A mixed-methods study on the effectiveness of a self-directed online education program on obesity and bariatric care for occupational therapy practitioners and students

Abstract

BACKGROUND:

Due to the rising rates of obesity in the United States, healthcare professionals will likely be seeing individuals from this population more frequently in service provision settings.

OBJECTIVE:

The purpose of this study was to examine the effectiveness of a self-directed online education program entitled BOOTH: Bariatrics, Obesity, and Occupational THerapy; How we can help. The educational program was directed to occupational therapy practitioners and occupational therapy students and designed to increase knowledge of obesity and bariatric care.

METHODS:

A convergent parallel mixed methods design was used in which the quantitative component was a one-group quasi-experiment with pre- and post-measurement. Surveys with Likert-style rating and open-ended questions were administered prior to the program and following completion.

RESULTS:

Paired samples t-testing revealed significant differences (p < 0.05) between pre- and post-program rated survey questions, which indicated an increase in perceived knowledge in the main topic areas. Qualitative data corroborated these findings, as most of the participants initially expressed concern about not being well-informed on obesity and bariatric care prior to taking the course.

CONCLUSION:

More education is needed on obesity and bariatric care for occupational therapy practitioners and occupational therapy students. An online education program was demonstrated to be an effective way of increasing knowledge on this important topic to reduce work-related injury.

Keywords

Safe patient handling work-related injury continuing education

1 Introduction

Since 1980, the prevalence of obesity in more than 70 countries has continuously increased, and in some cases, has doubled [1]. In healthcare, the annual expense of obesity in the United States is estimated to be 190.2 billion with childhood obesity accounting for 21% of the annual spending. Not only are healthcare costs rising, but it is predicted that there will be an increase in unemployment and disability due to obesity. Currently, it is estimated that $4.3 billion is being attributed annually to businesses suffering from absenteeism because of obesity [2]. These trends highlight the importance of ensuring that healthcare professionals, who are likely to be service providers for individuals with obesity, are adequately informed and trained.

1.1 Obesity definitions and prevalence

Obesity is defined as having a body mass index (BMI) of 30 or higher, and severe obesity is defined as having a BMI of 40 or higher [3]. According to the U.S. Centers for Disease Control and Prevention (CDC), from 1999-2000 to 2017-2018 the prevalence of obesity increased from 30.5% to 42.4% [4]. Moreover, severe obesity has risen from 4.7 % to 9.2 % [4]. In response to this drastic rise, bariatric practice among healthcare professionals has become well-established. The term bariatric is assigned to services provided in the areas of prevention, treatment and research to individuals with obesity [5]. The widespread hospitalization for obesity has been compared to the COVID-19 pandemic, caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), as another potentially silent killer [6]. Not only has obesity become common among adults, but in the United States particularly the incidence of obesity in children exceeds that of other chronic conditions [7].

1.2 Occupational therapy and bariatric practice

Depending upon region, the bariatric care pathway will incorporate a continuum of services for prevention, treatment and rehabilitation allocated to a number of settings. A person with severe obesity might receive care during acute hospitalization, inpatient rehabilitation, outpatient visits, referral to a bariatric specialty center, community-based interventions, and home health programs [8, 9]. Medical bariatric treatment focuses on weight loss and thereby the reduction of health risks and comorbidities such as diabetes, hypertention, cardiovascular disease, sleep apnea and osteoarthritis by means of education, medication, and surgery [10]. Occupational therapy practitioners may be part of the the bariatric intervention team in any of these settings [9] and can bring an expanded holistic and client-centered perspective to weight management and engaging in an active lifestyle in which program participants learn about the role of activity, receive technological support for exercise using virtual reality, and come to experience the enjoyment of being active [1]. “When assessing needs, setting goals, and developing and implementing interventions to assist clients who are overweight or obese, the occupational therapy practitioner works closely with the client to design specific plans or programs to meet individual goals and desires in whatever areas of occupation are affected” [11 p S42].

Individuals with severe obesity can face numerous barriers to adequate occupational performance created in the interaction between the person, their desired occupations, and the environment. Nossum and colleagues [12] investigated prioritized problem areas, as described by 63 study participants, via client-centered Canadian Occupational Performance Measure (COPM) qualitatitive interviews. The guiding theory for this project was the Canadian Model of Occupational Performance and Engagement (CMOP-E). Most frequently named problematic occupations were: 1) self care, including personal care, mobility and self-management in the community, 2) productivity, including paid or unpaid work, household chores, and playing with children or grandchildren, and 3) leisure, including active recreation and socialization. In their narratives, participants highlighted particular concerns connected with occupational performance barriers, such as not living up to cultural values about parenting or grandparenting, not purchasing affordable healthy foods, inability to find fashionable clothes or sportswear in needed sizes, and fear of glances when going to the public swimming pool. During occupational therapy intervention, assisting clients to overcome these barriers, often stemming from occupational injustice, social exclusion and stigma, may entail asking about what the person feels and wants to do, and then providing suggestions about reaching desired goals [12].

1.3 Education and training needs of occupational therapists

Indeed, “Occupational therapists possess key skills that help to promote health and to establish persistent lifestyle changes through participation in activities of choice, prevention of occupational deprivation, and increase in the perceived quality of life” [1 p. 2]. Nevertheless, more evidence-based continuing education programs on obesity, bariatric care, and safe patient handling techniques can be essential [13]. OT practitioners may not be fully prepared for this role, and may encounter increased risk of musculoskeletal strain while assisting clients with everyday activities and repositioning. As reported by the U.S. Bureau of Labor Statistics, the incidence of musculoskeletal disorders among healthcare workers is significantly higher than for workers in other demanding fields such as construction and manufacturing, and the expectation is that the risk of injury will increase as the current obesity epidemic in the United States worsens [14]. In order to identify tasks associated with work-related injury across typical practice settings, Darragh, Campo and King [15] administered a qualitative survey to a randomly-selected broad sample of licensed occupational and physical therapists in Wisconsin. Findings demonstrated that for the population studied, 26.6% of injuries occurred while transferring a client and 71% of injuries to OTs were connected with patient lifting [15]. Particularly of note was the weight of the patient being transferred as a contributing factor to work-related injury involving the lower back [15].

Important person-level factors that influence manual handling risk along the bariatric care pathway include the patient’s bodily shape and size, mobility, level of cooperation, pain, and considerations of comfort and dignity. Other key factors are the dimensions and design of vehicular and indoor spaces, available equipment and furniture, quality of communication, and organizational and staff issues associated with policies and training [16]. Flexibility in adjusting to variations in these factors is essential. For example, hospitalized patients diagnosed with COVID-19 who also had obesity were found to pose a unique management challenge if they must be shifted to the prone position for ventilation [6].

Given the potential contributions of occupational therapy practitioners in the healthcare system and community that will benefit the lives of adults and children who live with obesity, it is imperative that these service providers receive needed education and training [17]. Important areas of knowledge are the biological and medical characteristics of obesity, comorbidities, mental health, personal, social and environmental issues that impact occupational performance, social exclusion and stigma, and the evidence base on best approaches to occupational therapy assessment and intervention. Of utmost importance is training on how to safely reposition, move and assist clients in this population during treatment in order to prevent work-related injury as well as to increase positive outcomes. Occupational therapy practitioners need to develop awareness of existing staff education and whether it is supported by policies and sufficient resources. Promotion of no lift policies, use of patient lifts, and proper ergonomic practices [14] can be hindered by lack of clarity in written procedures and insufficient staff and equipment to properly implement manual handling techniques as instructed [13]. The primary aims of the study were to examine the effectiveness of a self-directed online education program, entitled BOOTH: Bariatrics, Obesity, and Occupational THerapy; How we can help, that was created to address knowledge and skill gaps.

2 Method

2.1 Research design

A convergent parallel mixed methods design, in which the quantitative component was a one-group quasi-experiment with pre- and post-measurement, was the basis of this study. Pre-test and post-test surveys with qualitative and quantitative questions were completed prior to beginning the course, and after course completion. The Boston University’s Institutional Review Board (IRB) determined the research as exempt and informed consent was obtained from all study participants.

2.2 Population and course overview

Occupational therapy practitioners and occupational therapy students were recruited via email, social networking websites, and AOTA’s community member board. Inclusion criteria were English proficiency, qualification as an occupational therapy practitioner or occupational therapy student, and Internet connectivity that would allow full access to the BOOTH course. Exclusion criteria were other health care professionals and no access to internet. Seventy-two respondents expressed interest and then followed instructions to register for the course, which was offered on the Blackboard Learn platform through the Boston University Information Technology (IT) department. Information collected at the time of registration, which was stored in a password protected electronic database, included date of birth, email address, country of citizenship, local telephone number, and any prior affiliation with Boston University.

Once granted access to the course platform, participants were allowed three months to complete the course at their own pace. BOOTH: Bariatrics, Obesity, and Occupational THerapy: How we can help is a fully online, self-directed educational program, in which the following topics are integrated through a case study approach:

Module 1: General Knowledge

Module 2: Stigma

Module 3: Occupational Therapy and Obesity

Module 4: Safe Patient Handling

Module 5: Bariatric Equipment

Module 6: Advocacy

Module 7: Telehealth

In the course design, participants followed two case studies. The multi-media approach included video clips on how to operate bariatric equipment and lifts and to complete a radial blood pressure reading, plus information on social stigma and its direct impact on clients living with obesity. Photos, diagrams, and drawn illustrations on various types of bariatric equipment, statistics, and sensitivity strategies were also employed to enhance learning. Short quizzes administered at the end of each module tested knowledge. As an interactive component, participants were asked to review a selected video and answer relevant questions. Data on learning from the quizzes were reviewed at the end of the three-month period.

2.3 Instrumentation

The investigators developed the pre- and post-program survey questionnaires after reviewing the evidence literature to discover areas of insufficient knowledge pertaining to occupational therapy intervention for obesity and bariatric practice among healthcare professionals. Five quantitative questions were administered both prior to and following completion of the BOOTH educational program. Participants rated each on a 5-point Likert scale with 1 indicating strong disagreement and 5 strong agreement. Three quantitative questions addressed feelings of competence for evaluating and treating a client with obesity, having the necessary knowledge base on psychosocial comorbidities related to obesity, and operating and working with bariatric equipment for clients with obesity. The remaining two questions asked participants to rate level of agreement with the positive role of occupational therapy practitioners in obesity and bariatric care, and with the negative effect of obesity-related stigma with best practice in healthcare settings.

One qualitative open-ended question was presented prior to the educational program in which participants were asked what they hoped to learn in relation to obesity and bariatric care. Post-program open-ended questions asked for comments about topics that needed more information and areas related to obesity and bariatric care where the participant would like more knowledge. In four post-program quantitative questions using the 5-point Likert scale, participants rated ease of using the online learning platform, perceived benefit of videos and pictures, and likelihood of recommending BOOTH to students or other health care practitioners. In a fifth question, participants were asked to respond yes or no if they believed that the BOOTH course with some editing could be applied to other health care professionals.

3 Data analysis

Using Microsoft Excel 365 2020, quantitative data were organized and basic descriptive statistics were completed to compute mean, median, mode, and range of survey responses. Inferential analysis consisted of paired samples t-testing to compare ratings on the five pre- and post-program Likert-style rating questions. The primary investigator first examined qualitative responses on the open-ended questions to identify recurrent themes. Responses in text format were then imported to NVivo, which is a qualitative analysis software designed to assist with classifying, sorting and arranging written material.

4 Results

4.1 Participant characteristics

Of the 72 prospective participants who were recruited and registered, 49 embarked on the course. Three did not complete the course in its entirety or respond to all survey questions, and therefore these individuals were not included in the analysis. The primary reason given for not completing the course was insufficient time, mostly due to work obligations. Respondent characteristics are depicted in Table 1. It is noteworthy that 67% of the group that completed the course were OT students, while 91% of the group that did not start the BOOTH course or that dropped out were OT practitioners.

Table 1
Comparison of individuals who completed the BOOTH course versus those that registered but did not begin the course or that dropped out

Characteristic Completed the course n = 46 Did not start the course or dropped out n = 23

Mean age 33 42

Age range 22–64 27–64

Female 37 (80%) 22 (96%)

Male 9 (20%) 1 (4%)

OT students 31 (67%) 2 (9%)

OTs or COTAs 15 (32%) 21 (91%)

United States Citizenship 46 21

Non-US Citizenship 0 2

Characteristic	Completed the course n = 46	Did not start the course or dropped out n = 23
Mean age	33	42
Age range	22–64	27–64
Female	37 (80%)	22 (96%)
Male	9 (20%)	1 (4%)
OT students	31 (67%)	2 (9%)
OTs or COTAs	15 (32%)	21 (91%)
United States Citizenship	46	21
Non-US Citizenship	0	2

4.2 Responses to the quantitative rating questions

Table 2 depicts participant perceptions in five areas prior to and after completing the BOOTH educational program. The bar graph in Fig. 1 provides means to visualize percent of change.

Table 2
Findings for the five rating questions administered prior to and following the BOOTH educational program

Pre-Test Mean (SD) Post-Test Mean (SD) Percent change Paired sample t-Test significance

I feel competent enough to evaluate and treat a client with obesity

2.9 (1.04) 4.13 (0.625) 43% increase P = 0.00001^*

(neither agree nor disagree) (agree)

I feel I have the necessary knowledge base on psychosocial comorbidities related with obesity.

2.73 (1.09) 4.22 (0.59) 55% increase P = 0.00001*

(neither agree nor disagree) (agree)

I feel competent enough to operate and work with bariatric equipment for my clients with obesity.

2.79 (1.11) 3.8 (0.91) 44% increase P = 0.00001^*

(neither agree nor disagree) (agree)

I feel that occupational therapy practitioners have a positive role in obesity and bariatric care

4.25 (0.81) 4.67 (0.52) 10% increase P = 0.00175*

(agree) (strongly agree)

I feel that obesity related stigma negatively affects best practice in healthcare settings

4.13 (0.73) 4.57 (0.62) 11% P = 0.00248*

(agree) (strongly agree)

Pre-Test Mean (SD)	Post-Test Mean (SD)	Percent change	Paired sample t-Test significance
I feel competent enough to evaluate and treat a client with obesity
2.9 (1.04)	4.13 (0.625)	43% increase	P = 0.00001^*
(neither agree nor disagree)	(agree)
I feel I have the necessary knowledge base on psychosocial comorbidities related with obesity.
2.73 (1.09)	4.22 (0.59)	55% increase	P = 0.00001*
(neither agree nor disagree)	(agree)
I feel competent enough to operate and work with bariatric equipment for my clients with obesity.
2.79 (1.11)	3.8 (0.91)	44% increase	P = 0.00001^*
(neither agree nor disagree)	(agree)
I feel that occupational therapy practitioners have a positive role in obesity and bariatric care
4.25 (0.81)	4.67 (0.52)	10% increase	P = 0.00175*
(agree)	(strongly agree)
I feel that obesity related stigma negatively affects best practice in healthcare settings
4.13 (0.73)	4.57 (0.62)	11%	P = 0.00248*
(agree)	(strongly agree)

An asterisk (*) indicates significance at P≤0.05.

Fig. 1

A visual representation of percent of change in pre- and post-program ratings on five questions pertaining to participants’ perceived competence, knowledge, and awareness of the role of occupational therapy in bariatric care, and understanding of the effect of stigma.

Table 3 portrays percent of favorable participant responses to questions about program accessibility, benefit and applicability after course completion. The bar graph in Fig. 2 provides means to visualize responses.

Table 3

Findings for the five rating questions administered post-program

Question	Post-Test Mean (SD)
Did you find the online learning module easy to use and navigate?	4.22 (0.87) (agree)
Were the pictures outlined in the education program beneficial to your learning?	4.28 (0.83) (agree)
Were the videos outlined in the educational program beneficial to your learning?	4.31 (0.73) (agree)
Would you be likely to recommend BOOTH to other healthcare practitioners and/or students?	4.24 (0.71) (agree)
With some editing, do you feel that BOOTH could apply to other healthcare professionals (yes/no)?	All respondents responded Yes

Fig. 2

A visual representation of participant’s quantitative responses to five questions related to the BOOTH course pertaining to course navigation, visuals, videos, recommendation of the course to other health care professionals, and the applicability to other health care professionals.

Participant responses to the Likert-style rating questions administered prior to and following the BOOTH online course demonstrated significant increases in self-perceived knowledge of psychosocial comorbidities, competence to evaluate and treat a client with obesity and competence to operate and work with bariatric equipment during treatment. Responses also indicated significant improvement in understanding of stigma and the positive role of occupational therapy. Scores on quizzes administered upon the completion of each module verified learning. These documented gains in essential areas of knowledge for occupational therapy practice with adults and children living with obesity are likely to enhance the therapeutic impact of occupational therapy services provided in bariatric care settings while minimizing the risk of work-related injury.

4.3 Responses to the qualitative questions

A listing of themes identified after manual review of participant responses to open-ended questions, followed by further qualitative analysis using the NVivo software, is provided in Table 4.

Table 4
Responses to each open-ended question organized into themes

Theme Frequency

What do you hope to learn from this module in relation to obesity and bariatric care? (pre-program)

How to treat a client with obesity 27

OT role in obesity 16

Healthy occupations 7

Adaptive equipment 5

Obesity related stigma 3

Family and caregiver support for clients with obesity 2

Were there any modules/topics that you felt needed more information? (post-program)

No other information needed 20

Bariatric equipment module 8

Specific ADL intervention techniques 5

Advocacy module 5

Childhood obesity module 3

Specific assessments 1

Psychological treatment 1

What would you like to know more about in relation to obesity and bariatric care? (post-program)

Promoting healthy occupations 12

Safety with bariatric equipment 8

Specific ADL resources 3

How to address obesity related stigma as a thin therapist 1

Bariatric surgery 2

Insurance 3

Causes of obesity due to mental health considerations 3

Social justice 1

Developing specific OT goals 1

Aging population with obesity 1

Theme	Frequency
What do you hope to learn from this module in relation to obesity and bariatric care? (pre-program)
How to treat a client with obesity	27
OT role in obesity	16
Healthy occupations	7
Adaptive equipment	5
Obesity related stigma	3
Family and caregiver support for clients with obesity	2
Were there any modules/topics that you felt needed more information? (post-program)
No other information needed	20
Bariatric equipment module	8
Specific ADL intervention techniques	5
Advocacy module	5
Childhood obesity module	3
Specific assessments	1
Psychological treatment	1
What would you like to know more about in relation to obesity and bariatric care? (post-program)
Promoting healthy occupations	12
Safety with bariatric equipment	8
Specific ADL resources	3
How to address obesity related stigma as a thin therapist	1
Bariatric surgery	2
Insurance	3
Causes of obesity due to mental health considerations	3
Social justice	1
Developing specific OT goals	1
Aging population with obesity	1

Selected Direct Quotes from Participant Responses to Open-Ended Questions

4.3.1 What do you hope to learn from this module in relation to obesity and bariatric care?

“[I would like to learn] Best practice for interventions with people with obesity. The population that I work with have a high percentage of people with obesity.”

“Our hospital has a bariatric surgery program, however there has been minimal education provided on specific considerations, so I am hoping this course enlightens me on this specific topic.”

“I would like to be able to address obesity and bariatric care carefully within OT and how we can help our patients improve their health by being able to participate in meaningful activities that they enjoy and would like to get back to doing”. “I would like to understand bariatric patients more than I do now and be able to recognize and combat any stigma or subconscious bias I may have”

4.3.2 Were there any modules/topics that you felt needed more information?

“I can’t think of any. The information was both relevant and complete, which is quite an accomplishment.”

“I feel as though all modules did a great job at describing and explaining each specific topic.”

“I thought more info on the Bariatric equipment module, as I am a student and just beginning to familiarize myself.”

“Module 6- Advocacy would benefit from more information. As a student, I am still learning about advocacy within OT practice, that I do not have a full understanding of requesting equipment and making sure insurance will cover it!”.

4.3.3 What would you like to know more about in relation to obesity and bariatric care?

“This course has given me a better understanding of the obesity and bariatric population that I hope to be able to utilize what I have learned on this course and provide hands-on learning skills during fieldwork/future career environment”

“I believe that this was a good course that helped us understand obesity and bariatric care in Occupational therapy. I would love to have more instructional videos on how to use the bariatric equipment to feel more competent in explaining to patients how it works.”

“I would enjoy gaining more resources in health and nutritional routine creation for patients who may benefit from these goals.” and a focus on the aging population with obesity (1).

5 Discussion

The purpose of this research was to evaluate the effectiveness of a self-directed multi-media online education program for occupational therapy practitioners, assistants and students centering on obesity and bariatric care with the aims of increasing practical knowledge on this topic area and preventing work related injuries in healthcare settings.

5.1 Implications of findings

Survey data from quantitative post-program rating questions and pre- and post-program open-ended qualitative questions provided valuable feedback on the feasibility, appropriateness, and acceptability of BOOTH presented as a self-directed multi-media online approach to adult learning. Participants assigned high ratings to ease of use of the learning platform, as well as the benefits of videos and pictorial supports, and also highly rated likelihood of recommending the program to other students or healthcare professionals. Desired topic areas of learning in responses to an open-ended question prior to embarking on the program were provided in the modules. To further develop participants’ understanding of the intricacies inherent in bariatric care, an expanded interactive approach will be considered in future courses. This might consist of asynchronous guided questions on a discussion board, shared journal entries, or real-time interactions using a virtual conferencing system. Cooperative social interchange could provide participants with a means for self-discovery, problem-solving, and mutual learning through exploration of experiences and expertise.

Corresponds with Figure 2 to describe values 1-5

Further input via open-ended questions reflected insights of the participants. In general, statements made expressed praise and support. Some participants felt that more information on bariatric equipment, specific ADL intervention strategies, promoting healthy occupations, advocacy, and childhood obesity would be beneficial. This hunger for more information is not surprising, as 67% of participants were occupational therapy students who had not fully embarked on their own role of being an independent occupational therapy practitioner.

5.2 Study limitations

Characteristics of the study population were not fully representative of practicing occupational therapy service providers, as two-thirds of participants were occupational therapy students with little direct clinical experience. Yet it is interesting that 31 occupational therapy students enrolled in and completed the course, perhaps in anticipation of the growth of occupational therapy services in bariatric care and aspiring to have more knowledge on the topic while in school. Additionally, prior knowledge of safe patient handling procedures for most participants was likely limited due to lack of experience. Recommendations by the study participants should therefore be considered in further iterations of BOOTH, particularly where the intended audience will be students or other healthcare professionals less familiar with this practice area.

Attrition was another issue. Though 72 prospective participants had registered, 46 were represented in the final sample. Those that did not complete the course were mostly occupational therapy practitioners working in the field who lacked sufficient time to complete the BOOTH course within the allotted time. When the next version of this course is offered, allotting a longer time-span selected for course completion will be considered.

The potential influence of bias cannot be ignored. As weight stigmatization and bias are so prevalent in the U.S., hidden or subtle biases might have played a role in how material was presented and the choice and wording of questions. To assist with identifying and mitigating the effect of hidden biases, the BOOTH course may benefit from addressing these topics via virtual or asynchronous interactive discussions among participants.

6 Conclusion

Occupational therapy practitioners, among other healthcare professionals who work with bariatric clients, are at elevated risk of work-related injury. After completion of the BOOTH online education program, participating occupational therapy students and practitioners gained improved awareness and understanding of occupational therapy evaluation and treatment in bariatric care, as well as techniques for safe work practices with this population. The BOOTH education program fills an essential knowledge gap, with the potential of reducing the incidence of work-related injury and increasing professional competency, thus leading to beneficial outcomes in which clients can overcome barriers to adequate occupational performance.

Footnotes

Acknowledgments

The authors thank the staff of the Boston University IT department.

Conflict of interest

None to report.

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