Perceived barriers and facilitators to implementing a weight management programme in a primary care setting in Singapore: a qualitative study

Abstract

Background

Obesity, a growing problem worldwide and locally, is a risk factor for many chronic conditions. Weight loss has been shown to improve health outcomes and weight management programmes are effective in achieving weight loss. However, the effectiveness and sustainability of weight management programmes are variable. The six-month, seven-touch-point Weight Management Programme (WeightWise) is a locally developed multidisciplinary programme based on the latest evidence and expert opinion. This study aimed to explore the perceived barriers and facilitators to delivering WeightWise prior to its implementation in the Singapore public primary care setting (polyclinics).

Methods

Between September 2023 and January 2024, a qualitative study was conducted across two polyclinics designated to pilot WeightWise. Twenty-six healthcare practitioners, including clinic directors, doctors, nurses, dietitians and physiotherapists, who would be involved in running WeightWise or referring patients to WeightWise, were interviewed by the researchers using an interview guide, in either a focus group or individually. Interviews were audio-recorded, transcribed verbatim, checked and analysed thematically using the NVivo software.

Results

The participants in this study expressed a gap in weight management in primary care and found WeightWise relevant and timely. However, they highlighted potential barriers to implementing WeightWise in terms of patient enrolment and programme delivery.

For enrolment to WeightWise, the participants were concerned about a lack of prioritisation by the practitioners on weight management, time constraint, complex referral criteria and pricing. However, they highlighted potential facilitators to enrolment including targeting young and motivated patients, as well as identifying eligible patients at pre-consult vitals measurement stations.

For WeightWise delivery, the perceived barriers were: increased workload for nurses, difficulty in accessing information on community exercise programmes, lack of weight management knowledge amongst practitioners, inconvenient programme timings and uncertainty in long-term benefits of WeightWise. The perceived facilitators to delivering WeightWise were: the use of remote care modalities, preventive care awareness through Healthier SG (a national health initiative), training programmes for practitioners and continuous peer support for patients.

Conclusion

This study identified the need to focus on both enrolment and delivery when implementing WeightWise. It also identified low prioritisation of weight management, lack of practitioner knowledge, lack of resources and costs as key barriers when implementing a weight management programme. Tailored healthcare professionals training, additional resources and cost analysis is recommended before its implementation.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-02940-9.

Background

Obesity is a growing worldwide problem. The global prevalence of obesity (defined as Body Mass Index (BMI) > 30 kg/m²) has increased from 11% in 2010 to 15% in 2020 and is projected to increase to 18% in 2030 [1]. A similar trend of increasing obesity has been observed in Singapore, which has worsened over the COVID-19 pandemic lockdown period. According to the National Population Health Survey, the prevalence of high-risk BMI (defined as BMI > 27.5 kg/m²) increased from 18.7% in 2017 to 20.7% in 2020 and 22.3% in 2022, while the prevalence of obesity in adults aged 18–74 years has increased from 8.6% in 2017 to 10.5% in 2020 and 11.6% in 2022 [2].

Obesity is associated with an increase in all-cause mortality [3–5] and is a risk factor for many health conditions [6], including cardiovascular disease [7], cancers [8, 9], osteoarthritis [10], diabetes [11, 12], obstructive sleep apnoea [13], non-alcoholic fatty liver disease [14], polycystic ovarian syndrome [15] and depression [16]. A sustained weight loss of 5–10% has been shown to improve the outcomes of fatty liver disease and cardiovascular risk factors such as hypertension, hyperlipidaemia and diabetes, with greater extent of weight loss associated with greater improvements [17, 18].

There are existing effective weight management programmes globally that have been evaluated, including the Counterweight programme in the United Kingdom [19, 20], the POWER studies [21] and the MOVE! Programme for veterans in the USA [22], the Change Programme in Australia [23] and Singapore’s Lose to Win programme by the Health Promotion Board [24]. It is known that three-component interventions (diet, physical activity, behavioural counselling) can lead to greater weight loss and are more effective at preventing weight gain than 1- or 2- component interventions; whereas single-component interventions are more effective in improving the targeted behaviour but less effective on weight reduction [25–27]. Other features of successful weight management programmes include having a programme for at least 6 months, with high-frequency touchpoints of at least 12 per year, either by face-to-face, phone or virtual means [28–30]. Training general practitioners to increase their competency in helping patients manage their weight also resulted in greater weight loss when compared to usual standard of care [31].

However, despite the increasing evidence of the effectiveness of various weight management programmes and understanding of their ‘mechanisms of action’, implementation of a weight management programme- which is often a complex intervention- in the primary care setting remains challenging [32]. The factors that influence successful uptake and implementation of a programme are multi-dimensional; they include patient factors (e.g. low self-efficacy and commitment, understanding of programme goals), healthcare-provider factors (e.g. lack of knowledge and training, scepticism about programme effectiveness, clinician interest) and systemic factors (e.g. presence of role delineation, a programme champion in the clinic, guidelines) [33–35]. As healthcare systems are localized and unique to each region, it is important to identify factors that may influence the success of implementing the programme in the local context and system [36].

‘Healthier SG’ is a national initiative rolled out in 2023 by the Ministry of Health (MOH) in Singapore which focuses on preventive health [37]. For patients with moderate- to high-risk cardiovascular conditions, it is envisioned that weight management, part of preventive care, will come under the purview of primary care practitioners [38]. One of the local primary healthcare clusters covering the central and north regions, National Healthcare Group Polyclinics (NHGP), runs weight management programmes for patients with chronic diseases over 6 months, consisting of 7 virtual group sessions held by a multidisciplinary team [39]. In the community, Health Promotion Board (HPB) used to run a 12-week programme “Lose to Win” [24], encompassing nutrition and exercise workshops. This has segued to a 6-week programme by ActiveSG, “managing obesity with exercise”, which is targeted for patients with low-risk cardiovascular conditions [40]. As one of three main public primary healthcare clusters in Singapore, SingHealth Polyclinics (SHP) has a multi-disciplinary team of healthcare practitioners across 10 clinics in the east and north-east regions in Singapore and is well-suited to provide the necessary support for patients with chronic health conditions, who require weight management. As part of the preventive health focus, SingHealth Polyclinics aims to pilot a weight management service before expanding it to other clinics.

Although there are several pre-existing weight management programmes that have been implemented in Singapore, they have not been evaluated for their effectiveness. Weight management programmes are complex interventions with multiple components, which account for varying degrees of success across programmes. This study therefore aimed to identify the barriers and facilitators perceived by healthcare professionals in implementing a multi-disciplinary weight management programme within a primary care clinic setting in Singapore before piloting the programme. Using the Knowledge to Action process framework [41], we hope to develop implementation strategies that are tailored to address the barriers and facilitators identified in this study, so that it would increase the likelihood of successful implementation of the weight management programme.

Methods

Study design, setting and time

This study used a qualitative approach [42] to explore the potential implementation barriers and facilitators in the context of Singapore primary care setting, which have not been previously reported. This study was carried out at two primary care clinics in the public sector, which were the designated pilot sites for the Weight Management Programme (WeightWise). This pre-implementation study took place before the pilot programme was implemented. It aimed to contribute to the development of the implementation strategies of WeightWise. The data collection (interviews) took place from September 2023 to January 2024.

Weight management programme (WeightWise)

Development

The WeightWise programme (outline available at Annex B) was developed via a combination of literature review and expert opinion, including meeting with another local public primary care cluster (NHG) who was running an established weight management programme; discussions with the community partner Active Health [43] which runs fitness and assessment centres in Singapore, and receiving input from a visiting weight management expert who had run the POWeR + [44] study in the UK. Sports medicine specialists who ran the Exercise is Medicine course [45] also contributed towards development of the triage pathway for the programme. “Exercise is Medicine” focuses on training healthcare providers in assessing the physical fitness of patients, providing medical clearance for exercise and encouraging the prescription of exercise as part of holistic management.

Content and delivery (Fig. 1)

Fig. 1.

WeightWise pathway over 6 months with 7 sessions. VC: video consult. F2F: face to face consult. PC: phone consult

The planned WeightWise is intended to be a multi-disciplinary programme consisting of a base package of seven sessions held by doctors and nurses over six months, with referrals to dietitians and physiotherapists by doctors or nurses when required. Referrals to WeightWise can be made from the clinic by doctors, as long as the patient meets the criteria of BMI ≥ 27.5 and is ready to make changes to lose weight, using the transtheoretical model (preparation or action). A care pathway and colour-coded triage which references the Healthier SG BMI protocol [38] serves to guide doctors in managing overweight patients.

Patient-healthcare provider interactions consist of face-to-face consultations at the start, mid- and end-points with phone calls made by nurses in-between. The programme will be anchored by the nurses and consist of target-setting and behavioural nudges towards tailored and personalised healthier eating habits and increased physical activity. Involvement of the allied health practitioners (dietitians and physiotherapists) are on a referral basis from doctors or nurses, in view of limited allied health manpower. As such, it was decided that dietitians and physiotherapists would only be involved when the need arose, such as a significant lack of knowledge regarding the topic area or the presence of complex comorbidities in the patient.

Participants, sampling and sample size

Two groups of participants were included in this study: the first group was the healthcare providers who were designated to deliver the WeightWise programme; the second group comprised of practitioners who were not directly delivering WeightWise but would be referring patients to WeightWise. There were no exclusion criteria. For the first group, a group of practitioners comprising nurses, doctors, dietitians, physiotherapists and clinic directors who were designated to be involved in WeightWise at the two sites were interviewed. For the second group, nurses and doctors who would be involved in the referral process to WeightWise were purposively selected according to their experience [46]. The participants were not involved in the conceptualisation of the WeightWise programme. As this is a qualitative study, no prior sample size was calculated and data collection was expected to stop upon achieving data saturation. However, the small pool of participants in our study limited the data saturation, which occurs when new data produces little to no new information to address the research question [47].

Research instrument

An interview guide was developed based on literature review, Tailored Implementation of Chronic Diseases (TICD) framework [48] and discussion among the research team. The TICD framework consists of 57 potential determinants in seven domains: guideline factors, individual health professional factors, patient factors, professional interactions, incentives and resources, capacity for organisational change, and social, political, and legal factors [48]. This framework allows for identification of determinants that might enable or impede improvements of healthcare practice; by identifying these determinants, specific implementation strategies can then be designed and applied to address these determining factors [49, 50].

The interview guide consisted of four sections (Annex A):

• Current practices for weight management.

• Views about the Weight Management Programme (WeightWise).

• Possible barriers and facilitators identified by the healthcare providers (from the perspectives of a doctor, nurse, dietitian and physiotherapist) in delivering the planned programme (including patient selection, referral, assessment, counselling, dietary and physical activity advice, follow up).

• Needs and suggestions to improve the design of WeightWise.

Data collection

The potential participants were invited via email followed by face-to-face explanation about the study. Participants who agreed to participate were emailed the design for the WeightWise intervention prior to the interview. They signed a written consent and completed a short baseline data collection form regarding the participant’s demography (age, gender, ethnicity, role, clinical experience).

Interviews were held via focus group discussions (FGD) or individual in-depth interviews (IDI). IDIs allowed for richer information to be shared by individual participants while FGDs allowed for increased interactions between participants and building on themes shared by other participants [51]. A mixture of methods used allowed for triangulation of themes gleaned from the various interview types, for a more comprehensive overview. For focus group discussions, participants were divided into groups, according to their profession and seniority level. In cases where participants were unable to make it to the group discussion schedule, uncomfortable with group interviews or deemed to be more suitable for individual interviews (e.g. senior management), individual in-depth interviews were conducted.

The initial five interviews were conducted by RL and observed by CJN and SSK, experienced qualitative researchers, who provided triangulation by taking field notes and provided feedback regarding the interview. RL then conducted the subsequent 13 interviews independently. As RL was known to some of the participants in her role as a doctor and had designed WeightWise, there was potential for the difference in power dynamics to influence the conduct and result of the interview. There was constant reflection on her role to reduce potential biases in interviewing, data analysis and writing up. An iterative process based on feedback from the experienced researchers and transcription of previous interviews was carried out to reduce assumptions and increase probing in subsequent interviews.

All interviews were audio-recorded and transcribed verbatim by a professional third-party transcriber. The transcripts were checked by an independent researcher (RL) for accuracy and used as data for analysis. NVivo© (QRS Pty Ltd., Australia), version 10, a computer-assisted qualitative data analysis software, was used to manage the data.

Data analysis

The data was analysed using a thematic analysis approach [52]. Two researchers (RL and SSK) coded the transcripts line-by-line to capture and label the meaning of the data, keeping in mind the research questions. These open codes were then consolidated into broader categories (axial coding). The two researchers met regularly to discuss the similarities and differences in the analysis and any discrepancy was resolved through consensus reached with a third researcher (CJN). Codes and categories from the first three coded transcripts formed the coding framework; RL and SSK coded the remaining transcripts using the framework, refining and adding new codes and categories where necessary. The participants did not provide feedback on the transcripts or findings.

Results

Participant profile

Four focus group discussions (FGD) and fourteen in-depth interviews (IDI) were conducted from September 2023 to February 2024. Twenty-six healthcare professionals comprising of eight doctors, six nurses, four physiotherapists, four dietitians, two nursing managers and two clinic directors participated in this study; their characteristics are shown in Table 1. The interviews duration ranged from 32 to 92 min and there was no repeat interview.

Table 1.

Participant characteristics (N = 26)

Characteristics	N (%)
Age, years
• 20–29	2 (7.7)
• 30–39	19 (73.1)
• 40–49	2 (7.7)
• 50–59	2 (7.7)
• 60–69	1 (3.8)
Gender
• Female	23 (88.5)
• Male	3 (11.5)
Years of experience in current role
• 1–5	12 (46.2)
• 6–10	7 (26.9)
• > 10	7 (26.9)
Highest Education level
• Diploma	2 (7.7)
• Degree	13 (50.0)
• GDFM (Graduate Diploma in Family Medicine)	3 (11.5)
• Masters	6 (23.1)
• Fellowship	2 (7.7)
Training in Weight Management
• Graduate Diploma in Sports Medicine	1 (3.8)
• Exercise is Medicine	20 (76.9)
• Obesity Scientific Congress	1 (3.8)
• Nil	5 (19.2)

Findings

Table 2 provides a summary of key topics and themes, including: views and experiences of the current weight management in polyclinics; views on running a weight management programme in primary care; perceived barriers and facilitators to the referral, enrolment and delivery of WeightWise from the study participants.

Table 2.

Summary of key topics and themes

1. Views and experiences in managing obesity in primary care

1.1. Views about obesity - Obesity: an important but challenging issue - Overweight is mainly managed by dietitians, with reduced emphasis on exercise - Lack of local, updated weight management guidelines

1.2. Views on WeightWise - Lack of a weight management programme in primary care

1.2.1. Role of WeightWise - WeightWise may help fulfil a need for guidance amongst overweight patients who are not keen for specialist review - WeightWise should aim to facilitate lasting behavioural changes among patients

2. Referral and enrolment into WeightWise

2.1. Barriers - Lack of prioritisation on weight management o By healthcare practitioners and patients o Lack of time to discuss weight - Weight is a sensitive topic to discuss - Exercise clearance evaluation is time-consuming in the general clinic - Additional costs would dissuade patients from joining the programme

2.2. Facilitators - Young and motivated patients - Suitable candidates can be identified at the existing Health Monitoring Station (HMS)

3. Delivery of WeightWise

3.1. Barriers

3.1.1. System - Increased workload for nurses o Competing demands for available manpower o High expectation and heavy burden on the nurses - Logistical difficulties with conducting in-house group exercise classes - Difficulty accessing information to community programmes - Short-term financial burden with uncertain long-term benefits of WeightWise

3.1.2. Healthcare practitioners - Potential lack of commitment from allied health practitioners (AHP) - Lack of in-depth weight management knowledge and skills

3.1.3. Patients - Perceived patient’s barriers to adhering to WeightWise o Inconvenient timing o Concerns about safety (scam calls)

3.2. Facilitators

3.2.1. System - Remote care options can help encourage attendance and achievement of targets - Healthier SG would increase awareness for preventive care and attract motivated patients

3.2.2. Healthcare practitioners - Attending ‘Exercise is Medicine’ course helpful for exercise clearance - Attachments with experienced practitioners

3.2.3. Patients - Peer support can sustain patients through the weight loss process

1. Views and experiences in managing obesity in primary care

1.1 Views about obesity

Obesity: an important but challenging issue

It was acknowledged by the healthcare professionals that there was an increasing trend of obesity amongst patients and that weight management was an important topic; however, they found it a challenging condition to manage for their daily practice.

I definitely think it’s important and it’s increasingly relevant, with a large number of our patients being obese and overweight.

(Doctor, E03).

Overweight is mainly managed by dietitians, with less emphasis on exercise

Participants expressed that the dietitian was frequently the main resource for weight management in primary care. There was inter-disciplinary management where dietitians and physiotherapists co-managed obese patients who had pain issues. However, participants verbalised that in general, there appeared to be a lack of focus on exercise in polyclinics, as the physiotherapists were more accustomed to seeing patients for musculoskeletal conditions and less for metabolic conditions such as weight management.

So, for now the existing resources would mainly be the dietitian in the polyclinic.

(Doctor, F11).

So exercise I think is something that is always, like in terms of in a polyclinic setting, not addressed very well or that patients usually don’t get much support on that. So I think having the physiotherapist helps to complete the whole programme a bit more.

(Dietitian, E07) I suppose on our end also because of the way our structure is, it’s more MSK [musculoskeletal] based.

(Physiotherapist, F12).

Lack of local updated weight management guidelines

There was a lack of updated guidelines locally; the primary care doctors tended to get their guidance on managing obesity from diverse sources, such as guidelines for other chronic conditions.

In terms of our old CPG [clinical practice guidelines], (it) is pretty outdated.

(Doctor, E12)

I think everyone gets a bit of info here and there. There are some dietary advice for like hypertension, hyperlipidaemia. There’s also the gout one. They all seem to be quite consisten.

(Doctor, E13).

1.2 Views on weightwise

Lack of a weight management programme in primary care

Referral pathways to specialist weight management centres were established for patients who were severely obese. However, participants noted that there was a lack of a structured weight management programme in polyclinics for which they could refer overweight patients to and felt that the planned programme could help fill this need.

I would say it’s my first time really grasping what it could look like to deliver a structured and comprehensive weight management support. Because all this while, all I’ve known is giving a bit of verbal advice or like, you know between me and my patient only? I don’t really know how to go in-depth talking about diet changes in a way that will, I think, make a clinical difference to their weight.

(Doctor, F01).

1.2.1 Role of weightwise

WeightWise fills the gaps for patients who are not keen for specialist review

Participants felt WeightWise could help manage patients whose BMI were between normal and severely obese, who may be keen for conservative management. They also felt that there were some patients who would prefer to be seen and followed-up in the polyclinics for their weight management, as it would be less costly and closer to home.

When we’re first introduced to this programme, I thought it was quite apt in the sense that, for people who fell between the cracks, like those that were not serious enough. Because I do have patients whose MSK [musculoskeletal] issues are affected by their weight. And they are struggling but they are not severe enough, their BMI [Body Mass Index] is not high enough to go to the specialized care at the hospitals.

(Physiotherapist, F12)

Generally, patients would prefer not to go to a specialist centre for conservative management of weight. But they will be open to having it in primary care. I think once they hear about, you know? It being a package and needing commitment. And then having to go down to a separate location that is a bit further from their home.

(Doctor, F11).

WeightWise should aim to achieve sustainable behavioural changes

Participants felt that attempts at weight loss might not be an easy journey; however, it was important for patients to take ‘ownership’ of their own weight loss efforts. The role of WeightWise was to facilitate behaviour and habit change which would then be self-sustaining.

To give them the idea that it’s not an easy journey but. you can achieve with the correct mindset. What exactly (do) you want to achieve that is so important? At the end of the day, why (do) you need to do this?

(Nurse, F10).

Ya, at the end of the day, I think this programme is to kick start them into creating a good habit. So that it’s sustainable.

(Doctor, E13).

In order to facilitate lasting behavioural change, it was recommended that expectations were set with the patient at the start of the programme, so that they were aware of the purpose of the programme.

I think one of the things that needs to be built in is that it’s not just a programme that ends at six months. It is a programme that is meant to give you the resources to continue this beyond six months, in order to get the benefits of weight loss.

(Doctor, F11).

2. Referral and enrolment into WeightWise

2.1 Barriers

Healthcare practitioners do not prioritise weight management in routine practice

Weight was rarely discussed by the practitioners during patient’s clinic visit; it was not a priority for the healthcare providers.

At the HMS (health monitoring station), the staff will say blood pressure is high. But they never say your weight is high.

(Nurse, E06)

Ya I’m trying to lose weight, so how? Every time 3-monthly I come and see the doctor also, the doctor don’t say anything about the weight neither does the nurse.

(Nurse, E06)

So, what we focus on generally, I mean as doctors in the primary care setting, is more of the acute or chronic conditions. Obesity is probably lower down in the problem list.

(Doctor, E12).

Lack of time to discuss weight management during a consultation

An issue which was frequently raised by doctors was the lack of time to discuss weight management, in addition to the multiple tasks that needed to be done during a consultation. As a result, it was usually a “superficial” discussion, as part of management for chronic conditions.

Most of the time, if we have multiple other tasks if, even if you want to talk a little bit about the weight it ends up being a side point.

(Doctor, E03)

What I tend to do is that, I will talk about it (weight) kind of indirectly, through the management of other chronic problems like fatty liver. Usually they will be interested in the management of fatty liver. Then, I’ll talk about, ‘Oh, so maybe lifestyle, then weight loss’. Ya, so it’s kind of quite a superficial touch on.

(Doctor, F03).

Patients don’t see it as a priority

Recruitment into the programme might be challenging as doctors felt that patients also did not usually prioritise obesity as an issue. Many were either not ‘ready’ to lose weight or did not actively seek help for it.

I mean first of all because patients don’t see it as a priority. They only come to seek medical attention for their current issues and not the background issue of obesity.

(Doctor, E12).

Weight is a ‘sensitive topic’ to discuss with patients

Healthcare practitioners expressed their difficulty in raising the topic of weight, as it could be a sensitive issue for some patients. A suggestion brought up was to raise the topic when weight was being measured at the health monitoring station, with follow-up discussion by the doctor or nurse.

Sometimes it’s very hard to directly tell them that ‘Okay, your weight is an issue now’. Unless they are also having the same concern. Because some people may find it like maybe a sensitive topic to talk about.

(Doctor, F03).

I find it hard to start the topic sometimes. So I feel the best person actually is at the place whereby the weight is being measured. Yes because sometimes, it’s difficult to start, so once we measure and let’s say the HMS (health monitoring station) can actually straightaway identify, say ‘Your weight is above the BMI. Will you be keen for like a program?’ So if let’s say patient already at the start indicated that ‘I’m keen’, then maybe later we can address it in the doctor’s room or the nurse room later.

(Nurse, E05).

Exercise clearance evaluation is time-consuming in the general clinic

The care pathway and colour-coded triage which were planned for use in the general clinic were shown to participants. (Annex B; slides 3 & 4). This encompassed the concept of exercise clearance to determine if a patient could proceed with exercise in community settings or required further specialist input. It was acknowledged by doctors that the exercise clearance was an important component in ensuring safety for participants and reducing possibility of complications during exercise. However, it was noted that the exercise clearance requirement could be a barrier to doctors referring patients to WeightWise, as the process was considered too complicated and would take up too much time in the general clinic. It was suggested that this could be sited downstream to WeightWise after patients had joined it.

For the exercise prescription, the initial triaging is quite important so that patients with co-morbidities are properly evaluated before they undergo the programme. Because if halfway through the programme, they start to develop some cardiac symptoms, that could be quite worrying to the patient and then that may discourage them from trying to exercise anymore in the future. So I think good patient selection is going to be very key for the programme.

(Doctor, E03).

If for example, you are going to say that, ‘Oh I’m not going to (allow patient to exercise) and you must do this triage before any referral to WeightWise, then I can see that being quite a significant barrier. People will be just like, ‘Oh, rather than going through this lengthy triage process, I’ll just stick to my status quo, give a very quick brief advice, I feel that’s sufficient and then let it be.

(Doctor, E03).

Additional costs to attend WeightWise would dissuade patients from joining the programme

Participants felt that the cost of WeightWise may dissuade patients from enrolling, especially if it were much higher than the current rates they were paying for consults and if they had to pay to exercise.

I think if let’s say the price of each session were to exceed the usual general clinic price, then it will again become a barrier.

(Doctor, F01)

They (patients) heard need to pay, the more they are not willing to participate in this so-called programme. There’s one patient, I think the doctor offered the Active SG (community-based exercise programme) upstairs and it’s about $60 for six or seven sessions, they were so-called (laughs) ‘Okay I try to, you know. (I’d rather) exercise at home’.

(Nurse, E04).

Nurses felt that patients would not want to pay for a generic dietary counselling by a nurse when they could see a dietitian for the same price.

So if let’s say I’m paying for a programme, and if it’s the diet I’m concerned about, I would prefer a professional dietitian to talk to me, rather than a nurse. I think we can do other parts, like the motivation part. But for diet wise I don’t think we are good enough yet.

(Nurse, E05).

2.2 Facilitators

Motivated and younger patients were more likely to succeed

Participants felt that patient’s motivation was an important factor in determining successful weight loss and in successfully completing the WeightWise programme. The younger population, who were felt to be more tech-savvy and willing to try new approaches, were also deemed more likely to take up WeightWise.

So I think in terms of managing weight, I think probably the most important thing is the motivation level of the patients themselves. I think that is a very big prerequisite if we want to see any success in terms of losing weight.

(Dietitian, E07)

Usually younger population. They try some apps [applications]. Ya, for like those caloric intakes, how much they taking. They try like (…) diet, ya. Intermittent fasting all those.

(Physiotherapist, E08).

Suitable candidates can be identified at the existing health monitoring station

It was thought the health monitoring station, where weight was routinely taken, could facilitate the identification of suitable patients for the programme.

It is good that the HMS [Health Monitoring System] does the BMI [Body Mass Index] and it comes together with the ideal weight as well as the blood pressure. It doesn’t take too much time. I think the question is just ‘Your BMI is high, would you want to consider joining WeightWise?’.

(Doctor, E13).

3. Delivery of WeightWise

3.1. Barriers

3.1.1. Systemic barriers

Competing demands for available manpower

The possibility that a large pool of patients might be eligible was raised, given the criteria was rather loose with simply a raised BMI. This would be taxing on the available allied health and nursing resources, which were already constrained. In particular the nurses, who were designated to be the anchor for WeightWise, already had multiple demands on their time from existing health programmes running in the clinics.

So actually a lot of patients do fulfil the criteria because it is by an absolute number, by the BMI [Body Mass Index].

(Doctor, E13).

If I see it from the nurse’s perspective, because we are running the PTEC [Primary Tech-Enhanced Care] programme, we have PTEC hypertension. Then, we have PTEC-DM for diabetes. Asthma we have SNAP [Singapore National Asthma Programme] counselling. Then, we have our MDT [Multi-Disciplinary Team] counselling. Then, we have our HAPI (Healthy Activated Patient Initiative) for diabetes. So, we actually do a lot of telephone counselling. And it can be quite intensive most of the time. And on top of that, we are seeing the walk-ins. It can be very stressful for the nurses.

(Nurse, F09).

High expectation and heavy burden on the nurses

Nurses were designated as the anchor for WeightWise. Non-nursing disciplines suggested that nurses could act as the main contact point who develop rapport with the patients, and a bridge between the patient and other healthcare professionals and community resources. Other roles included motivational counselling for the patients and providing them with dietary and exercise advice, with the intention to referring them to the dietitian and physiotherapist if more in-depth counselling was required.

Among all these different roles (within WeightWise), at least one person must be a constant touchpoint with the patient. I don’t think it can be the doctor because we come and go right? And then we don’t have the most air time with the patient. But I think the nurse is possible but it should be the same nurse.

(Doctor, E02).

In terms of nursing, I think the main thing will also be providing the patients with the resources to the community and really like being the bridge to all the different healthcare professionals including the dietitians and the physiotherapists.

(Dietitian, E07).

The nurse managers felt that the nurses had too many tasks in this programme and that the roles should be more equally distributed.

The nurses have the most roles. [Laughter] I think it should be fair. I mean everybody should play a part, right? I mean for weight loss.

(Nurse, E11)

There is only to a certain degree where the nurses can counsel and look at. I don’t believe in like, everything the nurses have to be involved in the whole programme. I guess we need to take certain ownership, like certain things should be done by the nurses, certain things should be done by the physiotherapist or the dietitian. And then, work as a team.

(Nurse, F10).

Allied health participants also voiced concerns that the nurses might not be ready to take on so many roles within the programme.

So, like nurses can give advice for stress, exercise, diet all those. But whether they are ready or not, whether they feel they’re competent enough to give (advice) or whether we are putting too much stress on them because of the cost. So, whether they are willing to do, to take all the parts on board.

(Physiotherapist, E08).

Logistical difficulties in conducting in-house group exercise classes

The in-house exercise programmes by the physiotherapists were initially planned to be in a group format. However, multiple barriers were flagged up regarding the feasibility of implementing a group exercise programme. This included the logistical difficulty in grouping patients of a similar demographic or comorbidity together in a class, the difficulty in fitting everyone’s schedule, lack of space and machines.

If like similar group, like similar age or background may be easier. Because if the younger ones, they may not have that much co-morbidities. Like you know, heart problems or hypertension. But the older ones will have. So, the exercises, who do you tailor to?

(Physiotherapist, E09).

If you say you want the group exercises, do you want machines like those stationary bicycles or treadmill. Then, that might be an issue because we don’t have that many in the first place.

(Physiotherapist, E09).

Difficulty accessing information to community exercise programmes

The WeightWise programme intends for patients who have no chronic conditions or have been cleared for exercise to be referred via the nurses to the community exercise programmes. However, it was noted that though there were many existing exercise programmes in the community, there was a lack of a consolidated resource which both healthcare providers and patients could access easily.

I think when we went for the EIMS [Exercise is Medicine Singapore] talk, that was where I learned about all the services available in the community. So, I think now they’re trying to put everybody under HPB [Health Promotion Board]. But they’re having problems because the way you access this information is different from each. So, they are still having difficulty harmonizing. So, it’s still hard to access. Because if it’s hard for me to find, it must be even harder for them.

(Physiotherapist, F12).

Short-term financial burden with uncertain long-term benefits of WeightWise

WeightWise imposed a short-term and immediate cost to the primary care system with uncertain outcomes from the programme. The cost and health benefits of WeightWise would need to be evaluated further.

Looking at the general population, if everyone has better weight, of course Singapore will benefit economically. But that’s a long-term goal. But short-term goal, if you look at just the dollars and cents, it wouldn’t make sense. Because it’s not certain.. the patient may just lose one kg [kilogram]. And like, “Okay, I give up”. Then, your initial investment of thirty minutes will not last.

(Doctor, E13).

3.1.2 Healthcare practitioner barriers

Potential lack of commitment from allied health professionals

A potential problem encountered with multidisciplinary team might be the lack of commitment from the dietitian and physiotherapist due to the ad-hoc nature of their involvement in the programme.

I think the relationship, the team dynamics is also very important because right now, from what I hear of the programme, actually the physiotherapist and the dietitian are only involved on an ad-hoc basis and that’s why I’m not very convinced that they will be very committed.

(Doctor, E12).

Lack of in-depth weight management knowledge and skills

Apart from the dietitians who had been involved in weight management counselling in polyclinics, the rest of the healthcare practitioners had limited knowledge and experience regarding weight management. The doctors were not adept at motivating and advising patients on weight loss. For example, they were also not experienced in providing appropriate exercise advice to patients for weight loss, when they had comorbidities of back or joint pain.

I think most doctors will know how to talk about weight. Most nurses also will know how to talk about weight. But the gap may be how to talk about weight in a meaningful way that can motivate the patient to actually change and to sort of give very practical advice to the patients, rather than just saying, “Oh, lose weight”.

(Doctor, F11).

We have patients with back pain and knee pain. They did say, “Oh, the doctor asked me to lose weight but never tell me how”.

(Physiotherapist, E08).

Concerns were raised by nurses and dietitians that nurses, being the anchor for this programme, might feel inadequate in answering more specific diet-related questions.

Sometimes the patient will ask you, “Oh recently I’ve been taking a lot of this, my son bought for me. Is this good or not? My son say this one is good, low in sugar low in GI [glycaemic index]. Can I take this? At that moment, because we are not trained right, I cannot answer that question. So even like if it’s on the phone, like what if the patient suddenly just ask me this? I mean, how am I going to answer?

(Nurse, E05).

I’m a bit concerned for those patients with like diabetes or other medical conditions. When they ask the diet question that’s specific to their medical condition, I’m not sure how comfortable the nurses are to answer them and whether they answer it correctly or not.

(Dietitian, E10).

Nurses were also unsure about advising on exercise in overweight patients who have comorbidities.

Nurses sometimes will give advice as well. And then they (patients) will say, ‘Oh, they (nurses) say I got pain but not sure whether I can start exercises or not’.

(Physiotherapist, E08).

I also find that sometimes we nurses may have not enough knowledge. Insufficient knowledge. Because sometimes if we see a patient who is obese, we may not know when it comes to the right type of exercise, whether they’re cleared to exercise.

(Nurse, F09).

It was found that physiotherapists were also not trained specifically with regards to weight management during their training. They indicated an interest in learning more about the haemodynamic or physiological responses to exercise with regards to weight loss.

I think (the physiotherapist curriculum is) not specifically on weight management. So, we do get educated about the general physical activity advice but I think that’s quite similar to people who want to lose weight, right? I think the recommended advice is about the same.

(Physiotherapist, E14).

So actually on my part, I would love to know more about like, the hemodynamic response to exercise. With MSK [musculoskeletal] practice, you are not quite thinking about all these things.

(Physiotherapist, F12).

3.1.3 Perceived patient barriers

Challenging for working adults to attend WeightWise

There were concerns that WeightWise would take place during working hours, which would make it difficult for working adults to attend or be reached by phone.

So definitely we will have some working age patients, while we are also doing this (WeightWise) during working hours. So the time we call does not match, and taking up twenty minutes from a working adult is not realistic.

(Nurse, E05)

Phone calls would then be challenging because in the middle of the day, the patient may be working, may not be ready to accept the phone calls.

(Doctor, F11).

The elderly might struggle with remote care

The participants were cognizant that the elderly might struggle with remote care options as some might not be technologically savvy and may be more cautious of incoming phone calls.

The majority of the elderly, they are very scared of scam calls.

(Nurse, F09)

I do see that there is a lot of like phone calls (in WeightWise). And then like, video consult and things. Depending on the age group of the patient, I think older adults will struggle.

(Physiotherapist, F12).

3.2. Facilitators

3.2.1. System facilitators

Remote care options can help encourage attendance and achievement of targets

It was felt that remote care modality options would reduce the commitment burden for patients and make it easier for them to attend the sessions. Frequent phone calls can also help with setting goals and achieving small targets.

I think with the phone calls, it also helps to reduce the burden. Some patients may find that it is quite troublesome to come down for face-to-face consult, especially for those with other commitments. I think that is also a good way of providing support for patients.

(Dietitian, E07)

The telephone phone calls does help you know, whatever goal that they want, we will work together to try and achieve. The patients (from an existing programme) that I have called, have reached their target and (asked) ‘what is next?’

(Nurse, E06).

Healthier SG would increase awareness for preventive care and attract motivated patients

On a larger national scale, it was felt that Healthier SG would attract patients who were motivated and ready to do something to improve their health, which would also match the target population of WeightWise.

Because now with HSG [Healthier SG], especially the ones who are coming forward without any chronic diseases, they are already inherently motivated. That’s why they sign up for HSG and are coming in. Lots of them do come from a position of wanting to engage in preventive health, ya.

(Doctor, F11).

However, some felt that the uptake of WeightWise would still mainly be influenced by readiness of the patient to reduce their weight.

Healthier SG may increase the patient awareness to take care of their health, then they maybe more motivated to (be) involved in our programme. But some patients if they are really not ready to make any changes, maybe it (would) make no difference to them.

(Physiotherapist, E10).

3.2.2 Healthcare practitioner facilitators

Attending the ‘Exercise is Medicine’ course is helpful for exercise clearance

The Exercise is Medicine (EIMS) course aims to train healthcare providers in assessing patients’ physical activity and their suitability to embark on exercise, as well as prescribe appropriate exercises for them. The participants who underwent the course found it helpful in equipping them in exercise clearance and prescription.

Because we went through the (EIMS) course, we know that we have to seek medical clearance. Even some of our colleagues may not be giving appropriate advice. So I think we also lack certain knowledge.

(Nurse, F09)

I think the EIMS gives us a clearer idea of the things that might be a contra-indicator or things to look out for.

(Physiotherapist, F12).

Attachments with experienced practitioners

The planned training for nurses and attachments with the specialist weight management centre was felt to be helpful. It was also suggested that attachments with our own institution’s dietitians and physiotherapists would help better equip the nurses in their anchoring roles within the programme.

I think the SEP [skills enhancement programme- training programme for nurses] will be very useful. I understand that you will be organising observations at [specialist centre], right? I think that’s a very good initiative.

(Dietitian, F05)

I would prefer to sit-in and see how the dietitian counsels. Because they can counsel many different types of cases.

(Nurse, F09).

Or even the physiotherapist, because I’ve not worked with the physiotherapy department. But I would really like to be given an opportunity to see what they do and understand what they do so that they know that the nurses are also trying to do something and then we work with them.

(Nurse, E06).

3.2.3 Perceived patient facilitators

Peer support to sustain patients through the weight loss process

The idea of group exercise classes was well received, as the participants felt that positive peer support could motivate patients to exercise together, support and spur each other to lose weight. It was suggested that patients could tap on the existing community resources for the exercise programmes.

So, if you put them in a group of people doing some kind of exercises together. They may find that on their own, they could already form some kind of social… a group, a social support for each other.

(Physiotherapist, E09).

I think that, if the patients are doing exercise together in a group, maybe with that peer support, it could be helpful to sustain them through the whole weight loss process. And if they see some positive examples in their group that managed to lose weight, that may motivate them further.

(Doctor, E03).

I think looking at the Healthier SG and like how we deal with the elderly, I suppose we can also work similarly in the sense that maybe we can reach out to community partners.

(Physiotherapist, F12).

Discussion

A number of barriers, facilitators and recommendations emerged from the interviews of the multidisciplinary team. In general, the participants acknowledged the importance of weight management and saw the proposed WeightWise could potentially fill a gap in weight management in primary care. In a study conducted by Damschroeder and Lowery, ‘tension for change’ was noted to be a distinguishing construct for effectiveness of implementation, where staff who expressed dissatisfaction with current management options and welcomed the suggested new programme were more likely to have high-implementation outcomes [53]. This could facilitate the implementation of WeightWise locally as participants appeared to welcome the rollout of WeightWise to fill the gaps in weight management programme at the primary care level.

Key perceived barriers that emerged from this study were: the lack of prioritisation on weight management by healthcare professionals and patients, lack of knowledge amongst most healthcare providers in weight management, lack of resources in providing the required support for patients during the programme.

There was a lack of prioritisation on weight management across the healthcare professions and patients. This was contributed to by a lack of consultation time, difficulty in raising the issue of weight loss by healthcare professionals and the lack of realisation by patients that weight was an issue for them. In a systematic review of qualitative studies on general practitioners (GP’s) and nurse’s perspectives on weight discussion in primary care, it was found that low priority of weight discussion was an overarching theme consistent over years of research, across seniority levels [54]. This was contributed by lack of knowledge and skills, lack of time, lack of confidence in treatment and patients, stigma and reluctance in assuming the responsibility of weight management [54, 55]. To help address the issue of a lack of consultation time and prioritisation of weight management, it was suggested by participants that the issue could first be initiated at the vitals measurement station when the weight was first measured and to allow for nurses to enrol patients to the programme at a separate touchpoint, apart from the doctor’s consult. The need for exercise clearance for the programme was also shifted to be carried out within the WeightWise programme instead, to reduce barriers to referral into the programme.

Lack of knowledge in management of weight was noted across the various healthcare domains- medical, nursing and physiotherapy, with the exception of the dietitians, who traditionally had been involved in weight management in our institution. Lack of weight management-related knowledge among primary care physicians and opportunities for improvement in obesity care through increased training has also been found consistently [55, 56]. This was also found in our study where doctors voiced that there was no updated local clinical practice guideline on weight management, which resulted in uncertainty in applying the latest evidence in managing patients with weight problems. They were also unaware of existing weight management services and resources in primary care and community. Notably, the physiotherapists interviewed were not traditionally trained in conducting aerobic-based exercise classes for weight management, as their main job scope in our institution was managing patients with musculoskeletal pains. This suggests that we may need to equip our staff with targeted skills regarding weight management concepts and aerobic exercises. The referral criteria to physiotherapists may also be altered to focus on patients with comorbidities and pain, impeding their ability to exercise. Participants also suggested the need to strengthen the working relationship between community exercise partners and our programme. This would contribute to continuity of care through a feedback loop and our physiotherapists could lend their expertise to community partners should WeightWise patients encounter certain pain or discomforts while exercising.

The decision to have a nurse anchoring the programme, instead of having a dedicated dietitian and physiotherapist for each patient, was to reduce the resource intensity required for WeightWise. However, this decision was perceived as a barrier by participants due to concerns about lack of adequate dietary and exercise knowledge by nurses and the lack of team cohesiveness in management. It has been shown in the POWER-UP [21] and Counterweight [20] programmes that lifestyle coaches and nurses, respectively, could be engaged to provide weight management education and behavioural counselling to patients, with significant improvement in weight loss compared to usual care. The POWER-UP and Counterweight programmes both provided training for their healthcare staff involved in the study and a structured curriculum detailing tasks for each visit. These features can be applied into our WeightWise programme to instil greater confidence in our nurses.

It was suggested by the participants that inter-professional education could occur through a shared digital platform, where dietitians and physiotherapists could support the nurses by helping with answering questions from WeightWise patients which were more specific. Using the CFIR (consolidated framework for implementation research) construct, the MOVE! Programme study found the quality of working relationships across disciplines, team formation and communications were integral to improved referral rates and increased collaboration within the team [53]. Apart from a common platform for discussion, deliberate efforts to strengthen the inter-disciplinary collaboration should be made during the pilot WeightWise programme, through designing for the WeightWise consultations to be held physically near each other and making efforts for all team members to attend multi-disciplinary discussions, where possible.

Lastly, we found that when delivering a weight management programme, it is not enough to just focus on the implementation process, there should be strategies in place to ensure an efficient and effective referral process; this will ensure adequate patient load which is vital for the sustainability of the programme.

Strengths and limitations

This study is one of the few implementation studies on health programmes in the primary care setting locally. The participants included members from a multidisciplinary team which captured a wide range of views from the weight management stakeholders. This inclusive approach makes the study findings more robust and transferable.

However, this study has several limitations. As WeightWise was an institutionally-crafted programme, the perceived barriers and facilitators to its implementation may not be readily transferable. Nevertheless, some of the findings, such as the use of remote care options and holding group classes to increase peer support, can be adapted to help inform design of multi-disciplinary weight management programmes in primary care settings in the future. Another limitation is that due to the small number of healthcare providers who are involved in WeightWise, data saturation could not be reached. Involvement of patients in the interviews would also have been helpful, particularly regarding the acceptability of the programme, cost, content and frequency of touchpoints, in order to make the programme more patient-centred. Purposive recruitment of patients could be considered to understand the patients’ perspective.

Future directions

Weight management in primary care is an ongoing expanding area of research. There has been recent work on the various models that can be applied in primary care practice [57] including ‘integrated into standard primary care model’, ‘other professional model’, ‘purchased programme model’, ‘group programme model’. This study serves to add to the information on the implementation potential of a hybrid model between ‘other professional model’ and ‘group programme model’.

Modality-wise, remote care options were well-received for populations which were tech-savvy, reducing the burden of physical commitment. Future projects could look at stratifying the population into those who are digitally savvy and not, look into the possibility of using digital means of behavioural nudges for patients in the programme and engage technology as a tool for communications and encouragement within a group setting.

Further work will be carried out on the pilot programme, including the efficacy of the various modalities and effect of interactions with different healthcare professionals, with findings used iteratively to inform future adjustments to WeightWise. The local patient population should also be interviewed for their views regarding WeightWise and its efficacy.

Conclusion

The study has highlighted the potential difficulties in recruitment of patients to WeightWise in view of the low priority provided to weight management in the routine care setting. As such, it is important to design care pathways with reduced task complexity or alternate pathways to recruitment, increasing the likelihood of uptake amongst healthcare practitioners. With barriers identified in the form of costs of WeightWise, strain on manpower resources and lack of knowledge regarding weight management, it is important to engage the management board for the necessary support and training and obtain funding from the government in alignment with Healthier SG, in order to implement a feasible and sustainable WeightWise programme in the long run.

Abbreviations

BMI

Body mass index

USA

United States of America

MOH

Ministry of Health

SHP

Singhealth Polyclinics

TICD

Tailored Implementation of Chronic Diseases

FGD

Focus group discussions

IDI

In-depth interviews

NHG

National Healthcare Group

SG

Singapore

HMS

Health monitoring station

AHP

Allied health practitioners

EIMS

Exercise is Medicine Singapore

CFIR

Consolidated framework for implementation research

Authors’ contributions

RL was involved in conceptualisation of the study, conducted the interviews, analysed the data and wrote the manuscript. SSK analysed and interpreted the data. CJN was involved in conceptualising the study and provided supervision for the write-up of the manuscript. All authors read and approved the final manuscript.

Funding

The study was funded by the Family Medicine Academic Clinical Programme Collaborative Research Support Grant (FM ACP CRSG). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

Data availability

The datasets generated and/or analysed during the study are not publicly available to ensure participants’ identity and data confidentiality. The de-identified transcripts and coding framework are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the declaration of Helsinki and approved by SingHealth Centralised Institutional Review Board (CIRB) (2023/2225). Participants consented to participating in the study by signing an informed consent form (Annex B) after reading through the participation information sheet, with any queries answered by the team. Only members of the research team had access to the data, which was stored in password protected documents; this ensured the confidentiality of the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.