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Transdisciplinary research

Qualitative research building real-life interventions: user-involving development of a mindfulness-based lifestyle change support program for overweight citizens

Abstract

Background/objectives:

This study is an experiment of putting social sciences to work in developing a support intervention for healthy lifestyle changes that would be attractive and manageable in real-life settings. Starting with a hypothesis that a class of intervention methods based on an unconventional ‘low-tension’ strategy may offer an effective support of stable, long-term changes well integrated in everyday life, difficult to maintain with conventional dieting and self-control approaches, this study focuses on designing and optimizing an intervention model combining several low-tension methods: mindfulness, small steps and group support.

Subjects/Methods:

In three consecutive ‘action research’ cycles, the intervention was run in practice with groups of 20 overweight or obese citizens. Qualitative data, mainly in the form of recorded group sessions and individual interviews with group participants and group leaders, were systematically collected and analyzed, using a framework of social psychological theory to focus on difficulties, resources and meanings connected with habits and everyday life. This information was recycled into the design process for the next version of the intervention.

Results:

We describe the user-involving development processes toward a more attractive and manageable intervention model. The model now exists as a well-articulated package whose effectiveness is being tested in a randomized controlled trial study.

Conclusions:

Social science can be put to work in systematically integrating real-life experience in a development process. It answers a very different kind of question than clinical trials—filling another place in an overall research program to create useful knowledge of what helps—in complex, everyday, real life.

Introduction

Cross-disciplinary cooperation is becoming important in nutrition and health research. This reflects a need to deal with food and nutrition as hypercomplex phenomena connecting many levels, from thermodynamics and molecules to emotions and societies. Social sciences and humanities (SSH) can contribute in several ways, producing different kinds of knowledge about social–cultural and social–psychological aspects of the ways we eat and drink. In this paper, we report the development of a social psychological, mindfulness-based support intervention model for health-motivated lifestyle changes and weight loss. Starting out from an initial model informed by the existing knowledge of lifestyle interventions, we used qualitative data collection and analysis methods to understand how different intervention elements could be pragmatically feasible and helpful—or not—in concrete everyday life. This was used to improve the model in an ‘action research’ cycle repeated three times and concluded with the description of the final intervention model, which is currently being evaluated in a randomized controlled trial study.

The high prevalence of obesity, overweight and related health problems and health risks are well known and much discussed.1 The fact that this prevalence is high but also varies very much with historical periods and socio–cultural–economic conditions is an indication of the importance of factors on other levels than the purely biological.2

Just as abundant availability of food is not a sufficient condition for becoming fat, abundant health information and motivational communication of it is not a sufficient condition for becoming slim. New details and stronger foundations are forthcoming, but the core concrete lifestyle changes that would produce the greatest health benefits have formed a solid biological platform for dietetic practice for decades.3,4 Nor is such well-founded core advice unknown to the majority of people with obesity and overweight, at least in contemporary Western societies. In fact, many of them have had repeated experiences of dieting along such lines, experiencing satisfying changes of body weight etc., only to suddenly ‘lose the grip’, fall back to previous patterns of lifestyle and body weight, and experience frustration and loss of social status.5

Traditional models of dietetic intervention are based on static lists of advice coupled with pedagogical communication seeking to overcome a compliance gap.3 Some more contemporary models include individualized advice, and motivational communication aiming to modify cognitive patterns that resist change (ibidem). What they have in common is a strong element of self-control and tension between desirable and undesirable behaviors—which probably explains much of the well-known fluctuations of body weight as well as self-esteem.6,7

Intervention studies have shown that all diets work for those who stick to them.4 Actual changes in diet, exercises and so on lead to weight loss and biological health benefits. The problem is that everyday life tends to get in the way of diet and exercise regimes—resulting in weight regain.8,9 Some studies even suggest that traditional diets have an independent weight increasing effect in the long term.6 The challenge is to achieve sustainable weight losses.10

Another challenge is to ensure that changes are in fact healthy. Intentional weight loss through diets is related to either no change or an increase in mortality among several groups of overweight and obese citizens.11,12 The reasons are not fully understood, but it seems that interventions that help people stop dieting and trying to lose weight may be healthier than weight loss diets.13

Another general class of interventions is based on a different fundamental logic than dieting and self-control. They seek to reduce or transform tensions through acceptance, articulation and self-organization of new patterns. Although not common in lifestyle interventions, such ‘low-tension’14 methods have been described on several levels: cognitive–experiential15,16 as well as social–psychological.14 In this study, we have developed a combined intervention with mindfulness training,17 group dynamics and a cognitive–practical method for self-determined, gradual changes in diet and exercise.18,19

In a famous early experiment, Lewin14 successfully used group dynamical methods to overcome resistance to new cooking habits with housewives during World War II. More recently some kinds of patient education programs have integrated elements of open, self-organizing group dynamics with some success.20,21 Mindfulness-based interventions have become systematized and widespread during the latest decades, with good results in conditions like stress, anxiety and depression.22,23 Special mindfulness-based programs for various kinds of addiction15,24 eating disorders25,26 and weight loss27 have been developed and tested with promising results.

Materials and methods

General methodology

Action research, a pragmatic current of social research pioneered by Kurt Lewin in the 1940s and 1950s, is a formulation of theoretical and practical frameworks to systematize and support the process of deliberate social practice development. In these frameworks, pragmatist and hermeneutical theories become tools for understanding how actors in an engaged life perspective, with different understandings and interests, can enter a particular kind of cycle of change, creating a focused feedback loop to develop an organization or a practice form, such as the practice of conducting group programs for lifestyle change. Furthermore, action research systematically aims at taking in a broad spectrum of experience and data types, including experiences and answers not anticipated in predefined categories.28,29

The conceptualization of lifestyle and habits has implications for practical approaches to them. Often they are regarded as a purely psychological phenomenon, an individual trait determining choice situations. This conceptual framework would restrict the focus of data collection and intervention tuning to targeting individual belief systems, desires, and motivations. Another way of regarding habits includes patterns of social interaction where experiences and preferences of individuals are strongly interdependent with group membership, recognition, cultural norms of body look and bodily conduct, and so on. The theoretical framework of ‘critical psychology’ is particularly useful for conceptualizing—and hence asking relevant questions about—the social–psychological everyday life world with supportive and resisting factors that the participants have to try to make the intervention work within. Critical psychology interprets everyday life events into a complex of different ‘contexts of action’ with various demands and implicit meanings and standards. Attention is focused on the ‘conduct of everyday life’ as a challenge to be negotiated in each individual case, with strains, priorities and compromises among such contexts. This makes critical psychology a useful framework for the analysis of data from individual and group articulations in the program, in terms of finding, enhancing and inventing intervention features that are supportive in the social–psychological landscape of everyday habits and habit modification.30, 31, 32

Specific setup

An initial model intervention was drafted, combining mindfulness, group dynamics and small steps. Details were described in an intervention protocol. Some of the main features are outlined in Table 1.

Table 1 Main features of the initial and final delta group intervention model

This intervention was carried out three consecutive times (Figure 1), each time with a new group. Participants were recruited via general practitioners in the Copenhagen area who had agreed to recommend participation to healthy overweight patients they deemed to be in elevated health risks that would make weight loss and healthy lifestyle changes desirable. The recruitment procedure via general practitioners was chosen in order to reduce the bias of self-selection.

Figure 1
figure1

Flowchart of the delta development study described in this article, and its place in a larger research program to develop and test the new intervention. The thin arrows represent the flows of information and development described in this article.

During each model intervention run, a range of data was collected and analyzed to inform a new round of adjustments. This included group session recordings, interviews with individual participants and group leaders, and systematic observations of interactions in and around the intervention group. Individual interviews were framed by an interview guide listing a number of concrete contexts and asking what had seemed helpful. Simple biometric measures (height, waist, hip, weight) were registered at onset at end of the 3-month intervention period. Finally, participants’ active home practice of the program’s mindfulness exercises was recorded using a self-report form.

Analysis

In the three model runs, only one participant dropped out entirely, and two other participants missed more than a third of the meetings. Before–after comparison of body mass data in each of the three model runs showed no change. This absence of short-term was expected and in accordance with the delta program’s shift of focus to sustainable and long-term changes rather than shot-term effective dieting (changes in body mass changes and quality of life after 12 months are the primary effect measures in the now ongoing randomized controlled trial effect study). In the first model run, participants’ average self-reported home practice was <50% of the 45 min per day recommended by group leaders during the meetings. Although this is a common observation in studies of mindfulness-based programs, it was considered important to increase this percentage, as previous studies of mindfulness programs have shown participant benefits to be strongly correlated with the degree of home practice.22,23 The percentage markedly increased after a modification of home practice structure (see below).

Qualitative data streams were mainly from three sources: interviews with individual participants, interviews with group leaders and recorded group sessions. The group recordings turned out to be a particularly rich source. When participants shared experiences and reflected on them together, the group tended to elicit and articulate ambiguous and implicit aspects of everyday life more effectively than the interviewer with an interview guide. Using group leader logbooks and sound editing software, all such parts of the recorded group sessions were identified and transcribed.

The theoretical framework of critical psychology was used to focus on meanings connected with the challenges of negotiating everyday life under various pressures and contexts of action, and to identify recurrent themes in them. To guide the development process toward enhancing elements that were helpful for participants in practice (negotiating eating practices, exercise practices and so on in everyday life), such themes were concurrently presented by the researchers in the intervention development team, and used to spur reflections in the design adjustment process. In some cases, observations of potentially important patterns were first made directly in the intervention group (for example, the ‘humor’ point below) and then later identified in the recorded materials and interpreted with the aid of the theoretical framework.

A series of large and small modifications of the intervention model resulted from this cycle of qualitative data, theory-aided interpretations and engaged practice—we describe a few typical and significant examples in the following. The flowchart of the overall structure of the process is shown in Figure 1, a more detailed list of main model features and their changes in Table 1.

The most persistent theme of everyday practice negotiation from the group articulations was the difficulty of upholding stable patterns of choices and habits coherent with a person’s explicit wishes, an ‘uphill struggle’, sometimes combined with a perceived helpfulness of group meetings and home meditations, things that ‘give tailwind on the bicycle lane’ as one participant said. For some participants this gave rise to a paradoxical problem with daily mindfulness practice. Although they perceived it as a welcome break and a helpful change of perspective, it also became an extra strain on the everyday negotiation of time and resources. Finding a 45-min period to sit down every day seriously ‘competed’ with other desired lifestyle changes, for time and energy. These experiences led to the reformulation of the home practice into a recommended 2 × 20-min practice that could be done separately or consecutively any time during the day (or indeed during the night, which was reported to be relevant and helpful by several participants who sometimes experienced sleeping problems). A ‘palette’ of eight 20-min guided mindfulness exercises to pick from and a logbook were designed to support this new pattern of home practice. After this change the role of mindfulness practice, as described in participants’ accounts and discussions, appeared more unambiguous as a support for other changes.

A similar conflict concerned participants’ wish to develop new habits in the field of physical exercise, the difficulty of access to satisfactory options of physical exercise when living in a big city and sense of sitting down too much. This led to an experimental formulation of a ‘mindfulness moving’ exercise with guidance and dynamic music—an adapted form of dynamic meditation practices developed in the 1970s and 1980s in several meditation schools.33 Although participants generally liked the mindfulness program, this particular form of practice was found helpful and attractive by about half of the participants; consequently, some chose it often, whereas others rarely. The final version of the delta program encourages this personalized use of the ‘palette’, although an ‘anchor’ of one classical sitting meditation per day is recommended.

A surprising observation was that humor in group sessions had an outspoken, supportive role. Incidents of spontaneous group laughter were frequent, and even directly observable and countable in the graphical representations of sound recordings. The typical humorous event would be one participant sharing a narrative of complex everyday life events with a stark contrast between automatic/unreflected patterns of acting and some kind of dawning self-awareness of the situation. What seemed to be making the stories funny and enjoyable was a certain characteristic combination of honesty and practical self-reflection in a distancing and warm acceptance. Apparently, the group was laughing with—not at—the person telling the story, and the laughter supported a sense of solidarity and playfulness, making the challenges more human and ordinary, and the everyday work with them more attractive. Reflecting on the humorous events, the intervention development group found that they tended to emerge spontaneously, especially in a particular configuration of meeting components, where a group discussion on topics on negotiating particular everyday habits was preceded by a silent group meditation—as if the meditation produced a sufficiently warm space and low tempo for it. The intervention model was modified to accommodate this by planning for the sequence of meditation and group articulation on everyday life patterns, whenever this sequence would fit into the curriculum, and it did indeed seem to support spontaneous humorous events in later groups. Humor in mindfulness interventions has not previously been subject to systematic study, and we will pursue it in more detail in a future article.

As a final example, a set of simple concepts gradually emerged within the delta group discussions as particularly handy for participants to share and mutually support deliberate attempts to change habits, which would sometimes be successful and sometimes not. A key concept was that of ‘experimentation’—used in the sense that a desired change could be tried out in practice for a while, with a keen interest in registering how it felt, what was difficult and what was supportive. This idea of experimentation seemed to reduce fears of personal failure and increase attractiveness of engaging with intentional habit change. It also seemed to allow participants to capture certain aspects of the mindfulness exercises—those of non-judgmental and curious observation—and connect them with active life. As a consequence of this observation, these concepts were given a central role in the group leader lectures and written standard material. As a further development of this conceptual intervention component, at one group meeting leaders improvised a mindfulness-based visualization exercise in which each participant carefully articulated the habit change they would find most meaningful to experiment with for the next week. Many participants found this exercise helpful—as one said at the next meeting ‘This meditative screening for habits we would try to change—could we please have this on tape—it was really nice to be able to sit and visualize the habit and find out what felt right and what felt wrong’. Consequently, this exercise was designed and recorded as one of the programs 20-min guided meditations, the ‘Delta meditation’, deliberately named by the Greek letter traditionally used to signify changes. Later this name and symbol were chosen as title for the entire program as well, as it seemed to act as a reminder of the approach.

Discussion

The immediate outcome of this development study is a new practice, a support intervention model with a core manual describing curriculum, sequence and central ideas, and with a set of teaching materials designed for this intervention (participants’ course book and logbook, and a set of 20-min guided meditations). In short, the intervention exists as a package ready for implementation in relevant settings.

The relevance of doing so will depend on the evidence of its effectiveness, a question that requires a different research logic and methodology than the present one. A randomized controlled trial is indeed underway, in cooperation with the prevention centers of the Municipality of Copenhagen.

In a Danish context, the new municipal health and prevention centers make the obvious relevant setting. Elsewhere it could be private, public or non-profit NGO organizations offering disease prevention interventions. A range of important pragmatic questions about transferability and implementation—physical requirements, training requirements for group leaders, translation of course materials and so on—will be discussed in a separate article if the results of the effectiveness trial makes it relevant.

In conclusion, it was possible to integrate intervention practices and components from three different ‘low tension’ traditions that approach the problematic of habits and habit changes from three different angles—but share a common logic of acceptance, self-organization and experimentation.

We found an action research setup, using a social–psychological theory framework, to be a feasible way of systematically collecting, reflecting and utilizing a range of qualitative data and practical experiences into a sequence of big and small adaptations of the model. The main sources for these adaptations were participants’ real-life observations of their work with everyday habits and group leaders’ observations of interactions of intervention components

This study illustrates how SSH can have an active role in nutrition research. It needs to be clear that they answer different questions and have different places in a research program’s cycle of hypothesis generation and testing than the discipline’s traditional quantitative methods. But contrary to widespread beliefs—even within SSH—SSH are well suited to be practically involved in interventions to help people with overweight and related health problems.

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Acknowledgements

This work was supported by the Danish Ministry of Research through a ‘UNIK’ network grant (‘Food, Fitness, Pharma’) and by the IMK Foundation.

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Correspondence to N V Hansen.

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Hansen, N., Brændgaard, P., Hjørnholm, C. et al. Qualitative research building real-life interventions: user-involving development of a mindfulness-based lifestyle change support program for overweight citizens. Eur J Clin Nutr 68, 1129–1133 (2014). https://doi.org/10.1038/ejcn.2014.106

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