Permanent health education in the context of obesity: a scoping review

ABSTRACT OBJETIVE To map the international literature on Permanent Health Education initiatives to care for people with obesity. METHODS In total, six databases were searched without any language or publication period restriction according to the Joana Briggs Institute manual for evidence synthesis and the Prisma extension for scoping reviews (Prisma-ScR). Articles were independently analyzed by four reviewers and data, by two authors, which were then analyzed and discussed with our research team. RESULTS After screening 8,780 titles/abstracts and 26 full texts, 10studies met our eligibility criteria. We extracted data on methodologies, themes, definitions of obesity, outcomes, and gaps. Most initiatives came from North American countries without free or universal health systems and lasted a short period of time (70%), had multidisciplinary teams (70%), and addressed sub-themes on obesity approaches (90%). Results included changes in participants’ understanding, attitude, and procedures (80%) and gaps which pointed to the sustainability of these changes (80%). CONCLUSION This review shows the scarce research in the area and a general design of poorly effective initiatives, with traditional teaching methodologies based on information transmission techniques, the understanding of obesity as a disease and a public health problem, punctual actions, disciplinary fragmentation alien to the daily work centrality, and failure to recognize problems and territory as knowledge triggers and to focus on health care networks, line of care, the integrality of care, and food and body cultures.


INTRODUCTION
In recent decades, the phenomenon of obesity has taken the center of the debate on global health concerns due to its complex and multifactorial character. In a recent report, the Lancet Commission on obesity offers the concept of a global syndemic, tracing an association between three pandemics: obesity, malnutrition, and climate change, phenomena with common systemic factors and complex relations interacting with each other to contribute to anew narrative needed to accelerate the social movement of change [1][2][3][4] .
A global panorama of this magnitude invites policymakers, researchers, managers, and healthcare providers to think about new forms of care which are articulated in a network, structured in longitudinal lines, and based on the integrality of care and body and food cultures 2,3 . Guidelines to organize obesity care lines point to Permanent Health Education (PHE) actions, programs, and primary care policies as a powerful political-pedagogical strategy to change health care providers' understanding, formulation, and thinking, turning territorial realities into beacons for critical, systemic, and transformative actions 2-5 . Thus, this review aims to systematically map and summarize the evidence found in this area via the following research question (RQ): what has the international literature produced about permanent education initiatives so health care providers can care for people with obesity? It also explores the following sub-issues:(RQ1) What themes and methodologies do these initiatives use?; (RQ2) How do these studies conceptualize obesity?; (RQ3) What are the results of these initiatives?; and (RQ4) What gaps do these studies show?

Protocol and Registration
The protocol of this review was elaborated according to Prisma-P 6 and the Joana Briggs Institute (JBI) 7 recommendations, which were reviewed by our research team. Its final draft was registered on Open Science Framework on February 24, 2021(https://osf.io/g5jkh/).

Eligibility Criteria
Studies (which could have included articles from peer-reviewed journals, dissertations, theses, and reviews) dealing with permanent education initiatives for the primary care of people with obesity (overweight and obese) were assessed by this review. Language or year of publication restrictions were ignored to expand the number of retrieved studies. Quantitative, qualitative, and mixed studies were included to map different methodological approaches.
Studies which met the following criteria were excluded: participants who were not primarily healthcare providers; initiatives ignoring PHE, i.e., if they had no intention of educating professionals to work in health care networks; those outside primary care; and educational initiatives which dealt with issues other than obesity. Invitro studies with animals, texts, opinion papers, letters, conference summaries, and editorials were excluded because they failed to meet the objectives of this review.

Information Sources
At first, a limited search was conducted on two databases, Medline (PubMed) and CINAHL, followed by an analysis of the words contained in the title and abstract of the retrieved articles and of the terms in the indices and keywords used to describe the articles. To find as much relevant evidence as possible, our search for studies was comprehensive and systematic. Medline via PubMed, Embase, CINAHL, Scopus, Web of Science, and Lilacs were the databases selected for research. Nevertheless, Google Scholar and Open Gray were also searched for grey literature. Our search strategy was developed with descriptors which were synonymous to those in MeSH (PubMed), DeCS (Lilacs), and Emtree (Embase). Our search strategy was applied to these data bases by a reviewer and results, exported to Rayyan for duplicate removal and initial sorting. Reference lists with the included studies were evaluated. A wide consultation with specialists in the area was carried out to recover important studies which our searches failed to retrieve. Subsequently, the selected publications were exported to EndNote web. Our research team was assisted in this process by a librarian specialized in health (GFXJ). The search strategies developed for each database are included in an additional file (Figure1).

Sources of Evidence Selection
The entire selection was accompanied by two pilot tests. On the first stage, 25 titles/abstracts from sources of evidence were read and, on the second, five others, in full. Random sample were included in both sources. These studies were screened by our entire team according to our eligibility criteria, showing an agreement above 75%, as per the JBI Manual for Evidence Synthesis. 7 Selections based on titles/abstracts and full texts were made in Rayyan by four independent reviewers (CGM, VMS, EMP, and AAFMS) and disagreements were resolved   Excluded full-text articles and reasons for their exclusion (n = 10) • Fails to adhere to our concept (n = 2) • Fails to adhere to our population (n = 2) • Congress summary (n = 5) • Editorial (n = 1) Studies included in our qualitative synthesis (n = 10) (1 study = 6 articles) in pairs or by a third reviewer's intervention. In the absence of additional information or data, the authors of the chosen studies were contacted.

Data Items and Data Charting Process
Data were summarized by the following characteristics: articles (country of origin, health system, funding, year of publication and authors); participants (demographic and sample size); educational initiatives (methodology, theme addressed, results achieved and gaps); and research (context, outcome and main results). The JBI Sumari software was used to map our findings.
The entire data extraction process was carried out by two independent reviewers (CGM and VMS), who discussed results and procedurally and simultaneously updated our data graph. To increase consistency among reviewers, a pilot source extraction test was performed with a random sample of four publications, about which reviewers showed an agreement above 75% on the mapped data. Any divergence was resolved by consensus or by the intervention of a third reviewer.

Result Synthesis
Results were synthesized by frequency and thematic analysis. Textual data were thematically analyzed by a reviewer and verified by a second one (CGM and MLPS) via ATLAS.ti. A tabular diagram, word cloud (Wordcloud.com), data graph, and narrative summary were elaborated by the authors according to Prisma ScR 8 recommendations, both in line and describing how results related to the questions and objectives of this review.

DISCUSSION
Regarding their general scope, results (n = 10) show a scarcity of research in the area and, consequently, novelty and importance for policymakers 24 . The included studies showed initiatives to educate healthcare providers with methodological profiles focused on specific actions, technical and instrumental biases, and subthemes which addressed obesity (especially from a biomedical perspective-among others which often failed to dialogue with the problems of healthcare providers' everyday life). Our sample addressed obesity as a public health problem, evincing a more quantitative bias between disease and risk factor. Initiative results showed changes in professionals' concept and attitude toward obesity but only slightly altered the procedural field of caring for these patients, showing, in their gaps, the concern that future longitudinal research can investigate changes in long-term care practices.
Although widely used in its health services, we retrieved no study conducted in Latin America, in which PHE emerged in the 1980s as a methodological strategy at the initiative of the Pan American and World Health Organizations, structured in 2004 as a public policy for health training linked to national health services and disseminated throughout the Brazilian territory 25 . Thus, it is necessary to consider the importance of encouraging the scientific dissemination of experiences in the everyday life of health services as evidence which can structure major scientific leaps in the area.
The fact that most studies come from the USA 11-13,16-18 endorses its pioneering and advancing spirit in scientific research on obesity handling and management. It historically adopted a mixed health system model, lacking universal health coverage and whose private sector lies higher than the public one. Moreover, it has institutionalized the issue of obesity -a process which corroborated, according to Poullain 26 , to place it as a world public health issue.
Such conditions signal a shift from the epistemological status of obesity to a more quantitative definition which suffers great interference from economic interests (private health insurance and food companies) 27,28 which outline the scope of such investigations, both assuming the hegemony of biomedical biases and the "warlike" logic of dealing with obesity, which, according to Foucault 29 , controls body mass structure biopower techniques centered on the individualized body and considers it relevant to understand the tensions, logics, and interests around obesity to think of care strategies more focused on integrality, respect for individuality, and a critical position against the stigma it carries.
This review assumed a conceptual-methodological difference between continuing education (CE) and PHE. The first, the traditional resource in health, centers around updating knowledge, usually with a disciplinary focus based on transmission techniques, thus constituting a discontinuous training strategy with time breaks 25,30 . PHE, on the other hand, proposes changing the conception and practices of health training and incorporating teaching and learning into the daily life of services, with practice as a source of knowledge and problems that increase teams' critical thinking based on network, comprehensive care, and multiprofessional, interdisciplinary, and intersectoral approaches 2,5,25,[30][31][32][33][34] .In our analysis of the context of these actions, the included studies show initiatives which mainly relate to CE -punctual actions 10,13,14,16,17,18,19 , disciplinary fragmentation 11 PHE presupposes the development of educational practices focusing on the resolution of concrete problems via team discussions based on the perspective of transforming work processes 2,5,25,[30][31][32][33][34] . Thus, four studies claimed, as their methodological strategies, to survey both participants' problems as guidelines to build themes/contents for their PHEinitiatives 14,15 and data on the health service reality 12,17 and on advocacy resources in the care forobesity 13 , a strategy based on what Ceccim 2 calls a four-way approach to training: teaching -care-management -social control, in which "each face involves a pedagogical call, an image of the future, an apolitical struggle, and a web of connections" (p.47). These strategies project participants' critical approach to their realities, promoting the recognition of possibilities for emancipatory action in the face of the actual situations experienced in health services.
The contents of the initiatives dealt with approaches toobesity 11,12,[14][15][16][17][18][19] , most only discussed its biomedical perspective 11,14,16,19 ; professional qualification strategies 12,13,16,18 ; relations with PHE, including the strategic development of intervention plans 12,13 ; and obesity handling and management 10,12,13,15 . In general, initiatives mainly discussed continuous self-improvement in the search for professional and personal competence and only slightly consider the situations problematizing work to transform reality 33 . The addressed sub-themes need to dialogue more with participants' yearnings for change since they show a greater number of possible points of analysis when facing the same situation -obesity -, subsidizing the critical analysis of their realities to promote more critical, creative, and autonomous decision-making.
Educational actions in health human resources traditionally have methodological designs consisting of short actions 10,13,14,16,17,18,19 which favor individual participations 11,12,13,17,18,19 and teaching strategies mainly based on oral exposure 11,12,14,15,16,19 ; methodological conditions which, allied to institutional, political, ideological, and cultural ones, anticipate and determine the space within which training can operate its limits and possibilities: a simplified and instrumental vision of education; its low discrimination of problems to be overcome; and immediacy in projects with predetermined beginnings and ends 25,34 ; results pointing to methodological designs far removed from what the National PHE Policy proposes in Brazil 25,32 .
Studies conceptualized obesity as a problem 10,11,14,15,18,19 in global public health 11,14,15 which has a complex system 19 and is common in primary care 15 . Recognition as a public health issue, according to Poulain 26 , occurs after two conditions are met: theme institutionalization and the change in the epistemological status of obesity to a more quantitative definition -either as a risk factor 17,19 or a disease, consolidated by the use of BMI as an evaluation method 14,15,17,18 -in a process which medicalized obesity 26  Since the WHO 36 used the term global "epidemic" (a concept which two studies 15,18 mention), obesity has gained prominence in the media and political debate, forming a true "warlike" scenario with considerable symbolic consequences and involving different agents which are motivated by different interests, offering questionable services, products, and information in the fight against the "enemy" 1,26-28 . Although this narrative represents the current hegemonic discourse, according to the Lancet 1 report and authors from the Social and Human Sciences 26,35,[37][38][39][40] , it offers a limited understanding in the face of the phenomenon of obesity because it ignores its complexity, a condition only one study 19 signaled and valued by the systemic approach of PHE.
Regarding the results of these initiatives, all studies point to changes in participants. However, the most expressive are, according to the typology in Zabala 41 , in their conceptual [10][11][12]14,[17][18][19] and attitudinal content 12,15,16,18,19 , with lower expression in the procedural one [13][14][15]17 , a great objective regarding primary care work collectives 31 . Moreover, some results describe the limits and potentialities of teaching strategies 10,14,17,18 , in which we find the success of those involving discussion and group work when we compared them to transmission strategies 10,14,17 . Thus, longitudinal studies may be a good strategy to promote more lasting changes also in the field of procedural contents installed in health services.
Also regarding results, two studies 17,18 highlighted that the use of strategies to understand cultural contexts (by race) within services provided significant conceptual and procedural changes for some participants, endorsing a premise of reorganizing their work process via the concept of territorialization 42 as an instrument to diagnose and analyze health situations in local planning. Finally, regarding the products of these actions, two studies 12,13 elaborated an individual intervention plan, a strategy qualifying social actors 33 for strategic thinking/reasoning and the ability to contextualize projects for relevant healthcare problems 43 . The latter results are the most significant and desired for health services for their transformative power and association with the real needs of the monitored population.
Regarding gaps, six studies 10,13,14,16,17,19 recorded the importance of further research designing longer and more targeted initiatives to assess the sustainability of conceptual, attitudinal, and procedural changes, considering that, even if these initiatives achieve individual learning, they fail to always translate themselves into organizational learning, i.e., the reorganization of collective work processes 25,33 , a premise of the Brazilian National PHE Policy 25,32 . Some studies 10,14,16,18 indicate the possibility of surveying more powerful and cost-effective teaching strategies given the exhaustion of so many traditional and discontinued strategies aimed at transmission. In this sense, the PHE launches itself as a potential political-pedagogical practice that, (…) at the same time as it disputes for the daily updating of practices according to the most recent theoretical, methodological, scientific, and technological contributions available, it is part of a necessary construction of relationships and processes which stem from within teams in a joint action -including their agents, organizational practices -involving the institution and/or the health sector and interinstitutional and/or intersectoral practices -linked to the policies in which the health acts are included 33 (p.161).
Interpreting international production shows that obesity is a public health problem, and that health education rarely questions food versus body. Bio pedagogical studies on the stigma of obesity, the "invention" of the obesity epidemic, or those with a cultural and anthropological basis are absent in the training of healthcare providers toward a clinical/assisting approach to obesity. Most studies stem from countries without a universal health system, evincing that obesity has meanings in these countries unlike those of a "Brazilian-style" PHE. Thus, the great need to encourage the dissemination of research in the area and of considering the use of PHE as urgent.
The strengths of this review include its comprehensive bibliographical research in various electronic databases via a rigorous methodology suggested by JBI 7 and Prisma-ScR 8 . Note also its novelty in view of the scarcity of publications in the national and international literature which focused on PHE focused on obesity care. Worldwide, the use of these syntheses is considered a priority to formulate well-informed and effective policies 24,44 .

Limitation
This study shows limitations regarding the scarcity of evidence, especially for Latin America and mainly for Brazil, regions which have consolidated PHE. Moreover, this scope review was a huge undertaking and our results include research only up to October 2020.