provide the possibility to enable knowledge from the different perspectives in evidence-based practice.
8 Study I: To examine Danish municipal weight loss programmes to identify and describe programme content and structure (i.e. dose, delivery format), the intended programme recipients, and the involvement of occupational therapists and other health professionals in programme delivery.
Study II: To understand what citizens with obesity who have not sought out municipal weight loss services would want in a weight loss programme.
Study III: To explore health professionals’ views of what an ideal, holistic weight loss programme should include.
Study IV: To obtain a description of what strategies could support the components of diet, physical activity, habits, social relations and occupational balance in a weight loss maintenance programme in Danish municipalities.
Results
In study I: Various health professionals conducted the programmes, and five involved occupational therapists. Programmes targeted children, adolescent and adults. Dose, structure and content were heterogeneous.
In study II: Three themes emerged from the analysis: “Creating structure for success”, “Needing support for making up for gaps in willpower”, “Changing to doing something with positive meaning”.
In study III: Three themes emerged from the analysis: “Support from the social network are important both during and after a weight loss”, “Changing the self-belief by positive discussions and doing activities”,
“Maintaining changes through daily life”.
In study IV: Five themes presenting each component arose: 1) Diet – Find the line between either or, 2) Physical activity – Break the comfort zone, 3) Social relations - Stand strong together, 4) Habits – Focus on possibilities instead of bad habits, and 5) Occupational balance – Handling life´s bumps.
Conclusion
In this PhD project five components was found important in a weight loss programme: Diet, physical activity, social relations, habits and occupational balance. These components could be supported by taking an occupational perspective on weight loss by focusing on competence and wellbeing and by focusing on finding common meaning by engaging in co-occupations for weight loss maintenance.
9
Dansk resumé
Introduktion
Overvægt og fedme ser ud til at være et stigende problem over hele verden og er derfor blevet kaldt ”Den største sundhedsudfordring i vores århundrede”. Fedme er forbundet med en række alvorlige sygdomme.
Udover risikoen for alvorlige sygdomme oplever borgere med fedme udfordringer ved deltagelse i betydningsfulde aktiviteter og frygt for fordomme.
I Danmark gennemføres vægttabsprogrammer i kommunerne, da det er denne sektor, der har ansvaret for sundhedsfremme og forebyggelse. Vægttabsprogrammerne er udviklet og gennemført forskelligt i alle kommuner. Vægttabsprogrammer internationalt udviklet og gennemført i det, der kan sammenlignes med de danske kommuner, har vist at være heterogene og uden effekt i forhold til vægttab. Det samme kan være tilfældet i de danske kommuners vægttabsprogrammer.
Der er signifikant evidens for at inkludere komponenterne diæt, fysisk aktivitet og adfærdsterapi i vægttabsprogrammer, men vedligeholdelsen af vægttabet er dog fortsat en udfordring, da borgere, der taber sig, synes at tage det meste på igen efter fem år. Dette kan delvis skyldes en reduktionistisk tilgang.
Ergoterapeuter anbefales at være en del af vægttabsprogrammerne i de danske kommuner og et nyere scoping review har vist positive resultater ved at inddrage ergoterapeuter på grund af et mere holistisk aktivitetsperspektiv. Vægttab indenfor ergoterapi er dog sparsomt beskrevet og skal udvikles yderligere. En måde at gøre dette er at inddrage et aktivitetsperspektiv med fokus på aktivitet deltagelse og sundhed.
Formål
Det overordnede formål med denne afhandling var at udvikle viden om ”bedste praksis” til at udviklet et ergoterapeutisk vægttabsprogram til de danske kommuner. ”Bedte praksis” blev forstået gennem begreberne fra evidens baseret praksis: evidens, erfaringer fra praksis og kontekst.
Design
For at besvare det overordnede formål blev der gennemført fire studier baseret på evidensbaseret praksis.
Begreberne i evidensbaseret praksis peger på forskellige epistemologiske forståelser, da det indeholder begreberne evidens og perspektiv. For at understøtte integreringen af disse forståelser bygger denne afhandling på en pragmatisk ekletisk tilgang. Fordelen ved denne tilgang er, at den giver mulighed for at kombinere forståelser og metoder, der er bedst egnet til at besvare de konkrete formål ved hvert enkelte studie.
10 Studie I: At undersøge vægttabsprogrammerne i de danske kommuner for at identificere og beskrive indhold, struktur (dosis og format), de tilsigtede målgrupper og involveringen af ergoterapeuter og andet sundhedspersonale i programmerne.
Studie II: At forstå, hvad borgere med fedme, der ikke har opsøgt kommunale vægttabsprogrammer, ønsker i et vægttabsprogram.
Studie III: At undersøge sundhedspersonalets synspunkter om hvad et ideelt, holistisk vægttabsprogram skal indeholde.
Studie IV: At opnå en beskrivelse af, hvilke strategier, der kan understøtte komponenterne diæt, fysisk aktivitet, vaner sociale relationer og aktivitetsbalance i et vægttabsprogram til de danske kommuner.
Resultat
Studie I: Forskelligt sundhedspersonale gennemførte programmerne og fem ergoterapeuter var involveret i alt. Programmerne var målrettet mod børn, unge og voksne, Dosis, struktur og indhold var heterogene.
Studie II: Tre temaer fremkom gennem analysen: ”Struktur til opnåelse af succes”, ”Brug for støtte til at kompensere for manglende viljestyrke”, ”Forandringer skal have positiv betydning”.
Studie III: Tre temaer fremkom gennem analysen: ”Støtte fra det social netværk er vigtig både under og efter et vægttab”, ”Støtte af selvtillid gennem diskussioner og aktiviteter”, ”Vedligeholdelse skal ske gennem de daglige aktiviteter”.
Studie IV: Fem temaer, der præsenterede fem komponenter, fremkom gennem analysen: ”Kost – Find balancen mellem enten-eller”, ”Fysisk aktivitet – Bryd komfortzonen”, ”Social relationer – Stå stræk sammen”, ”Vaner – fokus på muligheder i stedet for dårlige vaner”, ”aktivitetsbalancen – håndtere bumpene gennem livet”.
Konklusion
Gennem denne ph.d. - afhandling blev fem komponenter fundet vigtige at inddrage i et vægttabsprogram - kost, fysisk aktivitet, vaner, sociale relationer og aktivitetsbalance. Disse komponenter kunne understøttes ved inddragelse af et aktivitetsperspektiv gennem et vægttabsforløb. Aktivitetsperspektivet skal fokusere på kompetence og velvære igennem vægttabet og på ’sam-aktiviteter’ for at vedligeholde vægttabet.
11
Preface
I entered the education for occupational therapy by a coincidence many years ago. I really wanted to be a phycologist but when I failed going to the University, I had to find an alternative and it became
occupational therapy. For me, back then, I thought it was very much the same. Obviously, occupational therapy is partly phycology, but it is so much more and today I am so thankful for this misunderstanding and for failing going to University at that time. Becoming an occupational therapist has been a journey. A journey back and forth but a journey that has become part of me and my identity. I love being part of the circle filled with proud occupational therapists.
I only worked for few years as an occupational therapist as I was attracted to academia. Back then close to the millennium, there were no post-graduate occupational therapist studies in Denmark but the Master of Health for different health professions had just started and I entered in Odense in class number two.
Through this Master the point of occupational therapy “being so much more” was validated for me. Holism might be a clichéd, but I do not know how to explain it otherwise. I believe that our holistic view in people is unique because our focus is in helping people living their everyday life and navigate around the whole person and their environment. I believe in the saying: a doctor helps people stay alive, occupational therapist helps people live their life.
Since I finished my Master and became a lecturer for the occupational therapy education programme in Copenhagen, I have worked with health promotion. One of heads, Gitte Matthiessen, introduced me for Lifestyle Redesign® and this approach really open my eyes for the important link between my education as occupational therapist and my Master of health. Working with occupation the way it was done in Lifestyle Redesign® by teaching the participants about the importance of occupations for growth and wellbeing has guided my academia path since then. Already in 2012, I was supported by my workplace and University of Southern Denmark to work with a PhD about Lifestyle Redesign®. However, different circumstance prevented me from following that dream and I decided not to go along with doing a PhD. But then I met Jeanette Reffstrup Christensen back in 2017. We shared a common interest in occupational therapy and health of science but her enthusiasm in obesity inspired me. It was a new field for my as it is a new field in occupational therapy.
This thesis is part of a project with the aim of developing, evaluating and implementing an occupational therapy-based weight loss programme (WLP) in the Danish municipalities. The project is called Danish Obesity Intervention Trial (DO:IT). The initiative for this project was Jeanette´s based on her PhD project FINALE showing substantial reduction in body weight, BMI and body fat among overweight female health care workers after one year (1,2). The intervention was supported by diet, exercise and behavioral therapy.
12 It was inspired by occupational therapy, but no theory or research science from this field was directly introduced. Based on our common interest and believe in occupational therapy we wanted to make this explicit in the DO:IT project. And therefore, this thesis takes an occupational perspective defined as “a way of looking and thinking about human doing” (3). The definition holds the understanding that occupations are doing on both an individual and social level and can contribute to being, becoming and belonging (3).
Humans are perceived as occupational beings who engage in occupations to constitute oneself and evolve as humans (4). Occupations has great influence on health and wellbeing and is defined as all that people need, want, or are obliged to do across the sleep-wake continuum (5). They are personal constructed perception from a unique context opposite to activities that are more objective and described as general shared ideas about categories of action (5–7). In short, people seek to cover daily needs, create meaning and wellbeing by seeking engagement, challenge and development through occupations (5).
I hope you will enjoy my thesis.
Christina Jessen-Winge, Måløv 2020
13
List of publications
Study I: Jessen-Winge C, Ilvig PM, Jonsson H, Fritz H, Lee K, Christensen JR. Obesity treatment – a role for occupational therapists? Scandinavian Journal of Occupational Therapy. 2020:1-8.
https://www.tandfonline.com/loi/iocc20
Study II: Jessen-Winge C, Ilvig PM, Fritz H, Brandt CJ, Lee K, Christensen JR. What a weight loss programme should contain if people with obesity were asked – A qualitative analysis within the DO:IT study. In review, BMC Public Health, PUBH-D-19-03811
Study III: Jessen-Winge C, Ilvig PM, Thilsing T, Lee K, Fritz H, Christensen JR. Health professionals’
perceptions of weight loss programmes and recommendations for future implementation: A qualitative study. Accepted for publication, BMJ Open, bmjopen-2020-039667
Study IV: Jessen-Winge C, Lee K, Surrow S, Jonsson H, Christensen JR. Five vital components in a cross- disciplinary occupational therapy-based municipal weight loss programme obtained through research circles. In review, Australian Occupational Therapy Journal, AOTJ-2020-177
14
Background
The challenge for adults living with obesity
More than 1.9 billion adults are overweight and 650 million are obese globally (8). It has been forecasted that the number of citizens with obesity will continue to rise for decades to come (9). In Denmark, the prevalence of obesity is still increasing (10). According to the Danish Health Authority, 51% of the Danish population is estimated to be overweight or obese (10). The prevalence of overweight and obesity is highest among people living with a partner, with low socioeconomic incomes and low educational
attainment (10). Overweight and obesity are terms that are often classified according to Body Mass Index (BMI), which is defined as an individual’s weight in kilograms divided by the square of their height in metres (kg/m2) (WHO 2000). Overweight is classified as a BMI ≥ 25 kg/m2and obesity is classified as a BMI ≥ 30 kg/m2 (WHO 2000). In this thesis the focus will be on both overweight and obesity. based on the recommendations made to Danish municipalities by the Danish Health Authority (11). However, for readability I will use the term obesity.
Obesity is seen as ‘the greatest public health challenge of the twenty-first century’ (8). Its health consequences include reduced life expectancy and serious health diseases such as diabetes, cancer and cardiovascular diseases (12). Obesity is also related to both physical and psychosocial consequences, as citizens living with obesity often experience physical pain, fatigue and difficulty moving around and experience a feeling of being less valued, stigmatised and can have low self-esteem (13,14). These consequences affect the whole spectrum of everyday life, because they have a great impact on
engagement in both activities and occupations (14,15). Citizens with obesity experience a high degree of disabilities in varies daily physical activities, such as walking up/down staircases and stairways, performing pedicure, dressing the lower body and doing outdoor exercise. These disabilities are experienced because of pain, fatigue, exhaustion and size (13–15). Occupations such as shopping for clothes, playing with children, swimming and dining out are avoided because of psychosocial challenges (15,16). Citizens with obesity explain that they fear prejudices from others which results in a feeling of embarrassment and humiliation (15–17). In a personal reflection of occupational consequences of weight loss surgery, Linda Wilson reflects about her ability to do things differently following weight loss surgery (18). Her capacity for engaging in occupations changed because of increased musculoskeletal flexibility, stability and overall fitness. This capacity directly influenced her occupational patterns and routines during the day because activities took less time, e.g. dressing in the morning, needing fewer hours for sleep and more energy for doing occupations compared to when she was obese (18). She also noted a change in the way people responded to her presence: “People in shops ask if I would like assistance, where previously I would have
15 needed to seek a shop assistant. People look at me, catch my eye and smile at me in the street much more often, and children come and sit on my lap (because I now have one)” (18). The qualitative studies shows that people with obesity face challenges in their occupational engagement because of individual norms and societal norms, substantiating a need for taking an occupational perspective in a weight loss process (14,15,17,18).
Weight loss programmes in the Danish health care system
The Danish health care system is organised across three political and administrative levels: the state (the national level), five regions (the regional level) and 98 municipalities (the local level) (19). The state has the responsibility to regulate and supervise the health care system (9). The five regions are mainly responsible for acute care at hospitals (9). The 98 municipalities holds a variety of obligations related to healthcare, including health promotion and prevention (9). This division of obligation means that Danish hospitals provide surgical and medical treatment for obesity while Danish municipalities provide lifestyle programmes.
Every municipality in Denmark is obligated to offer WLPs for citizens. The primary recommendation from the Danish Health Authority is for the municipalities to include physical activity and diet in the WLPs they carry out followed by recommendations about behavioural therapy and psychosocial elements such as wellbeing and communities (11). The recommendations are concretised in a programme called ‘Small steps’
(‘Små skridt’) focusing on changing diet and activity habits through small steps (20). The ‘Small steps’
programme is directed at the citizens with obesity as a supplement to a weight loss process (21). Both the Danish Health Authority) and the Danish Association of Occupational Therapists (‘Ergoterapeutforeningen’) recommend that occupational therapists should be involved in WLPs (11, 22). The recommendation from the Danish Association of Occupational Therapists refers to the need for habit and routine changes with a holistic, occupational-based focus (22). However, no evidence is directly cited in either of the
recommendations about how to include occupational therapists or how the municipalities should work with psychosocial elements, habits or routines. This could be due to the fact that weight loss in the field of occupational therapy is still in its infancy (2, 23). Even though occupational therapists are recommended as part of municipality WLPs, it is not known how many occupational therapists participate in these
programmes. It is also not known which other health professionals are included in the WLPs and thus it follows that the impact of their professional knowledge and experience on the development of the WLPs is also unknown. Another important aspect not emphasised in the recommendation but which should be taken into account is that in Denmark, it is a political goal that citizens should be involved in decisions regarding how to prioritise their treatments to secure treatments that are aligned with their daily lives (24).
16 This is often described as patient or citizen involvement and has been shown to provide better outcomes of treatment (24).
As stated, every municipality is obligated to provide and develop WLPs and it seems likely that these programmes may be affected by the health professionals involved and that citizens’ wishes are not
included. Furthermore, only a few of the WLP´s are evaluated. One programme from Syddjurs Municipality called ‘Gør livet lettere’ (‘Make life easier’) was evaluated using survey and focus group methods (25). The result showed that the participants had a mean weight loss of 3.1 kg over a 15-month period. Before the programme started, 45% were physical active whereas 67% of the participants were physical active at the end of the programme. The participants were especially satisfied with the use of body age measurement, psychology, cooking and exercising (25). Another programme called ‘Vind over vægten’ (‘Conquer weight’) from Halsnæs Municipality showed positive results on weight and BMI, but no methods were descripted (26). However, none of the WLPs related to adults were evaluated in randomised controlled studies (21,25,26). A systematic review from the United Kingdom has shown that primary care WLPs are very heterogenous and no clinical significant reduction in weight loss was found (27). Even though it cannot be concluded that more systematic evaluations from the Danish municipalities would give the same
disappointing results on weight loss it might be expected because of the missing alignments in the development of the WLPs
Knowledge about weight loss treatment and maintenance
Guidelines from the American Obesity Society there are based on strong evidence from systematic reviews recommends people with obesity to participate for six months in a programme that included assistance to adhering to a low-calorie diet, and increased physical activity through the use of behavioural therapy (28,29). A 5% weight loss has been shown to improve health outcomes and is currently described as a standard goal (28,30). Despite the positive results with weight loss there are still great challenges with finding strategies for maintaining weight loss as many people with obesity regain the weight six month after the programme has ended (31). On average people regain about a third of the lost weight within a year and regain the renaming lost weight within a 3–5 year period (30,32). The fact that successful weight loss maintenance has been more or less ignored until recently might be because obesity is now
conceptualised as a chronic condition which requires long-term treatment and care (33). The research on traditional weight loss founded in a reductionist paradigm is demonstrative as a model not maintainable for long-term health benefits. A reductionistic paradigm focuses on the body as a mechanism where it is possible for people to reach a goal based on calories in and calories out (34). This approach has been criticized in a Ph.D. for negatively effecting eating disorders, body dissatisfaction, low self-esteem and
17 stigmatisation (35). In addition, the pattern of weight loss and regain called ‘weight cycling’ further
negatively influenced health and quality of life (35). There is a need to challenge this reductionist understanding and Robison has argued that weight loss and weight loss maintenance should be viewed from a holistic paradigm (34). A holistic view would support understanding ‘the whole through learning as much as possible about all the parts’ (36). Holism is understood as capturing the complexity in a weight loss process by focusing on physical, social and emotional factors (36). This understanding is still relatively diffuse and difficult to grasp but taking an occupational perspective could narrow it down to factors that can be combined with occupational engagement.
The acceptance of obesity treatment from an occupational therapy perspective
The point about taking an occupational perspective was stated by Clark in 2007 as she wrote that occupational therapists have the potential to support citizens with obesity engaging in daily life through occupations (37). This statement has been further supported by several scientists arguing that occupational therapists can play an important role in facilitating occupational engagement by reducing challenges experienced by people with obesity (38–40). It has been argued that occupational therapists should include the interaction between the person, environment and occupation (PEO) when developing WLPs (15,41,42).
PEO was first developed in the 1996 by Law to show how occupational performance results in a dynamic relationship between the three elements from a dualistic view (43).
Turning to existing WLP´s for adults, the specific role of occupational therapists is described only sparsely (39,42). One promising WLP was a family-based intervention called Lighter Living (LiLi) (44). This was an occupational-focused intervention that altered lifestyle changes by focusing on everyday routines and increasing the time family spent together to decrease the BMI of the children (44). The parents increased the time they spent with the children by 91 minutes per day. The children’s BMI did not decrease in a significantly statistically way, but the authors emphasise point at the clinical importance (44). Despite the missing statistically significant results in lowered BMI, this intervention is interesting from an occupational perspective view as it succeeded in merging weight loss and occupations though routines in lifestyle on an individual level. The same transparency is not detected in occupational WLPs directed for adults. A recent scoping review, mapping weight loss interventions involving occupational therapists, has shown that the involvement might support weight loss in the short term (39). Thirteen articles on 11 studies were found with three of them being RCT studies. Two of the studies were solely led by occupational therapists. The most commonly used outcomes were weight loss, body mass index and waist circumference. Overall, the role of occupational therapists was not very explicated but teaching about the activity’s role, focusing on enjoyment and a holistic approach involving family and friends were only mentioned in the articles that
18 gave a more detailed description of the occupational therapy role (39). The authors conclude that
occupational therapy interventions might operate with a broader perspective than the three elements usually recommended in WLPs; diet, physical activities and behavioural therapy because of a focus on the whole person and situation (39). This conclusion seems relevant compared to the challenges perceived by citizens living with obesity in engaging in occupations (15). However, the conclusion is tentative as
knowledge about what an occupational-based WLP could look like is still purely described from the perspective of occupational therapists and citizens with obesity, and from a theoretical perspective.
Changing obesity from an occupational science perspective
In order to change the circumstances for citizens with obesity, as an occupational therapist, it is relevant focusing on occupations and health from doing, being, becoming and belonging, occupational balance and occupational justice (5,45).
In this section, theoretical concepts will be outlined which together can expand the occupational
perspective of the human being (5) and provide the base for occupational therapists in WLPs. As outlined, a recent concept mapping study on occupation centred interventions ‘doing as an agent of change’ was put forward to express the uniqueness of an occupational therapy intervention (46). This builds on the core assumption that humans are perceived as occupational beings (4).
Doing, being, belonging and becoming
Ann Allart Wilcock’s occupational perspective is in line with the one presented in this thesis as she argued that taken an occupational perspective improves the understanding of health and wellbeing by examining the complexity of occupational engagement. Understanding doing as contributing to being, becoming and belonging is the basis of the theory (5). The concepts are complex and Wilcock states that the concepts should be understood both separately and interdependently to understand the link between occupation and health (45,47). All four concepts hold a subjectivist perspective but according to Wilcock this
perspective is influenced by collectivism, culture, society and history (5). Her understanding is in line with occupational scientists like Clark who connects occupations as unfolding phenomena that are products of sociocultural, contextual and individual factors (48) and Whiteford who recognises occupations in the context of economic, historical, social and political forces (49).
Doing is the core concept, because according to Wilcock, it is a basic need that is associated with survival and conversely, if people are not doing, serious problems can arise (4,47). Doing is often associated with occupations but the other concepts being, becoming and belonging need to be included to avoid it having a superficial and reductionistic understanding. Doing is the medium for engagement which is central in linking occupation and health (5). Occupational engagement is beyond occupational performance in a
19 physical sense, including engagement at a mental or emotional level. In other words, occupational
engagement can be both active visually, mentally or emotionally (50). Morris et al. puts positive value on engagement, showing a taxonomy where participation is a neutral word in the middle, with the words indifference, disengagement and repulsion having negative value, and interest, engagement and absorption having positive value (51).
Wilcock states that there are more than active doing processes related to occupations. She believes that beyond the process, which is partly about self, lies the concept being (45). Being is a very individualistic concept and Wilcock was influenced by Heidegger in understanding being as ‘being-in-the-world’ (Dasein) (5). The experiences carry a truth within themselves, which enables insights and interpretation of different kinds of wellbeing within the individual (52). For Wilcock, this meant that being is about being true to oneself and having time to discover, think, reflect and simply to exist (45). She believes that health and wellbeing are linked to living in a state of nature and having time (5,45). Doing and being might somehow hold the core of occupational science by connecting occupation and the meaning they hold for people in the light of health. People are described as human beings, as a state of existing indicating that doing and being gives opportunities for satisfaction, meaning, purpose, energy, pleasure and balance (5). Therefore, facilitating health for people with obesity could be done through occupations driven by people’s choices that meet their needs as occupational beings and not just related to weight and BMI (53).
Development and change are important in Wilcock’s arguments for the connection between health and occupation. She shows that people do not become but are constantly becoming, because we are social and self-actualizing beings with a constant need to fulfil both personal and social goals for the pursuit of happiness (5). Development should not be driven by a reductionistic view in weight loss by focusing on calories in and calories out, but by what we are best suited to become naturally. We have to be true to ourselves (45). Engaging in occupations that people perceive as self-actualizing provides opportunities to ground a sense of competency (5). Self-actualizing occupation is connected to self or being and the motivation for becoming are therefore founded in being but also in the social forces (5). This brings us to belonging that is fitted with a sense of being suitable or acceptable and being comfortable and secure in what one does. These positive feelings derived from belonging are fundamental for development of the individual (5). Belonging is partly grounded in occupations as it provides access and assistance to valued occupations, it provides meaning to doing because it is perceived as sharing interest, intimacy and obligation. Belonging is enacted through daily life, either by doing something on behalf of another or by participating in collective occupations. Wilcock sees doing and being as maintaining the relationship with others and connects this relationship as a foundation for health and wellbeing (5).
20 In summary, the concept of doing, being, becoming and belonging have the potential to theoretically address how engagement in occupations can be used to promote weight loss (doing and being) as well as weight loss maintenance (becoming and belonging).
Occupational balance
Wilcock states that a positive relationship between doing, being, becoming, and belonging leads to occupational balance (5). She states that “the balance may be among physical, mental and social
occupations; between chosen and obligatory occupations; between strenuous and restful occupations, or between doing and being”. For Wilcock, occupational balance is not a static process, it is a dynamic process (5).
Wilcock’s definition might seem difficult to grasp as it is very general. In this thesis, it seems relevant to expand the definition. Håkonsson, Morville and Wagman have conceptualised the concept by defining occupational balance as a subjective experience of having the right amount of variation in an occupational pattern (54). By this understanding, the balance is to have varied occupations and not just a single
dominating occupation, to have an experience of meaningfulness overall and that the occupations are in line with the person’s resources of time, energy and ability (54). The linkage between occupational patterns and occupational balance under influence of environmental factors is visualised by Eklund el al (55). They describe occupational patterns as being objective, containing taxonomies, complexities and alterations, and occupational balance as subjective, containing ability and resources, congruent with values and meanings and having the right mix (55).
If a balance between occupations are not found it will lead to occupational imbalance. Occupational imbalance occurs if occupations are not aligned with subjective and physiological needs and routines.
Experience occupational imbalance can have a tremendous effect on health (56). Occupational imbalance can appear based on injustice in society but in this thesis occupational balance and imbalance will be understood as an individual condition (56).
Occupational injustice
To capture the whole understanding of occupational perspective, this section will focus on the societal view. Individuals have the right to equal opportunities to engage in occupations within the context of their environment in order to meet basic needs and maximise their potential (5,56). If these opportunities are not given, occupational injustice occurs. Wilcock states that occupations are unfairly assigned across
different groups in society, as some groups are excluded from occupations that support and enhance health and wellbeing (5). Wilcock and Townsend presented four forms of occupational injustice (57). One of them was (as previously mentioned) occupational imbalance and the others were occupational alienation,
21 occupational deprivation and occupational marginalisation. Occupational alienation is described as a prolonged experience of being disconnected or isolated from occupations and having a sense of
meaninglessness (57). Wilcock defines occupational deprivation as preclusion from engaging in necessary or meaningful occupations due to factors outside the individual’s control (56,57).
The concept of occupational marginalisation will be the concept used in this thesis to understand how norms and values in society can affect peoples’ ability to engage in occupations. The concept is described as a major force of injustice being normative standardization of expectations about how, when and where people “should” participate’ (57). Informal norms and expectations within sociocultural and collectively context do not restrict people from participation in occupations because of law or policy but rather because of norms and traditions (56). Occupational marginalisation might lead to stigmatisation as specific groups of people might be excluded from mainstream life because of norms and expectations (57). One group could be citizens with obesity, as society holds many norms and values about this group.
The concepts presented are linked to each other as the interaction between doing, being, becoming and belonging, can be either positive or negative related to health and from both a subjectivist and society understanding (58). The understanding is shown in figure 1.
Figure 1 The understanding of Wilcock´s theory in this thesis
Evidence-based practice
Through the background I have shown significant knowledge, combining diet, physical activity and behavioural therapy with weight loss from a positivistic perspective (2,28,29), and the challenges obesity
22 has on engaging in occupations from a more interpretive perspective (14,15,34). Despite the diversity in research, weight loss maintenance is still difficult to gasp. Weight loss and weight loss maintenance is without doubt a complex process and it seems therefore unrealistic that a single perspective will be able to fill the gaps in knowledge about weight loss and weight loss maintenance programmes. Even though understanding a field from different perspectives might be difficult because of different ontological views, the philosophical assumptions do not have to be mutually exclusive but rather they should be seen as offering multiple frameworks to enrich the study of weight loss (59). Within this thesis the framework will be evidence-based practice (EBP). Even though there are different philosophical assumptions, weight loss, occupational therapy, science and EBP hold an individual perspective.
EBP developed from evidence-based medicine (EBM), which was pioneered by practitioners and
researchers at McMaster University, with David Sakett as the leading researcher. EBM was descripted as the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients/clients” (60). This focus had a significant influence on clinical practice as it became more scientific and empirically grounded, resulting in safer and more consisting treatment (61). Despite its influence, clinical practice was not able to include all of the new evidence. One reason was the amount of knowledge and a lack of opportunity to find and even understand the evidence. Even more importantly the positivistic approach, only focusing on the best science, was not always congruent with the specific practice and the people involved (61). Mary Law has defined EBP as: “EBP can be considered to be a combination of information from what we know from research, what we have learned from clinical wisdom, and what we learned from information from the clients and their family. This combination of information enables us to work together with clients and families to make the best use of knowledge”. (60). This definition has often been illustrated as a tripartite model by integrating research, professional expertise and patient´s values and priorities often shown as three overlapping circles with practice represented in the middle (62). The three circle model has been expanded with a fourth circle surrounding the others in form of ‘context’ (63).
Combining the four concepts together with literature, explicitly analysing professionals and citizens
perspectives in a specified context is a way to support practice implementing best available treatment (64).
In this thesis, the combining of the four concepts discussed within occupational science will provide knowledge for developing the occupational-based WLP DO:IT.
Summary
In conclusion, the following arguments are important as the foundation of the aim of this thesis.
First, citizens with obesity experience challenges engaging in occupations which influence their health and wellbeing.
23 Second, the evidence for weight loss intervention is high but even though the tendency for weight loss maintenance has been shown, there still seems to be a knowledge gap.
Third, in Denmark, municipalities are obligated to offer WLPs. Occupational therapists are recommended to be included in these programmes. No evidence is described about how occupational therapists or other health professionals are included. Involving citizens in the prioritisation of their treatments is also a political goal in Denmark but citizen involvement is not mentioned in the recommendation for developing WLPs.
Fourth, science shows that WLPs that include occupational therapists take a more holistic perspective by focusing on daily life and social relations. However, transparency of the specific roles of occupational therapists is lacking.
Fifth, theory from Ann Wilcock has illustrated the link between engaging in occupations and wellbeing and health, and since people with obesity are challenged in engaging in occupations her theory will be used as a foundation for building knowledge about the role of occupational therapists in a weight loss process.
Sixth, the missing relation between the positivistic knowledge about diet and physical activities and the interpretative knowledge about occupational engagement in WLPs could be found in the framework of EBP.
Research objectives
The overarching aim of this thesis was to develop knowledge about ‘best practice’ to develop an occupational therapy WLP for the Danish municipalities. ‘Best practice’ was understood through the concepts of evidence-based practice: evidence, experiences from professionals and citizens and context.
Approach for understanding
To answer the overarching aim of this study, four studies were made, related to the circles in evidence- based practice. The circles point at different ontological understandings as they contain the concepts evidence and perspectives. To integrate different understanding in one study a pragmatic eclectic approach was chosen for this thesis. A pragmatic approach offers ontological justification for bringing together multiple sources understandings with the goal of finding pragmatic solutions to a complex practical
problem (65). Knowledge is an iterative never-ending process rather than a linear process to a product (65).
From a pragmatic viewpoint, the truth is ‘what works’. Truth is only considered truth as long as it works best. It makes sense to combine occupational therapy and evidence practice with this understanding of truth because the end point for both occupational therapy and evidence-based practice is to apply what works the best in practice (66).
24 As the studies hold different ontological understandings, they will be presented and discussed separately, except for study II and III, which will be presented and discussed together as they hold the same ontology.
The conclusion will be made across all studies.
Specific aim corresponding to the four studies
Study I: To examine Danish municipal weight loss programmes to identify and describe programme content and structure (i.e. dose, delivery format), the intended programme recipients, and the involvement of occupational therapists and other health professionals in programme delivery.
Study II: To understand what citizens with obesity who have not sought out municipal weight loss services would want in a weight loss programme.
Study III: To explore health professionals’ views of what an ideal, holistic weight loss programme should include.
Study IV: To understand what strategies could support the components of diet, exercise, habits, occupational balance and social relations in a weight loss maintenance programme in the Danish Municipalities.
(See figure 2)
25
Figure 2 Framing the studies within evidence-based practice
Study I
The aim of this study was to examine Danish municipal WLPs to identify and describe programme content and structure, the intended programme recipients, and the involvement of occupational therapists and other health professionals in programme delivery (67). This study helps clarify the evidence in WLPs within Danish municipalities. This study took a quantitative descriptive perspective.
Materials and methods
To achieve the aim of Study I, a survey and quantitative content analysis were chosen as the
methodological approach. Quantitative content analysis is used to make replicable and valid inferences about a subject of interest in any type of communication (68,69). Inferences are central as analytical constructs (or rules of inferences), which are used to move from a text to the answer of the research question (68,70). The text or the data in the communication often seems to be qualitative but quantitative results are emphasised (69). The approach in Study I is derived from a positivistic tradition and is deductive because categories and coding rules are laid out to show what goes where (70). The content analysis in this study focused on the manifest content (67,69).
Following recommendations from White et al., ten steps (70) are involved in the research process:
26 1. Establish hypothesis or hypotheses
2. Identify appropriate data (text or other communicative material) 3. Determine sampling method and sampling unit
4. Draw sample
5. Establish data collection unit and unit of analysis
6. Establish coding scheme that allows for testing hypothesis 7. Code data
8. Check for reliability of coding and adjust coding process if necessary 9. Analyse coded data, applying appropriate statistical test(s)
10. Write up results
In the following the ten steps will be described in five headlines (establish hypothesis, identify appropriate data, sample, coding and analysing).
Establish hypothesis or hypotheses
This study was a survey, and its aim was to describe practice, so it is not suitable for establishing a hypothesis. Therefor no hypothesis was made.
Identify appropriate data
To answer the aim of the study we had to find relevant text. In Denmark, every municipality is legally required to provide WLPs for adults and to register and update a list of all health programmes offered in the municipality, including WLPs (10,67). The general Danish population and health professionals can see this list, which is published on the website “sundhed.dk (the official portal for the public Danish Healthcare Services) (10).
To account for the possibility that municipalities may not have complied with registering their programmes on sundhed.dk, perhaps because of newly developed programmes, a search on Google.dk was also
conducted, to ensure that all of the Danish municipal WLPs were included (67).
Sample
In a quantitative study one important aspect is working with generalisability or in other words, going from the specifics to the general (70). The sampling method is essential in order to do this. In Study I, the legally required registering of all health programmes was a unique opportunity of being able to sample all WLPs provided by Danish municipalities (67).
To find the sample units relevant for answering the research question, the same keywords were used in both the search on sundhed.dk and Google.dk (67). The keywords were the name of each of the 98 municipalities, combined with the following keywords: ‘obesity’, ‘overweight’, ‘BMI’, ‘diet’, ‘physical activity’ and ‘weight loss’. The keywords were combined with the name of each municipality using the Boolean logic term ‘AND’. The keywords were found by finding ten different WLPs on sundhed.dk to detect
27 what words were used. Danish terms were used in both searches and three of the researchers involved in the search conducted independent searches, the results were then compared, and any discrepancies were resolved through consensus.
To ensure that the text was appropriate, we used different exclusion criteria. First, WLPs including specific diagnoses like diabetes were excluded because the content might be different from programmes solely working with weight loss. Second, programmes combining the public and private sector or primary and secondary sector were excluded because different content might be present and therefor would not directly give us an idea about the context in which this study was directed for.
The sample was drawn between October 2017 and January 2018, with a final search carried out in November of 2019 to account for potential changes during the completion of this manuscript. We did not find any new programmes with the final search (67).
Coding
After having selected the sample, the next step was to do the coding (70). In the process of doing this, the WLPs offered by the five largest municipalities in Denmark were reviewed and several codes were written down (67). The codes detected were then established for relevant and valid categories by discussions between the researchers who were part of the study. Even though this initial review revealed different codes, it showed that the descriptions of the WLPs were very much alike, as almost all of them introduced health professions, intended programme recipient, dose, form and content (67). Therefor the researchers agreed upon these categories. This left a few codes which were further discussed, resulting in one more category about currently available programmes. As three researchers was responsible for the coding variables relevant for operationalisation of each category, these were described to make sure that everyone understood the categories in the same way. Categories and variables are presented in Table 1.
Table 1. Conceptual framework with categories and variables
Categories Variables
1. Health Professions
The occupation or discipline of the health professionals who were conducting the programme and the multidisciplinary expertise
• Nurse
• Public health nurses
• Physiotherapist
• Dietitian
• Occupational therapist
• Health consultant
• Other 2. Intended programme recipient • Children
• Adolescent
• Family
28 The population which a programme
was directed
• Adults BMI +25
• Adults BMI +30
• Adults BMI +35
• Pregnant 3. Dose
Number of treatment contacts and length of treatment sessions
• Length of programme
• Number of sessions
• Follow up 4. Currently available programmes
well established programmes
designed for weight loss treatment in the municipalities
• The Holbaek concept/inspired by the Holbaek-concept*
• ‘Small steps’/inspired by ‘Small steps’**
• Other
5. Form
The programme structure as well as interventionist role
• Individual
• Group
• Digital/app
• Consultant/coach
• Educator
• Peer exchange
• Activities 6. Content
The domains of information included in a programme
• Physical activity
• Diet
• Sleep
• Habits
• Well-being/social
* The Holbaek concept is a family-centred behaviour-modification technique with 30-minute meetings held at the clinic quarterly, biannually or annually.
** ‘Small steps’ takes a health-promoting approach including behavioural treatment strategies.
Analysis
The first step for the coders was to extract the data from the WLPs descriptions into a matrix divided into each category. The qualitative data was kept in this step. During the second step, each coder used the matrix to search the specific variables in each WLPs. If the variables were present in the WLPs, this was shown in another matrix divided into WLPs and variables.
After the second step, the researchers discussed the results of the coding. If there was disagreement, the main supervisor made the final decision (67).
In the third step, a count was made of the number of variables that were extracted across the dataset and finally the extracted variables were summarised. For this thesis, the third step was repeated, only now focusing on the WLPs aimed at adults and therefor some of the numbers in the results section are different
29 than in the article: ‘Obesity treatment – a role for occupational therapists?’ (67). This was done in order to link the results directly to the overarching aim of the thesis.
Results
The results from Study I showed that across the 98 municipalities in Denmark, 234 different WLPs were identified and from these 126 WLPs were aimed at adults. The BMI criteria for participation in the WLPs aimed at adults ranged from 25±35, while 45 (57%) WLPs had no specific BMI criteria (67). The health professionals conducting the WLPs varied with dieticians and public health nurses as the most commonly involved (67). Five WLPs were led by occupational therapists and the WLPs were all multidisciplinary, with the occupational therapists collaborating with dieticians (2 programmes), a physiotherapist (1 programmes) and a nurse (1 programme).
The length or number of sessions in the WLPs aimed at adults were not described for all WLPs, but in those where it was described, the lengths ranged from 8 weeks to 2 years and the number of sessions ranged from 1 to 47 (67). Some form of post-programme follow-up was offered by 21 (9%) WLPs approximately 3 months after the last session. Eleven WLPs (5%) included one follow-up visit and 8 (3,4%) WLPs offered three follow up visits over a 6-month period (67).
Two current available programmes were detected in the WLPs either described following the
recommendations from the programme fully or described as inspired by the programmes (67). The two WLPs were the ‘Holbaek programme’; a family-centred approach, understanding obesity as a complex and chronic disease, which uses family-based treatments to identify lifestyle changes needed to optimise daily life thereby helping families to achieve successful weight loss (71). And ‘Small steps’ focusing on the assumption that habit change is possible, when focus is on small changes and goal setting developed as a supplement to weight loss process for citizens (21). Fifteen (6%) of the WLPs aimed at adults were based on
‘Small steps’ and one WLP on the ‘Holbaek programme’(67).
Thirty-seven WLPs (29%) of the 126 WLPs aimed at adults were individualised, 34 (27%) were only groups and 25 (20%) were hybrids, consisting of both individual and group sessions. The structure of the WLPs was supported by peer exchange in 20 WLPs (16%) and hands-on activities, such as making dinner in 48 WLPs (38%). Technology (e.g. mobile phone apps) was used in 11 (9%) WLPs (67).
30 Ten WLPs (8%) had multi content, by having diet, physical activity, habits and social participation. The most frequently delivered WLPs content was diet and physical activity recommendations, followed by
information about how to develop healthy habits and the promotion of social participation. Twenty WLPs (16%) combined diet and physical activity and 18 WLPs (14%) combined diet, physical activity and habit (67). Habit change education was combined with diet in 10 (8%) WLPs and was only combined
with physical activity in one of the WLPs. Six WLPs (5%) only had habit change education as their
programme content. Social participation-related content was combined with physical activity in three WLPs (2%) but was not combined with diet or included as the only content (67).
Study II and III
Study I showed the relevance of developing a municipality WLP because of heterogenous approaches. The next step was to include the people who would be affected by the WLP, to understand their perceptions.
Therefore, the aim of Study II and III was to understand what citizens with obesity, would want in a WLP and to explore health professionals’ perceptions of what an ideal, holistic WLP should include. These two perspectives are related to two of the circles in evidence-based practice – clients and clinics (63). And also to comply with the Danish health care system’s ambition to involve citizens in decisions about their treatment to make the treatment more effective (24). Qualitative research is suitable for approaching and understanding human perceptions and experiences and was therefore ideal for Study II and Study III. The methodology for the two studies was based on the process of interpreting and describing the central nature of human experiences by choosing a phenomenological and hermeneutical perspective especially founded in the theory of Paul Ricoeur. Ricoeur was influenced by Husserl’s phenomenology trying to grasp the ultimate essences of human experiences by bracketing previous habits of thinking and by Heidegger’s hermeneutic trying to understand the nature of human being by letting preunderstanding influence the interpretation illustrated by the hermeneutic circle (72).
Methodology
The epistemological basis of Study II and Study III is interpretation illustrated by a connection between hermeneutic and phenomenology (73). This connection was cemented by the French philosopher Paul Ricoeur (1913–2005), who is especially known for his theory of interpretation (72). He postulated that knowledge was created through interpretation that opens the opportunity to understand the meaning of being in the world and that interpretation is the ‘hinge between the language and the lived experience’
(74). Ricoeur moved above subjectivity to objectification. By objectification he meant that a text had many meanings (74). To understand his theory of interpretation four concepts are important: distanciation,
31 appropriation, explanation and understanding (72). Ricoeur used the concept distanciation to show the difference between the spoken language and the written text. A text changing from spoken language to written text makes the text both autonomous in relation to the intention of the author and from the situation or original context and audience. Thereby, the focus for interpretation moves from the authors unique intention or meaning to the appropriate meaning of the text (72). For qualitative interviews this is central as the spoken language is transformed to a text during transcription. The second concepts
appropriation Ricoeur explain that: “By appropriation I understand this: that the interpretation of a text culminates in the self-interpretation of a subject who thenceforth understand himself better, understand himself differently, or simply begins to understand himself” (75). Meaning of the text occurs through appropriation as the interpreter expand his or her horizons.
The concepts distanciation and appropriation forms the paradigm for the interpretation. The two concepts explanation and understanding are concrete related to the analysis of the qualitative text going from a phenomenological to a hermeneutic perspective. Ricoeur talks about interpretation of a text as “moving beyond understanding what it says to understand what it talks about”. Embodied in this quote are the two stages of Ricoeur’s theory of interpretation: explanation (what the text says) and understanding (what the text talks about) (72). The explanation stage is directed towards the internal relation of the text (the parts) and are relatively immature, while the understanding stage are directed towards understanding the whole in relation to its parts.
Design of Study II and study III
The aim with Study II and Study III was to explore how citizens with obesity and health professionals perceived what a WLP provided in by Danish municipalities should contain. The process for this
understanding includes multiple meanings grasped by Ricoeurs objectification (73). Therefore the design founding these studies was based on qualitative content analysis (QCA) which is a process characterised by many realities developed to multifaceted perceptions of a phenomena (73).
QCA evolves from quantitative content analysis. The understanding of QCA is very different across the literature (76). Some authors highlight the link between the quantitative and qualitative approach and by that describing it as a qualitative approach that enables both qualitative and quantitative results (76). This perspective has been labelled naive (76). However, in the work with QCA, especially in Scandinavia, QCA has been described more as an interpretive approach aimed to find themes at a latent level (76,77). This approach is used in these studies.
