Abstract
Background
Metabolic and bariatric surgery (MBS) is currently the only clinically proven method of weight loss that is effective in treating severe obesity and its related co-morbidities. However, only about 36% of MBS-eligible patients complete MBS. This qualitative study used the psychosocial framework to identify barriers and facilitators to MBS utilization among patients who had been referred to, or were considering MBS, but had not completed it.
Methods
A combination of focus groups and in-depth interviews were utilized (Spring 2019) among ethnically diverse patients (N=29, 82% female, 62% non-Hispanic black, 10% Hispanic) who were considering MBS. All data was audio-recorded, transcribed, and coded. Interview questions were grouped by the four psychosocial model domains (intrapersonal, interpersonal, organization/clinical interaction, societal/environmental) within the context of why patients would/would not follow through with MBS. The analysis included a combination of deductive and inductive approaches to generate the final codebook. Then, each code was input into Dedoose to identify overarching themes and sub-themes.
Results
A total of 9 themes and 17 subthemes were found. Two major intrapersonal themes and four subthemes were identified as facilitators to MBS utilization and included a desire for improvement in existing comorbidities, mobility, and anticipated changes in physical appearance. Primary barriers to MBS completion included concerns about potential change in dietary behaviors post-MBS and safety of procedure.
Conclusions
Providing educational materials to address MBS common fears and misconceptions MBS may increase utilization rates. Providing community-based pre- and postsupport groups for this patient population may also increase MBS completion rates.
Keywords: metabolic, bariatric surgery, ethnicity, health disparities, psychosocial model, utilization
Introduction
Currently, metabolic and bariatric surgery (MBS) is the only clinically proven method of treating both obesity and obesity-related comorbidities [1–5]. Moreover, studies have shown that MBS can be more effective at maintaining long-term weight loss compared to lifestyle interventions alone [4,6]. However, even though previous reports document the effectiveness of MBS, only about 36% of MBS-eligible patients elect to commit and follow through with completing MBS [7]; among the ethnic minority MBS-eligible population, the commitment rate is even lower [8]. Specifically, Latino and non-Hispanic Black males comprise less than a quarter of MBS patients among eligible males [9].
Previous studies have cited various reasons as to why MBS-eligible patients choose to elect or forgo the procedure; medical expenses, availability of established surgeons, and insurance eligibility have been identified as common barriers [7–9, 10–13]. However, there has been little investigation into further psychosocial factors that may drive the decision to undergo MBS. Specific identified patient psychosocial characteristics (intrapersonal, interpersonal, clinical, and other environmental interactions) can, in turn, inform the development of pre-MBS culturally sensitive screening, recruitment strategies, tools, and future interventions to improve MBS completion rates. Defining a psychosocial framework using these characteristics will allow clinicians, surgeons, and researchers to understand their complex interactions to ultimately improve patient outcomes.
The purpose of this qualitative study was to utilize the four domains of the psychosocial framework (intrapersonal, interpersonal, group/community/institutional, and macro- level/public policy factors) to explore underlying psychosocial factors that influence ethnically diverse MBS-eligible patients to have, or not have, the surgery. Here we report the results of focus groups and in-depth interviews that were conducted to gain an understanding of what psychosocial factors support MBS-eligible patients who are considering the procedure but have not yet completed it. To allow a deeper analysis of the interview and focus group results, The Stages of Change Model (SOC) was utilized to capture the stages of decision making by the participants. The SOC is a behavioral change model that describes change in habitual behavior in a continuous cyclical process. It describes the process of intentional change in six stages; precontemplation, contemplation, preparation, action, maintenance, and termination [14] (see figure 1). This study focuses on the pre-contemplation, contemplation and preparation stage of the SOC, as no participants had yet completed MBS.
Figure 1.
Stages of Change Model
Material and Methods
Design
A qualitative study design and methodology was used to explore the psychosocial factors associated with the decision to undergo MBS. Specific factors included self-efficacy (personal belief in oneself), social environment (family, friends, social network) and the built environment (neighborhood, safety, and access to health-related resources). A series of focus groups and individual telephone interviews were utilized to identify the various potential factors among patients who qualified for MBS but had not yet committed to the procedure. This study was approved by the university Institutional Review Board.
Procedures
Primary recruitment was conducted at informational Bariatric Intake Seminars (BIS) hosted at one academic institution. All MBS eligible patients must complete a BIS as an MBS qualifying criterion. The research team attended BIS and support meetings to explain the purpose of the study and to enroll participants. The total study population included 29 pre-operative MBS-eligible participants comprised of 2 focus groups with 3 and 4 participants, respectively, and 22 individual phone interviews. The research team conducted the focus groups and phone interviews. All information provided for the focus groups were video and audio recorded, and all phone interviews were audio-recorded. Participation eligibility criteria were: participants must be 18 years of age or older, participants must consent to participate, and participants must be willing to spend a minimum of 60 minutes responding to questions in a group setting or at least 30 minutes responding to questions individually via phone call. All participants for the focus groups were aware that they would be audio and video recorded, and all participants for the phone interviews were aware they would be audio recorded.
Grand tour questions
Participants were asked a series of open-ended questions about their exposure, knowledge, thoughts, concerns, and experiences related to MBS. Each of the grand tour questions were developed based on the four domains of the psychosocial model (intrapersonal, interpersonal, group/community/institutional, and macro- level/public policy factors). Example questions include: “Do you think your relationship with food will change after the surgery?”, “Do you think your self-esteem/the way you view yourself will change after surgery?”, “How do you feel your community or the place you live will support your surgery?”, and “Do you feel those with excess weight are discriminated against?”. See table 3 for more of the grand tour questions.
Table 3.
Grand Tour Participant Questions
| Grand Tour Participant Questions: |
| 1. Everyone seems to know about weight loss surgery or knows somebody who has had it these days. Is that true for you? How did you learn about it? |
| 2. What were your main concerns and issues when you were considering having the surgery for yourself? |
| 3. Did you feel like the relationship you had with your primary care or specialist made a difference in your decision to have surgery? |
| 4. Did other people affect your decision to have the surgery? Or not have it? |
| 5. A lot of people who have had bariatric surgery tell me that some of their experiences change from before and after surgery. In what ways is this applicable to you? |
| Probe 5A: What about differences in the way people treated you from before compared to after surgery? |
| Probe 5B: What about differences in how you view yourself/self-esteem/identity? |
| Probe 5C: Do you feel you experienced any changes with who you socialized with/spent your free time with after bariatric surgery (i.e. peer group/group of friends?) |
| Probe 5D: What about your relationship with food… |
| 6. How do you feel your community or the place you live supports your surgery? For example, are there good places to exercise and buy the foods you need that are affordable? |
| 7. What would you like to see in your neighborhood, community, workplace, etc. that would really make you feel supportive after the surgery? |
| 8. How do you feel your community in general views those who have had weight loss surgery? |
| 9. Do you feel people with extra weight are discriminated against? How? |
| 10. How does the safety of the community affect your lifestyle changes after surgery? |
| 11. Is there anything else that you would like to discuss or contribute that you think is important when people are deciding to have bariatric surgery? |
Participants
The study had a total of 29 participants (Mean age=48.89 years, SD= 12.02); the majority (72.4%) of the total study population were ethnic minorities (Multi-racial, Hispanic, or Non-Hispanic Black). 82.76% of the participants were female, and 17.24% were male. In total, 7 subjects participated in the focus groups, and 22 subjects participated in the phone interviews.
Analysis
Each audio file from the focus groups and phone interviews were manually transcribed verbatim by the research team. Thematic analysis using a combined deductive and inductive approaches were used to analyze the data. This information was used to create a codebook designed by the research team to structure and define the thematic codes. The codes were developed based on keywords and quotes repeatedly mentioned in both focus groups and interviews. Two graduate-level trained researchers worked in tandem to meticulously code multiple transcripts in order to refine the codebook. Transcripts were then manually loaded into a qualitative analysis program, Dedoose, to accurately analyze and develop themes using qualitative charts provided by the program.
Results
A total of 34 codes were utilized throughout the qualitative analysis process. Several reoccurring themes manifested among the pre-MBS patient transcripts after applying the established codes. These themes were then organized according to the varying levels of the study’s psychosocial model: intrapersonal, interpersonal, organizational/clinical interaction, and societal/environmental interaction (see figure 2), and focused on topics such as motivational factors, perceived discrimination, and requested pre- and post-MBS support programs. Key facilitators identified were improvements in obesity related health conditions, increase in mobility, increase self-esteem, better physical/self-image, and support from family/friends and physicians. Conversely, concerns about diet and the safety of MBS procedure were highlighted as barriers in the decision to undergo MBS. Below we describe these key facilitator and barriers in detail within the SOC categories. Additional themes identified are also detailed below.
Figure 2.
Visual Summary of Themes Organized by Psychosocial Framework Domains
INTRAPERSONAL
Theme 1. Motivation
Subtheme 1a. Co-Morbidity/Medication Resolution
The majority of participants in this study suffered from two or more obesity related comorbidities. Several participants reported taking multiple medications daily to manage their conditions and expressed a need for a long-term solution. Our findings indicate that participants emphasized the desire to improve obesity related co-morbidities as a key facilitator to MBS utilization. Many looked forward to eradicating or alleviating obesity related diseases such as diabetes (1.1.1 &1.1.2) Participants who expressed the intent to improve their health conditions were individuals in the preparation stage (SOC model). They were resolute about their decision to undergo MBS and were intentional about taking the necessary steps to start the process to undergo MBS. These participants have attended MBS informational seminars to learn more about the types of procedures, insurance approval process, health benefits, and lifestyle and dietary changes. In addition, participants had either attended or scheduled their first consultation with an MBS surgeon.
Subtheme 1b. Mobility
Another facilitator to considering MBS was the improvements in mobility. When prompted by researchers, pre-MBS study participants expressed the expectation for MBS to help decrease joint pain. Participants conveyed the desire to travel (1.2.1) and partake in physically-demanding activities that they were once able to do prior to their weight gain (1.2.2 & 1.2.3). Many of these participants were in the contemplation stage (SOC model). A few were aware of the problem and conveyed an intent to change, but no commitment to action. The research team noted that several patients vocalized a strong will to dedicate themselves to a hobby or passion that they never/previously participated in, and MBS was a way to accomplish this.
Subtheme 1c. Physical Appearance/Self-Image
Post-MBS weight loss was an additional facilitator driving the decision to complete MBS. Participants expressed excitement about the possibility of reaching their weight loss goals if they were to undergo MBS. Some have struggled with their weight for several years and made unsuccessful attempts to lose weight through various fad diets, which often resulted in short-term weight loss. Subsequently, our study found that preoccupations about appearance due to body size were common. (1.3.1) These ruminations often included a hatred of oneself because of one’s body, and many participants believed that MBS would solve long-standing, low self-esteem (1.3.2). One participant stated that she was looking forward to wearing clothes that suit her personality more (1.3.3) This suggests that these participants are in the preparation stage. There is a strong desire to feel and look better. They are aware that their self-image/appearance is suffering and intend on taking action to address the issue.
Theme 2. Dietary Changes
Subtheme 2a. Concerns about maintaining dietary changes long-term
Dietary concerns were pervasive in the study sample and was a barrier for participants considering MBS. Many participants were unsure of their ability to maintain a post-MBS diet long-term. They expressed fear of possibly returning to former toxic dietary habits (1.4.1 & 1.4.4). Some participants stated they were surprised at the amount of dietary change that would be required post-MBS (1.4.2 & 1.4.4). Those who expressed concerns about their inability to change their dietary behavior were typically in the pre-contemplation stage. There is no intent to change their behavior. Overall, many participants are delaying their commitment to MBS over concerns that they will not be able to maintain the dietary changes required for long-term weight loss.
Theme 3. Self-Esteem
Subtheme 3a. Anticipated Changes in Self-Esteem
An increase in self-esteem was a facilitator to MBS utilization. Many participants stated that they believed MBS would lead to increased self-esteem. Several participants articulated the desire for increased confidence and a more positive attitude post-MBS (1.5.2 & 1.5.3). Although an increase in self-esteem was indicated as a facilitator to MBS among many, one participant stated that she was worried about how MBS would change how she thinks of herself and how others view her (1.5.1). However, she was not opposed to having surgery because of this. Most participants either did not expect any change or hoped for an increase in self-esteem post-MBS These participants have a strong intent to see changes in this area and are therefore considered to be in the preparation stage.
Theme 4. MBS Related Concerns
Subtheme 4a. Surgical concerns
Success, ethics, and maintenance were the primary concerns among the pre-MBS study population. These concerns were highlighted as a barrier to MBS utilization. Some worried that the surgery would not work properly for them (1.6.3), and some worried that even if the surgery was successful, that the lifestyle changes might not be sustainable (1.6.2). Several participants mentioned facing an ethical dilemma with certain types of MBS (particularly the Roux-en-Y or the gastric sleeve) wherein that they were worried about changing the baseline anatomy of the digestive system (1.6.1). In addition to post-surgery concerns, pre-MBS participants expressed concerns about the surgery itself. More specifically, participants alluded to the fear of dying as a result of the surgery (1.6.5 & 1.6.6). One participant worried that going under anesthesia might provoke complications (1.6.4). Another mentioned that their age was a primary concern going into the surgery (1.6.6). For some participants, this may be the precontemplation stage. These are participants who might have been in the contemplation stage, but their overwhelming concerns about the fear of undergoing a surgical procedure may set them back to the pre-contemplation stage.
INTERPERSONAL
Theme 5. MBS Referral Network
Subtheme 5a. Family/Friends
Most participants in the study population initially learned about MBS through personal contacts such as family members, friends, or co-workers (2.1.1, 2.1.2, & 2.1.3). One participant listed several family members that had undergone MBS (2.1.1), while another mentioned current and former school friends that had MBS and were happy with the results (2.1.3).
Theme 6. Social Support System
Subtheme 6a. Pre-MBS
Establishing a network/circle of supportive family members or friends was highlighted as a key facilitator to MBS utilization. Participants who are in the contemplation stage could potentially move forward into the preparation and action stage because of support received from family members and friends. In an in-depth interview, one support member mentioned that to support the efforts of her pre-MBS daughter, her family not only purchased an activity tracker for the participant but that all of her family members purchased activity trackers and worked to compete against each other in healthy activities (2.2.1).
Theme 7. Discrimination
Subtheme 7a. Discrimination in public settings
Lack of appropriate seating in public areas, such as restaurants, was a common frustration among the study participants. One participant stated, “everything gets made to fit a certain size as far as seats and booths and things of that nature. I can’t go to [an] amusement park and ride” (2.3.1). In addition to seating, many participants mentioned being discriminated against while shopping for clothing. Specifically, participants have mentioned being judged for entering conventional clothing stores, “I recall one lady, and she said she knows she’s too big to be shopping [in] here” (2.3.2).
Subtheme 7b. Discrimination within the community
Many study participants stated that they felt that a common misconception within the community over motivation/would power and weight made them feel discriminated against. For example, one participant shared with the research staff that ““they make assumptions that you don’t take care of yourself”” (2.4.2). Another participant expressed that by being overweight, she felt that the community viewed her as having no willpower and that her weight was a character flaw (2.4.3). Others mentioned feeling invisible or overlooked, “[…] You’re treated like you’re a second-class citizen” (2.4.4) and that they believe that this stigma will never be resolved (2.4.1).
Subtheme 7c. Discrimination in the workplace
Mistreatment by employers and coworkers was one of the most frequently mentioned forms of discrimination throughout the entire study sample. Participants stated that they felt that their weight held them back from being hired because employers would view them as lazy or would assume, they would regularly call in sick (2.5.2). Another participant mentioned that her employer confronted her about her weight gain during a personal meeting (2.5.1). Many believe that their weight is a barrier to gaining meaningful employment.
GROUP/COMMUNITY/INSTITUTIONAL
Theme 8. Physician Influence
Subtheme 8a. Primary care
Among the pre-MBS population, many participants stated that the support of their primary care physicians (PCP) and their specialists was a facilitator to MBS utilization. Their physicians helped fortify their decision to pursue MBS (3.1.1 & 3.1.3). One participant explained that her surgeon convinced her that MBS would be a better option for her by explaining the hormonal impact that MBS has on the body- something diet and exercise cannot do (3.1.2). Another participant mentioned that her physician suggested MBS as a means to help control her diabetes (3.1.3). Patients who had the support of their physician were confident in their decision to undergo MBS and may likely be able to move from the contemplation stage to other subsequent stages of the SOC faster than those who lacked support from their physicians.
MACRO-LEVEL/SOCIETAL/ENVIRONMENTAL
Theme 9. Community-Based Support Program
Subtheme 9a. Education
Participants expressed the desire for more education within the community- programs tailored for the overweight/MBS population about the surrounding built community. For example, one participant conveyed that she would like to have a program where she could learn where to go within her neighborhood/community for healthy food, groceries, and exercise programs (4.1.1).
Subtheme 9b. Community safety
The study population’s concern over the safety surrounding their community was separated into two categories: lack of safety due to people and lack of safety due to their built environment. Several female pre-MBS participants mentioned that they would not feel safe walking or being outside alone after dark (4.2.3); “people here are crazy” (4.2.2). Other participants mentioned not feeling comfortable because of the lack of walking trails/sidewalks and adequate street lighting (4.2.1).
Subtheme 9c. Support group
There are several support groups held within the local area; however, most are not accessible to those that work conventional hours. Online support groups or telephone support lines were among some of the suggested alternative support group options (4.3.1 & 4.3.2).
Subtheme 9d. Access to healthy food
The desire for easy-to-access healthy foods was frequently brought up by study participants. One participant expressed concern over being able to easily access the protein drinks required post-surgery, “I wish they would put protein drinks in the vending machines…just healthier choices you know in the workplace more than anything” (4.4.1).
Subtheme 9e. Access to exercise facilities
In addition to healthy foods, participants mentioned that they would like to see more workout facilities (4.5.1). Specifically, workout facilities that are tailored to the obese/MBS population (4.5.2).
Discussion
This qualitative study among participants who had qualified for and were considering MBS but had not yet followed through found 14 codes that reoccurred frequently. Specifically, these codes formed seven overarching themes that communicated anticipated barriers, facilitators, and expectations surrounding MBS and obesity. These themes included motivation, dietary changes, self-esteem, MBS related concerns, MBS-referral network, social support systems, and discrimination. These findings can inform MBS practices, surgeons, physicians, and the community to better understand the needs of those who are considering having the procedure but have not yet committed.
The motivation was one of the commonly discussed themes throughout the study. This theme targets possible reasons that MBS-eligible patients would choose to undergo MBS. These reasons include co-morbidity resolution/medication management, mobility, and physical appearance/self-image. Our findings here are consistent with previous studies that report patients have communicated that the desire to control health-related issues associated with obesity and the hope of increased mobility were primary push factors for deciding to go through with surgery [15,16]. However, one motivating factor found here that has not been reported consistently elsewhere was the motivation to change physical appearance/self-image. This motivating factor was expressed primarily among women study participants. One participant admitted to the research staff that her motivation to complete MBS was driven by her belief that the surgery would help her conquer her experience of having constant negative ruminations about body size [CM2].
Another frequently occurring theme among study participants was the want/need for additional support programs pre- and post- MBS, a finding that has not been discussed in prior studies. Most suggested programs involved the built environment in their communities and neighborhoods. For example, more convenient access to healthy foods and exercise facilities and better walking trails and street lighting in neighborhoods. Currently, many participants feel that their community may not provide everything they need in order to be successful after MBS. Other programs commonly suggested among participants dealt with education. Participants relayed the need for more accessible support programs delivered both digitally and in-person. It has been shown that regular attendance of a support group can help with long-term weight loss maintenance [16]. Additionally, some participants mentioned the need for more community education over how to best utilize the neighborhood and community around them; for instance, where the cheapest and most accessible places to get healthy foods are and where it is safe to go for a walk.
Discrimination was consistently discussed among both focus groups and individual interviews and quickly became a significant theme throughout the analysis. It was clear that the study participants were experiencing weight-based discrimination in public settings, in the community, and the workplace. Workplace discrimination was the most commonly discussed form of discrimination and was repeatedly brought up among study participants. Specifically, personal discrimination by employers and the inability to secure stable careers due to employer discrimination was a key theme. This finding is consistent with many published studies documenting weight-based workplace discrimination in which overweight and obese employees are shown to be at a disadvantage when compared to employees with a healthy BMI (<25) [18,19].
Study Limitations and Strengths
There were some limitations to this study. First, it should be noted that most participants were recruited through a single academic institution, and therefore likely, our study population has limited health insurance representation to companies within the DFW network. Second, all focus groups were held at night, which could have prevented any potential participants that serve as caretakers to be left out of the study if they could not schedule a phone interview. Finally, since the research team was comprised of English-only speakers, there is a potential that many Spanish-speaking participants were excluded from the study. Study strengths included the use of the psychosocial framework to support all facets of the study. Participants identified several built environment barriers in their communities that are influencing their decision to delay MBS. These particular findings have not been as well developed in the literature as intra- and inter-personal themes to completing MBS.
Conclusion
This study utilized the psychosocial framework to determine the underlying factors (intrapersonal, interpersonal, group/community/institutional, and macro-level/public policy factors) that are influencing ethnic minority, MBS-eligible participants, to commit to MBS. The analysis concluded that there were no differentiating themes or subthemes among ethnic groups. Increased mobility, co-morbidity resolution, and physical appearance were identified as familiar facilitators of MBS utilization within the study population. Lack of support, education, and access to healthy foods and exercise facilities were identified as reoccurring barriers to MBS-utilization.
Qualitatively identified themes of the study included motivating factors, anticipated changes post-MBS, concerns about surgery, perceived discrimination against the overweight/obese population, and desired support programs. These themes allowed the study to focus the findings of this research on minority populations so that PCPs and specialists in the MBS healthcare community can better tailor care pathways to the needs of their patient population. Due to the severe lack of MBS utilization among minority populations, these findings will ideally help MBS-eligible patients within these populations to feel more empowered to undergo MBS. The findings from this study will help inform future studies by narrowing down the main factors contributing to MBS utilization in MBS-eligible patients.
Table 1.
Participant Quotes, Organized by Themes and Sub-Themes and the Psychosocial Framework’s Intra-and Interpersonal Domains
| Themes and Sub-Themes | Supporting Quotes |
|---|---|
| INTRAPERSONAL | |
| Theme 1. Motivation | |
| 1a. Comorbidity Resolution |
(1.1.1) “I’m just hoping that they alleviate a lot of the medical problems.” - 46 year old African American female (1.1.2) “I am diabetic so overall it could improve the quality of my health you know to be able to lose some weight...” – 58 year old African American, Male |
| 1b. Mobility |
(1.2.1) “I’m hoping to be more mobile. I want to travel. I mean there’s lots of things lots of hopes that I have ok that are riding on this surgery” – 60 year old White female (1.2.2) “The main thing is I want to be able to move. I can’t hardly move anymore and I used to be in football and karate and all kinds of stuff...I’m hoping after surgery you know I can actually get back into karate and get my black belt and all of that.” – 47 year old White male (1.2.3) “I have 2 kids, so I think that I’ll definitely be more active. I have two boys so they’re very very active...I just want to keep up with them and make them more tired” -28 years old African American female |
| 1c. Physical appearance/self-image |
(1.3.1) “So right now I have pretty severe body dysmorphia. I have a husband who loves me and doesn’t really care, but like I care you know. I’m at the point where myself image is suffering.” – 29 year old Biracial female (1.3.2) “I already look good, but I’m going to be looking good”- 44 year old African American, Female (1.3.3) “I think that right now I don’t feel my age. I’m 28 and I feel like I’ll get to wear different clothes that I want to wear even if it’s just jeans and a shirt. I don’t wear that now. I want to wear normal 28 year old clothes that other people wear...Afterwards, I’ll be able to be young.” – 28 years old African American female |
| Theme 2. Dietary Changes | |
| 2a. Concerns about maintaining dietary changes long-term |
(1.4.1) “...am I going to go back to nasty habits and that is the only thing I have concerns about” – 58 year old African American, male (1.4.2) “The change in my eating habits is that something I was going to be able to sustain. You know was it going to be very restricted as far as what I can eat long term.” – 58 year old African American male (1.4.3) “You have to eat protein shakes and protein bars. I didn’t know you had to do that kind of stuff. It’ll be okay. It’s just more change than I thought.” – 54 year old African American male (1.4.4) “...So I’m going to really have to start to think about the way that I reward myself because right now it’s very much with food.” – 45 year old White female |
| Theme 3. Self-Esteem | |
| 3a. Anticipated changes in self-esteem |
(1.5.1) “You know what I think about myself all that kind of stuff that’s all at risk maybe you know of changing who I am, my identity, my self-identity, the way I think about myself, what I think others think of me, how others pursue me. That’s on the line right now.” – 60 year old White female (1.5.2) I think as far as me viewing myself I think I’m going to have a whole lot more positive attitude.” – 47 year old White male (1.5.3) “I feel like that I will have more confidence to just keep the weight off and have a better attitude about life than what I have in the last six to seven years” – 58 year old African American, Male (1.5.4) “So I’m not expecting it to change everything in my own right, but I do wonder is it going to help my self-esteem”- 64 year old White female |
| Theme 4. MBS-related concerns | |
| 4a. Surgical concerns |
(1.6.1) “My main concern was if I get this surgery but I haven’t changed my lifestyle then I’m putting a lot of damage on my body only to get back to where I was.” – 46 year old African American female (1.6.2) “What kind of support I was going to have and need to be successful and how to sustain it. From what I heard you’re eating little and those protein bars” – 60 year old African American female (1.6.3) “Am I going to be able to do it successfully” – 65 year old White female (1.6.4) “You know going under is always a concern...” – 44 year old African American female (1.6.5) “And the past I was scared of mortality really. You know cause people typically and especially a long time ago when the first gastric bypass came out people always had complications” – 54 year old African American male. (1.6.6) “My concern is my age...older maybe problems” –69 year old African American female |
| INTERPERSONAL | |
| Theme 5. MBS Referral Network | |
| 5a. Family/Friends |
(2.1.1) “Some of my family members had it. My niece did, my sister in law, her parents.”- 65 year old White female (2.1.2) “I learned about that through a colleague of mine” – 55 year old African American female (2.1.3) “I have a friend that had it done, a couple of people from high school who got the surgery and they were really happy with the results and so they were talking about it on Facebook and stuff so that’s how I found out about it.” – 37 year old African American female |
| Theme 6. Social Support System | |
| 6a. Pre-MBS | (2.2.1) “My younger daughter got her a Fitbit and she comes up with you know activity ideas for us as you know group. We all got Fitbit and so we’re trying to work together and be kind of competitive about you know our sleeping habits, drinking habits and our eating habits and exercise...”– 64 year old African American, Female |
| Theme 7. Discrimination | |
| 7a. Discrimination in Public Setting |
(2.3.1) “I feel like they’re discriminating against, as far as public places, everything gets made that fit you know a certain size as far as seats and booths and things of that nature. I can’t go to amusement park and ride. In that sense I think that overweight people are discriminated against.” – 52 year old African American female (2.3.2) “You know you go to the shop and they don’t carry your size. I recall one lady and she said she knows she’s too big to be shopping up on here” – 58 year old African American male (2.3.3) “I had an employer once call me into a personal meeting and said you’ve gained weight what’s going on. I’m like seriously” – 60 year old White female |
| 7b. Discrimination within the Community |
(2.4.1) “There’s always going to be stigma about fat people.” – 47 year old White male (2.4.2) “You know they make assumptions about you and they make assumptions that you don’t take care of yourself or that you don’t take care of yourself or that you eat fast food...” – 40 year old African American female (2.4.3) “I think that people look at people who are overweight as having no willpower. There’s something wrong with their character.” – 66 year old White female (2.4.4) “I mean you’re invisible you know, you’re treated like you’re a second class citizen.” – 40 year old African American female |
| 7c. Discrimination in the Workplace |
(2.5.1) “I had an employer once call me into a personal meeting and said you’ve gained weight what’s going on?” – 60 year old White female (2.5.2) “I think that at the weight that I am now a lot of employers they’re not going to hire me because when they see me the first thing they’re going to say is that I’m a health risk...maybe calling in all the time because of my health issues and basically the type of work that I was doing that I’m not going to be able to do the job.” - 43 year old African American female |
Note: The numbers in parentheses are for text references. Italicized text next to each number are direct quotes from participants.
MBS – metabolic and bariatric surgery
Table 2.
Participant Quotes, Organized by Themes and Sub-Themes and the Psychosocial Framework’s Community and Environmental Domains
| COMMUNITY/INSTITUTIONAL | |
| Theme 8. Physician Influence | |
| 8a. Primary Care |
(3.1.1) “...I asked my primary care physician what she thought about the bariatric, and then I asked my orthopedic doctor and they’re both saying yes, go for it.” – 65-year-old, non-Hispanic White female (3.1.2) “Why should I have this surgery instead of just diet and exercise? And he told me about the hormone impact that your body changes and your hormones change to fewer hunger triggers. That’s something that having the surgery can do for you. That just diet and exercise could not do, and I was like, ‘What? I did not know that!’ … and that was pretty compelling to me. Oh, that was a compelling reason to consider the surgery.” – 60-year-old, non-Hispanic White female (3.1.3) “My physician advised that it could be beneficial to me because I am a diabetic.” – 58-year-old, non-Hispanic Black male |
| SOCIETAL/ENVIRONMENTAL/PUBLIC POLICY | |
| Theme 9. Community-Based Support Programs | |
| 9a. Education | (4.1.1) “I would like community education that can help you where you’re at… somebody to actually be able to take the time out to look at, you know, 10-mile square block radius, and actually identify these are the places where you can exercise. These are the places that have, you know, like vegetarian options or even not vegetarian options…these are the restaurants that tend to use fresher food or things like that. That type of resource would be helpful.” – 46-year-old, non-Hispanic Black female |
| 9b. Community Safety |
(4.2.1) “street lighting” – 60-year-old, non-Hispanic White female (4.2.2) “I don’t know, but the people here are crazy. I don’t know if I’ll be jogging or walking in the evening…” – 52-year-old, non-Hispanic Black female (4.2.3) “It’s during the day sure. As a woman, I don’t know if you ever feel safe going out after dark.” – 45-year-old, non-Hispanic White female |
| 9c. Support Group |
(4.3.1) “…like a support line that you call up.” – 60-year-old, non-Hispanic Black female (4.3.2) “I would like to see more support groups for people.” – 65-year-old, non-Hispanic White female |
| 9d. Access to Healthy Food | (4.4.1) “I wish we had healthier choices… I wish they would put protein drinks in the vending machines …just healthier choices, you know, in the workplace more than anything.” – 58-year-old, non-Hispanic Black male |
| 9e. Access to Exercise Facilities |
(4.5.1) “I wish we had a workout facility” – 58-year-old Non-Hispanic black male (4.5.2) “It would be nice if they had a gym, for overweight and obese people, that works specifically with people of my nature; like, you know, where when you go you see more people like yourself there.” – 43-year-old, non-Hispanic black female |
Note: The numbers in parentheses are for text references. Italicized text next to each number are direct quotes from participants.
MBS – metabolic and bariatric surgery
Acknowledgments
This study was funded by the National Institutes of Health, National Institute on Minority Health and Health Disparities (grant #R01MD011686).
Footnotes
Disclosure
a. All authors have no conflict of interests to disclose.
Informed Consent
b. Informed consent was obtained from all individual participants included in the study.
Statement of Human and Animal Rights/Ethical Approval
c. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
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