The Resident Experience of an Obesity-Focused Home Visiting Curriculum

Abstract

Background

The prevalence of obesity in the USA has risen to 39.8% of adults and 18.5% of children, yet there has not been a compensatory rise in residency training to reflect this epidemic.

Objectives

To examine pediatric residents’ lived experiences of completing a novel home visitation curriculum for children with obesity in resource-poor areas of Washington, DC.

Methods

Pediatric residents completed a home visiting curriculum consisting of four modules followed by two home visits to families with a child struggling with obesity. Within 2 weeks of completing the curriculum, individual interviews were conducted with participants about their experience. Inductive coding was used to analyze the data, followed by clustering and theming.

Results

Saturation was reached after individual interviews with 13 residents between 2013 and 2015. Five themes emerged describing the residents’ experiences: (1) enhanced understanding of home and community life, (2) awareness of personal biases and assumptions, (3) challenges of losing control and not being intrusive, (4) deeper relationship and enhanced empathy with patient and family, and (5) changes in delivery of care.

Conclusions

The findings from this study suggest that an obesity-focused home visiting curriculum may provide residents with a deeper understanding of social determinants of obesity and the opportunity to gain other necessary skills that may help them better care for individuals with obesity.

Electronic supplementary material

The online version of this article (10.1007/s40670-018-00642-9) contains supplementary material, which is available to authorized users.

Introduction

In the USA, 18.5% of children and 39.8% of adults have obesity (body mass index [BMI] percentile for age > 95th and BMI > 30 kg/m², respectively) [1]. Including those who are overweight (BMI percentile for age > 85th and BMI > 25), the figures rise to 32% of children and 69% of adults [2]. In children, non-Hispanic blacks and Hispanics continue to have higher obesity rates than non-Hispanic whites [1]. Obesity is a multiorgan system chronic disease associated with many sequelae in childhood, including abnormal liver function, glucose intolerance, depression, hypertension, and dyslipidemia [3]. Most importantly, obesity in children is associated with obesity in adults, which results in a cumulative burden of disease [4].

Over the last three decades, as the prevalence of obesity has increased, medical training has not risen proportionally [5–7] resulting in residents feeling overwhelmed, using biased inflammatory language, creating unrealistic goals, and lacking confidence in obesity management [8–11]. Additionally, despite several national medical organizations emphasizing the need to teach obesity with a strong community context [12], most of the published obesity-focused residency curricula emphasize knowledge building, behavioral modification, nutrition, and physical activity counseling [13–16]. Therefore, we developed a home visitation curriculum to attempt to provide the community context for residents. We hoped that using an experiential learning modality such as home visitation would allow for a greater depth of knowledge and understanding of the community environment and social determinants of health (SDH) that influence obesity [17, 18].

Although previous home visitation studies with residents have demonstrated an improvement in cultural awareness, communication skills, awareness of community resources, empathy, and improved awareness of the overall health of patients, [19–25] to our knowledge, no previous studies have examined the effects of an obesity-focused home visitation curriculum for residents. Therefore, given the educational opportunity and its potential impact on obesity management, this qualitative study aimed to gain an in-depth understanding of residents’ experience participating in an obesity-focused home visit curriculum. We also aimed to explore residents’ thoughts on how it affected their management of obesity.

Methods

Healthy Homes, Healthy Futures Program Curriculum

Healthy Homes, Healthy Futures is an obesity home visitation curriculum designed in 2012 and implemented in a large urban pediatric residency program. The curriculum was mandatory for first-year pediatric residents in a community-oriented track. The didactic portion consisted of self-directed PowerPoint modules on home visiting, nutrition, and SDH, as well as an interactive online motivational interviewing module [26]. After module completion, residents selected a family from their continuity clinic with a child aged 5–13 years with a BMI of greater than 85th percentile. The residents requested two home visits to assist families improve their health and weight management. The families chosen typically experienced poverty and were predominantly African American or Hispanic. A total of 22 residents completed the required curriculum between 2013 and 2015.

Study Design and Setting

Using a purposeful sampling strategy, all residents who completed the curriculum were invited to participate in an individual interview within 2 weeks of their last home visit, with no repercussions associated with their decision. The individual interview script, co-created by the principal investigator (CL) and a seasoned qualitative researcher (EFG), focused on exploring the residents’ overall experiences after completing the home visits. Each resident provided written and oral consent before participating. Residents also completed a demographic questionnaire. Due to the vulnerable population being studied, individual interviews allowed residents to give a private and candid reflective account of their experiences. Individual interviews were conducted in a private office by one of two trained interviewers who had no other interactions with the residents. The interviewers used probes when needed to ensure that participants provided a rich description of their experiences. Interviews were digitally recorded and professionally transcribed with personal identifiers removed. The institutional review board at Children’s National approved this study.

Data Analysis

The data were analyzed using inductive coding followed by clustering of codes and thematic determination [27]. Two team members (KDE and CL) coded the initial five interview transcripts by consensus and created a codebook that identified clusters of codes. Two other team members (EH and a resident) reviewed the coding and discussed the codebook with the first two coders until consensus was reached. Next, the first two coders coded the remaining transcripts and identified themes for each cluster. The themes were reviewed by the other coders and the interviewers. Once all reached consensus, supporting quotes were selected to illustrate each theme [27].

The trustworthiness of the study was ensured by using interviewers outside of residency program; member checks of the transcribed data; code checking by a senior resident and member of the research team; theme verification by the interviewers; and the provision of thick, rich description to support the themes [27].

Results

Saturation was reached after the transcripts from 13 residents were analyzed, and no new additional information was obtained. Therefore, no additional residents were enrolled in the study. All participants were female, seven were White/Caucasian, and six were Black/African American or Asian/Pacific Islander. Most participants (69%) came from families with advanced degrees, and most (54%) indicated growing up in a household with an income of > $100,000 annually. Only one resident indicated a parental household income of < $50,000 annually (Table 1). Five themes emerged from the data.

Table 1.

Resident participant demographics characteristics

Demographic	N (%)
Gender
Female	13 (100)
Age range
25–30	10 (77)
31–35	3 (23)
Race
White/Caucasian	7 (54)
Asian/Pacific Islander	3 (23)
Black/African American	3 (23)
Household income as a child
> $150,000	6 (46)
$100,000–$149,000	1 (8)
$50,000–$99,999	5 (38)
$25,000–$49,999	1 (8)
Highest education of parent
Professional degree (i.e., MD, JD)	5 (39)
Doctoral degree (i.e., EdD, PhD)	2 (15)
Master’s degree	2 (15)
Bachelor’s degree	4 (31)

Theme 1: Enhanced Understanding of Home and Community Life

The home visitation provided residents with a tangible, intimate understanding of lived experiences of their patients and families. Residents began “to see firsthand how a patient lives…and how the environment can affect health.” The experience also gave them “a better appreciation for their [patients’] lives and what it means to live where they live and have the resources that they do and have the jobs that they have” (see Table 2). It increased their awareness of different underserved community settings while making the SDH more palpable.

Table 2.

Exemplar quotes about home and community life

Category	Quotes
Community	● I know now that they do have space where they can play outside; they do have a safe park nearby. ● We were able to go more in depth about the physical activity the patient is actually doing…In the office she may say, “Oh, I walk to school” or “I go to the park,”…but having seen exactly where the park was, knowing how far she actually walked to the bus stop to go to school, which is only about two blocks,…it wasn’t appropriate physical activity so we could…delve into that a little bit further. ● When she comes home from school, she passes a convenience store,…so almost every day after school she’s buying a big soda and a bag of Cheetos,…another detail that probably would not have come out in clinic. ● When I did the drive around the area, I saw there’s a recreation center nearby and there’s a playground there, so I could tell mom: Maybe you can take her out there and let her play around. ● In a neighborhood that’s not safe, you cannot walk for 30 minutes…to get your exercise in, …but if you’re going to be watching TV, do jumping jacks during the commercials.
Home	● I feel like I have a much better picture because I literally saw the insides of their cabinets. ● Truly seeing their actual kitchen allowed us to talk about what they actually cook for dinner…There were some great things they were doing,…like baking chicken each night trying to incorporate vegetables, and we could see the canned vegetables that she brings home from work. ● There’s stairs in the house, so trying to incorporate that into her routine to get her more active—so then she’s not relying on her parents as much to take her somewhere to play but she can do a little bit of exercise at home. ● It was helpful to see that they buy in bulk, shop a lot at Costco…A lot of their things are not put away in cabinets…[They] leave chips lying all over the house or juice,…boxes all over.…The kids would admit, “I walk by and grab a juice box.” ● The two daughters were sleeping on couches in the living room. There was a dresser.…Mom was also sleeping downstairs because they do not have enough rooms for everyone. It was just very eye opening because it put the context of their health condition in a much broader social situation which I think really does make a difference. ● It was really interesting to learn that mom is the sole breadwinner but the only one who cooks, so time constraints are a real factor. That’s probably why they eat so much processed foods.

For the residents, the visit also put the lives of families struggling with obesity into the broader context of what was happening in the home and neighborhood. Being physically in the home provided residents personal knowledge of what was occurring, rather than relying on family reports. As one resident stated:

The most powerful part of the whole experience for me was that feeling of having a family open up their fridge in front of me and being struck really strongly with the feeling that no matter what they’re telling me they’re eating, I’m never going to know until I’ve actually looked in the fridge and seen that this was a mom who was telling me that there were vegetables in every meal but there were no vegetables in the fridge. . . . [Trying to reconcile this] in front of the family while I was in their kitchen was an experience that I think will always stick with me.

Theme 2: Awareness of Personal Biases and Assumptions

The home visits made residents more cognizant of their own personal biases, such as what a home will look like and what is feasible for a family to accomplish after school:

I think the table is just something that growing up was where my family sat. And when I recommend to families to eat together as a family, . . . in my mind that’s at a table. . . . It had not really occurred to me that for a lot of families that’s not possible; they don’t actually have a table where they can all fit around, especially if they have multiple family members in the household.”

“Both my parents worked, but they were able to get home, take me to extracurriculars, make dinner, and stuff. [Here] it’s just Grandma, and her hours are just such that sometimes she’s not home for dinner. The kids are making the food for themselves, which inevitably means it’s a lot of canned ravioli. Grandma doesn’t feel safe with them walking to different places . . . [and] being involved in after-school activities is a little bit harder because there’s no direct transportation. So it really highlighted for me how much harder it is just given the circumstances.

Theme 3: Challenges of Losing Control and of Not Being Intrusive

Being in the patients’ home made the residents more cognizant of the inequalities present in a typical patient encounter. The first thing they became aware of was a shift in the power differential—specifically, who was in control of the visit. As described by one resident:

In the office I have more control over the situation, where in their home I felt like I didn’t have as much control. . . . For example, their TV was on during the interview and . . . I wasn’t sure if it was appropriate to ask them to turn it off because it was their home. . . . In the office if I were to see a patient and they had something playing on their cellphone, I would feel completely comfortable just asking them to turn it off.

Trying to maintain control of the visit, while at the same time being respectful of the family, became a balancing act. Most prominently, residents were trying to think of ways to get through the visit without being insulting or being perceived as meddlesome, especially since the topic was obesity. This is exemplified by the following quote:

I didn’t want them to feel like they were being judged by us, which was hard, . . . because by coming in and saying it’s an ‘obesity home visit,’ by nature that sounds judgmental.

Theme 4: Deeper Relationship and Enhanced Empathy with Patient and Family

The home visitation experience enabled a deeper layer of intimacy with the family, which participants believed would strengthen the patient-clinician relationship and be sustained throughout their residency. One resident said:

There is that aspect of building a relationship with the family that is different than that 15-minute visit in clinic. I got to spend an hour. They showed me their family photos. The dog licked my feet. I really built a rapport that I think will translate into a good, lifelong physician/patient relationship.

Additionally, the intimacy changed the interaction during the visit and allowed for more openness. Another resident articulated:

I think by being in their home they felt like they could open up about some things. For example, I learned more about [the mother’s] job and when she has to go get the bus, when she’s there with her daughter, when she’s not. . . . More details about their personal home time than we would have time for in the clinic.

Residents also developed more empathy for families after seeing how the sociocultural and home environment can affect health. They developed an increased sensitivity to the multitude of uncontrollable factors that affect patients’ chronic conditions. As stated by one resident:

Though I always try to express empathy to my families, I think sometimes it’s difficult because you just don’t know what their circumstances are. Having seen it firsthand, my empathy towards families will change [from] ‘Why aren’t you doing this?’ [to] ‘What barriers are there for you to doing this?’

Theme 5: Change in Delivery of Care

Residents described the home visit as something that would alter how they interacted with patients in the future, including families that they previously followed in their clinic. Most of the changes they described focused on changes they would make during visits for children with obesity but some were more general. Specifically, they spoke about incorporating motivational interviewing. As one resident noted:

It has to be an open-ended conversation. Behavioral change is all motivation. Me telling them what to do is not going to change their behavior unless they want to and they’ve come up with it on their own, so it’s the whole idea of motivational interviewing.

Residents also described how their experience expanded their depth of questioning to explore sociocultural and economic influencers.

In addition, residents spoke about including caregivers that may not be in the room. One said:

When I first approached mom about doing this home visit, she said, ‘My child doesn’t really live with me,’ and I felt like: ‘Oh, I don’t know how to do this because the person that I should be speaking to is not even here.’ . . . But now being able to be comfortable to say, ‘Do you mind if I call them?’ and not being afraid to reach out beyond the scope of the immediate caregiver.

Finally, they spoke about being much more specific with their recommendations. Table 3 provides additional quotes that exemplify changes in questioning and recommendations.

Table 3.

Exemplar quotes about changes in delivery of care

Category	Quotes
Change in questioning	● I do think it helped to reinforce [using] open-ended questions [about what they keep in the home] and to really listen to what they are saying and to maybe pick up on some other clues about what their financial situation is like and what their style of shopping is. ● I will ask more specific questions about: Do you have a kitchen? Do you like feel comfortable using recipes? ● Before this I would ask questions about what types of foods and maybe whether mom cooks or not, but never really getting past that: Why does mom cook? Or why does not mom cook? Or why do not we eat our fruits and vegetables? Is it because they are physically not there or is it because you tried and they do not like it? Maybe we need to do a better job of introducing it and that’s the hold up. Or is it mom does not like fruits and vegetables so mom does not buy it? ● I think things I did not ask before that I might ask now are: Who’s preparing the meals?…[Because a] 10-year-old might have to make her own food. ● I think one of the biggest things that in the past we have focused on is juice consumption. I think stepping back and not attacking that first necessarily and actually asking: What does dinner look like? What does breakfast look like? When you are home, do you sit at the table? Are you all there? Walk me through dinner last night, kind of thing; give me a little bit more of a picture of what’s going on.
Change in advice	● When making a plan incorporating the parents in terms of what works for your schedule because that’s pretty much the determining factor in what happens to their child.…Recommendations would be more detailed. ● I gave him some recipes that might be helpful for them that are quick, because they have a very busy schedule with mom working at night, dad working during the day and minimal overlap, and trying to deal with the three kids. ● So instead of just telling them you need to eat more fruits and veggies, you could say: I know you are able to get canned veggies from work, so that’s great; get those canned veggies, then try to just buy the fresh greens by themselves. So you could tailor it more direct advice to knowing their kind of financial status.

Discussion

To our knowledge, this is the first study to look at residents’ in-depth experiences with an obesity-focused home visitation curriculum. The use of a qualitative approach allowed for a broader understanding of the effect of residents’ experience related to caring for children with obesity. This is important because previous studies have demonstrated a gap in preparedness of residents to manage obesity [5, 6, 15, 28].

Despite a lack of national standards for obesity training in residency, the Provider Training and Education Workgroup of the Integrated Clinical and Social Systems for the Prevention and Management of Obesity Innovation Collaborative recently released a set of recommended core competencies for the prevention and management of obesity [12]. One recommendation is that residents demonstrate a working knowledge of the social, cultural, environmental, and other factors that contribute to the obesity epidemic [12]. Consistent with previous home visiting studies, [19–25] the residents in our study reported gaining a much deeper contextual understanding of the community they serve along with the sociocultural barriers that challenge their patients. The participants reported that the home visitation experience allowed them to better understand these concepts and apply them to obesity care in a practical way, especially when it came to understanding access to nutritious foods and having a safe outdoor space for physical activity.

Another recommended competency is that clinicians incorporate the environmental and cultural context of obesity in their counseling [12]. Learning about resources or lack thereof through home visits appears to have changed the participants’ counseling approach, so that residents consider these issues before issuing blanket recommendations. Instead of a problem with an instant fix, they described a care model that is consistent with the reality of the chronic disease state [10]. Additionally, the residents reported that they would be more likely to use motivational interviewing in their counseling in the future. To our knowledge, this finding has not been reported in other home visiting studies and is especially relevant in obesity education, as previous studies have demonstrated that residents are significantly more confident in the effectiveness of their obesity counseling when they feel they have strong motivational interviewing skills [29].

An increased awareness of personal biases and assumptions was another important theme in this study. This is another competency in the workgroup recommendations [12] seen as an important step in minimizing discrimination against people with obesity. We could not find any previously published home visiting studies that looked at whether the visits had decreased reported biases, but our participants felt that their experience gave them better insight into what was happening in the patients’ home (which was very different than how they had grown up). This is especially relevant in working with individuals with obesity as previous studies have demonstrated that many healthcare professionals, including medical trainees and physicians, have high rates of both explicit and implicit bias towards people with obesity [30, 31].

Another finding from this study that may improve obesity care is that residents reported a change in the relationship they had with families. This result is consistent with previous non-obesity-related home visiting studies [20, 25]. Residents described increased empathy for their patients after being able to see how the home environment has affected the health of the family. They additionally reported better rapport with the family that allowed the family to open up about additional aspects of their lives, such as who was involved in the care of the child. Residents felt that this would not only allow them to build more continuity with this family but also help in their interactions with other families and thereby improve their ability to manage obesity.

An additional benefit of this home-visiting study not directly related to obesity was a reported increased sensitivity to understanding challenges faced by low-income families. According to the Association of American Medical Colleges, medical trainees often come from the top two quintiles of family income. In 2006, the median family income for a medical student was $100,000 [32], which is consistent with our sample. Income separation may contribute to a decreased understanding of health disparities by clinicians and increased sensitivity to challenging questions around a family’s social history [33]. Residents often work in community clinics with underserved populations, but even after multiple years, there is often very little immersion, understanding, or basic knowledge of their community [34]. This sociocultural barrier limits clinicians’ ability to effectively counsel patients and make practical recommendations necessary for health behavior changes. By having an experience that immersed them in the home and neighborhood, residents believed they had better tools to address the needs of the low-income families they serve.

Limitations

There are several limitations to this study. First, consistent with qualitative inquiry, the numbers of participants were small in addition to their being limited variability by gender, which may limit transferability. This was addressed by providing quotes which richly described the residents’ experiences, so that others could determine the applicability of the findings to their contexts. Second, several members of the research team have a close relationship with the topic of study as practicing clinicians who have focused on working with underserved populations and training residents, and may have potentially introduced bias into the study. This was addressed by having the primary authors (KDE and CL) who developed the in-home program use memo-ing throughout the study. In addition, other techniques were included to optimize research credibility and trustworthiness. Triangulation was used during data collection through the use of multiple interviewers and during the development of themes through the use of multiple coders and group consensus to reach the final themes. Finally, the themes were member-checked with the participating residents and found to be reasonable.

Conclusion

Our results suggest immersive experiential learning opportunities such as this can teach clinicians about the effects of social determinants of obesity. Our findings additionally indicate that an obesity-focused home visiting curriculum can strengthen interpersonal relationships establishing the framework for culturally sensitive healthcare. This home visit experience allowed residents and families to better identify barriers to healthy living and generated empathy by virtue of direct and lengthy contact. Future exploration will include an evaluation of family experiences, expansion and analysis with more trainees and their clinical experiences, consideration of multidisciplinary teams for home visits, and study of how this experiential learning technique could influence clinicians’ unconscious biases.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.