An Exploration of Health Inequalities in a Tier 3 Specialist Weight Management Service

doi:10.21203/rs.3.rs-4992197/v1

Download PDF

Research Article

An Exploration of Health Inequalities in a Tier 3 Specialist Weight Management Service

https://doi.org/10.21203/rs.3.rs-4992197/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background:
Almost two thirds of the adult UK population is either overweight or obese, a condition associated with physical and psychological comorbidities. Evidence shows that engaging with specialist weight management services can lead to significant reductions in weight. However, little is known about how legally protected characteristics impact on access to services and on outcomes. The purpose of this evaluation was to explore any barriers and health inequalities related to patients’ age, gender, disability, ethnicity, and socio-economic background in access or outcomes within a Tier 3 specialist Weight Management service in the UK.

Methods:

The evaluation was conducted in a pragmatic paradigm. Mixed methods were used in an iterative design where findings informed action. The evaluation included a narrative literature review, a quantitative demographic analysis on equity of access to the service (n=1896), a quantitative analysis on patient pathways and outcomes (n=2148), a patient focus group and interview (n=3), staff interviews (n=7) and a survey amongst referring General Practitioners (n=9).

Results:
Both weight stigma and male gender are perceived as barriers to accessing and engaging with weight management. Fewer men than women are referred to and access the service. However, after 52 weeks, both genders have similar outcomes in terms of BMI reduction. Older adults are under-represented in the service due to a lower referral rate, but they achieve higher than average BMI reduction. People from areas with the highest levels of deprivation are over-represented at referral and as starters in the service, and whilst they have lower-than-average BMI reduction after six months, longer engagement (12 months) achieves above average outcomes. Mistrust and disempowerment can be barriers to access but support from staff can help build trust and empowerment, facilitating positive outcomes. Staff’s existing skills facilitate working with people with protected characteristics, yet skills gaps still exist that act as barriers.

Conclusions:
Individual, societal and structural factors intertwine to generate inequalities. Relationship-building and empathy skills from health professionals, combined with improved communication, practical information, and support may alleviate these inequalities. However, some sample sizes were small and generalisations may only be made with caution.

Obesity has been defined as a progressive chronic disease characterised by excess body fat which increases the chances of developing life-limiting diseases including heart disease, type 2 diabetes, and certain cancers ^[1]. According to the WHO ^[2], overweight and obesity have reached epidemic proportions in Europe and based on data from the last Health Survey for England in 2019, the prevalence rate for overweight and obesity among adults in the UK is 64%, and there has been a significant increase since 1993 ^[3]. Closely related to socioeconomic disadvantage, obesity is considered a major public health issue ^[4] associated with comorbidities in both physical and mental health.

The Derbyshire Community Health Services NHS Foundation Trust Tier 3 (T3) Weight Management Service provides specialist support to individuals presenting with a Body Mass Index of 35–49 and a qualifying comorbidity, or a BMI greater than 50 (with or without comorbidity). The service is accessed through referral from primary care professionals or physicians. The focus is on managing weight through long-term behavioural and lifestyle changes, exploring the relationship with food and how it features in patients’ lives. After completion of a T3 service, patients may be referred on for bariatric surgery. Two service evaluations conducted on this T3 service ^{[5, 6]} concluded that it demonstrates statistically and clinically significant weight loss, as well as a significant positive impact on psychological well-being. These findings are supported by several systematic reviews which have reported statistically significant reductions in weight and BMI in individuals engaging with specialist weight management services in general ^{[7, 8]}. Research funded by the National Institute for Health Research ^[9] also suggests that although the evidence is mixed regarding their specific components, weight management programmes are cost-effective compared to taking no action, and they are one of the recommended lines of treatment by NICE.

However, a report by the King’s Fund states that weight management services are rarely targeted to meet the needs of population groups with the greatest prevalence ^[10]. Little is known about the equity of accessibility, adherence, and outcomes for different populations with obesity ^[11]. According to the Equality Act ^[12] it is against the law to discriminate against an individual or group based on protected characteristics including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. There appears to be a lack of data source that considers all these protected characteristics in terms of prevalence of obesity, although recent data show that prevalence does vary by age, disability, sex and ethnicity ^[13]. In order to consider any reasonable adjustments that may be required and to provide an equitable weight management service, this service evaluation focused on the characteristics for which robust data is available: gender, ethnicity and age. Additionally, a fifth characteristic was explored, learning disability. This was because initial analysis of service use for this evaluation showed under-representation of this group, so our literature review focused on this specific disability. Pregnancy is an exclusion criterion for the service and therefore was not considered. Although not a protected characteristic, socioeconomic inequalities are known to undermine physical and psychological health and were included as part of the evaluation.

Below we describe in more detail the link between obesity and the characteristics considered in this service evaluation.

Obesity and socio-economic background

The impact of socioeconomic status on health inequalities has been reported widely ^{[14, 15]}. Data from OHID ^[13] show that whilst the prevalence of obesity in the population is 19.2% in the least deprived areas of England, that figure rises in line with deprivation up to 36.8% in the most deprived areas. Furthermore, there is evidence that deprivation does not affect everybody equally: in areas of lowest deprivation in England, the prevalence of obesity amongst men and women is the same (22%), yet for women in the highest areas of deprivation it reaches 39%, compared to 30% for men ^[3].

Derbyshire is one of the counties with a higher-than-average prevalence of obesity ^[13]. Reasons proposed for geographical differences include the relative price of food, making healthy choices unaffordable for many, and a strong relationship between deprivation and “food deserts”: areas with high density of fast-food outlets and a lack of availability of affordable healthy food ^[10]. The WHO ^[2], identifies both diet and exposure to obesogenic environments as key components of the obesity epidemic. Data from the Active Lives adult survey ^[16] also show that the least affluent social groups have the lowest levels of physical activity. In addition to environmental and economic barriers, Holmes ^[10] suggests that people living in poverty are faced with a combination of psychosocial factors such as food insecurity and stress which are further barriers to dedicating time and effort to preparing healthy food or engaging in physical activity.

Both the Marmot Review ^[14], its update ^[15] and the WHO ^[2] highlight that community, societal and population-level interventions are at the centre of reducing health inequalities. This does not mean that interventions at an individual level cannot and should not be optimised: Coupe et al. ^[17] have argued that lifestyle interventions such as weight management programmes must be tailored to individuals from low socioeconomic populations, and need to consider affordability, language and literacy barriers, and cultural diversity.

Obesity and learning disabilities

According to the Health and Care of People with Learning Disabilities report ^[18], people with Learning/intellectual Disabilities (LD) are 3.7 times more likely than the general population to have a BMI that classifies them as obese. In addition, women with LD have a greater likelihood of obesity than men with LD. Evidence indicates that adults with LD are less physically active than adults without LD ^{[19, 20]}. As the British Dietetic Association ^[21] states, people with LD are not only at higher risk of being either underweight or obese, but also of having gastro-intestinal conditions (e.g., constipation and reflux). They also highlight that people with LD face additional aetiologies for obesity: from undiagnosed medical conditions and poly-medication that affects appetite and weight, to lack of support, competence, and confidence to implement dietary changes, thus making obesity amongst adults with LD a complex health and social challenge.

Weir et al. ^[22] highlight the paucity of studies about diet, exercise, and sleep patterns of autistic adults. Their research concluded that, compared with non-autistic adults, people with autism, particularly autistic females, are less likely to follow recommendations about healthy diet, exercise, and sleep, and that this may partly account for the excess risk of cardiovascular conditions in autistic adults. Similarly, Doherty et al. ^[23] highlight the lack of weight management research involving adults with LD. In both their study with health professionals ^[23] and their study co-produced with adults with LD ^[24], Doherty et al. highlight barriers to referral for people with LD, driven by communication challenges, a potential lack of knowledge and awareness of appropriate services amongst health professionals, and challenges working with carers.

Further barriers include family and carers’ perceptions of weight loss as a priority, and the extent to which carers perceive an adult with LD’s freedom of choice as a barrier to adhering to a recommended diet or weight loss plan ^{[23, 25]}. Finally, adults with LD also identified income constraints, the marketing and availability of unhealthy food, and barriers to physical activity as further obstacles on their weight loss journey ^[24].

Obesity and gender

Since 2015, data from the Active Lives survey ^[16] show that men are more likely to be overweight and obese than women, with the latest data estimating the overweight and obesity rate amongst men as 68.5% and amongst women as 58.3%. The data for obesity alone do not show such a stark difference between genders, with 23.1% of men living with obesity compared to 22.1% of women ^[13].

It has also been identified that men are less likely to attend commercial weight loss programmes ^[26], and less likely to access weight management interventions through primary care ^[27]. One contributing factor could be that overweight and obese men are less likely to identify themselves as being “too heavy” (i.e. overweight) compared to women. In addition, men are less likely to perceive their body weight as a health risk, which is in turn associated with a lower likelihood of trying to lose weight ^[28]. Several systematic reviews have identified that men can be motivated to lose weight for health reasons, and that in some cases, this motivation is contrasted with female “vanity-led” weight loss ^{[29, 30]}. However, Tudor et al. ^[31] argue that the gender imbalance in referrals to weight loss programmes is largely due to a bias in GP referral, and that when referrals are offered on a randomised basis to all obese patients, there is no statistically significant difference between the proportion of men and women accepting referrals, attending, or achieving positive outcomes.

In terms of the intervention itself, Hunt et al. ^[32] have argued that men are more likely to engage in gender-sensitized weight management programmes, and Archibald et al. ^[29] found men were more motivated to attend if the setting was convenient, non-threatening and congruent with their masculine identity. Some studies looked at linking sports such as football and rugby to weight management programmes ^{[33, 34]} and reported that men valued the peer support and camaraderie of the group-based programme, as well as the emphasis on physical activity rather than just diet. However, both Archibald et al. ^[29] and Robertson et al. ^[30] found that some, but not all men valued male-only interventions.

Obesity and ethnicity

There are ethnic differences in the prevalence of obesity and the related risk of ill health. Of all ethnic groups, the highest prevalence is amongst Black adults, with 72% overweight and obese, and 31% obese ^[13]. Whilst the prevalence of obesity is at its lowest amongst Asian adults ^[13], it should be noted that according to the WHO ^[35], there is an increased risk of ill-health at lower BMI amongst this population, and the WHO have argued for a different obesity threshold for Asian adults to which this service adheres. Data also indicate that Asian and Black women report the highest rates of physical inactivity ^[16].

There is also some evidence that cultural misunderstandings around what constitutes a healthy diet or a healthy weight, or about the nutritional values in the preparation of ethnic foods may be a contributing factor, as well as a lack of culturally suitable exercise facilities and family and cultural expectations ^[36]. Research has also shown that service providers having an appropriate level of knowledge of different cultures, tailoring content, and relationship-building leads to successful engagement in interventions ^[17], and highlights the importance of considering both language and literacy barriers ^{[17, 36]}. However according to Birch et al. ^[11], few studies on weight management interventions report data by ethnicity, and further research is needed to investigate the health outcomes for individuals from ethnic minority groups engaging in weight management services.

Furthermore, there is evidence that shows a link between ethnicity and medical mistrust which acts as a barrier to health behaviours, reduces uptake of services ^[37], and ultimately negatively influences health outcomes ^[38]. Whilst much of the literature on medical mistrust has originated in the US and focused on the African American population, Jaiswal ^[37] argues that it is a phenomenon that goes beyond a specific community and could affect any marginalised or stigmatised group. There is UK-specific evidence linking ethnicity and medical mistrust in the context of Covid vaccinations, often related to inferior NHS experiences ^[39] or experiences of discrimination or racism in a medical setting ^[40], but these conclusions are arguably applicable to other therapeutic areas.

Obesity and age

The prevalence of obesity in older adults is on the rise in Europe ^[41] and the prevalence of obesity amongst men is at its highest in the 65–74 age group ^[3]. Data also show that across both adult men and women of all ages, the prevalence of obesity is 25.3%, but rises to 29.1% for the 65–74 age group ^[13]. Older adults are also at higher risk of sarcopenic obesity, a condition characterised by reduced muscle mass and function and increased fat mass, which in turn has been found to be a risk factor for increased frailty, co-morbidities, and mortality ^[42]. However, several sources ^[43–45] have described what is sometimes referred to as the obesity paradox: in older adults, obesity may be associated with lower mortality than in younger adults. In addition, aggressive weight loss may further contribute to the reduction of muscle mass ^[46]. These two aspects have led to debates about whether obesity should actually be less of a concern in older adults. However, Gill et al. ^[44] argue that some of the obesity paradox could be explained by unintentional weight loss due to ill-health in older adults. They also maintain that benefits of weight loss in older adults with obesity include both increased function and improvement on a range of health indicators, and that whilst exercise and diet in isolation can each improve outcomes for older adults, these are further improved when they are combined.

Whilst metabolic changes (such as reduced energy expenditure or increased fat storage) may contribute to weight gain in older age ^[46], biology is not the only factor. A further contributing factor could be that loneliness and emotional eating act as a barrier to weight loss amongst older adults ^[47]. Their findings also indicate that whilst being overweight was perceived as more acceptable than at a younger age, participants reported that they would welcome support for weight management from health professionals which they felt to be lacking.

Furthermore, Newberry & Dakin ^[46] have argued that although the US restrictions on bariatric surgery for the over 60s were lifted in 2006, the procedure remains controversial due to a lack of data from randomised control trials on bariatric surgery vs dietary management in over 60s. This absence of evidence may also lead to health professionals’ reluctance in the UK to refer older adults to a T3 service and potentially towards bariatric surgery.

In summary, there is evidence that our chosen characteristics of ethnicity, gender, learning diasability, age and socio-economic status play a significant role in the prevalence of obesity. However, our search of the literature has revealed that for many of the population groups included in this review, there is limited research on the barriers to access services and any adaptations needed, which in itself reflects the inequalities that these groups face. Furthermore, many of the studies outlined above do not differentiate between overweight and obesity and were conducted in group weight management settings. There appears to be limited research on Tier 3 one-to-one programmes. Finally, our review of the literature shows that there is a paucity of research on inequalities of outcomes within weight management services. Therefore, this service evaluation aimed to identify health inequalities with regards to both access and outcomes in the context of a specialist Weight Management Service.

The aims of this evaluation are exploratory rather than confirmatory, and this service evaluation has therefore been conducted in a pragmatic paradigm, which is in keeping with the aim of solving real-world problems in the context in which they arise ^[48], and with a focus on producing actionable research using the most appropriate methods ^[49]. This pragmatic approach has been combined with an action research orientation, as well as an iterative approach to knowledge generation ^[50], and was carried out by and with input from individuals working within the service. For this evaluation, mixed methods were used to provide elaboration and complementarity ^[51]. Both qualitative and quantitative methods were used concurrently, allowing early insights from one element to refine the questions addressed in others. The initial quantitative analysis of the demographic make-up of the service provided part of the contextualisation for the evaluation, and highlighted that men, older adults and people with LD were under-represented, which contributed to the focus of the literature review, influenced the recruitment of participants for the focus group, and informed the GP survey. The qualitative elements allowed both patients, staff and referrers to have a voice within the research. The main findings from the evaluation were discussed with the Weight Management team to gather their input and feedback on the insights generated.

This service evaluation included five key components:

Equity of Access Quantitative Demographic Analysis

A health equity audit was conducted to understand inequities of access to the service based on specific characteristics. Data recorded from April 2018 to December 2021 for 1,896 eligible referrals and 899 starters were compared to ONS demographic data (based on the 2011 census) for Derby and Derbyshire to identify whether selected protected characteristics (age, gender, ethnicity) were under- or over-represented within the service. An analysis on the proportion of patients who have a disability was also carried out, but could not be compared to local population norms, due to a lack of data availability. In addition, patients’ postcode data were mapped on to LSOAs (Lower-layer Super Output Areas) to obtain an Index of Multiple Deprivation (IMD) and data were compared to demographic data for Derby and Derbyshire from the English Indices of Deprivation (2019). An adjustment for the prevalence of obesity (by gender, age, ethnicity, IMD) was applied. The significance of any over-index or under-index was then assessed using a 95% confidence interval.

Pathways and Outcomes Quantitative Analysis

Data on patients referred into the service between January 2018 and March 2022 were analysed using descriptive statistics. All ineligible referrals (for which no data is gathered) were omitted, leaving a sample of 2,142. Analysis was carried out on age, gender, ethnicity and IMD. Comparative analysis was carried out on those referred to the service, opting-in and commencing in the service, as well as expected or unexpected discharge, to understand inequities. Outcomes included in the analysis were changes at 24 and 52 weeks for the following measures: BMI, EQ5-D by EuroQol (a measure of quality of life across five dimensions of mobility, self-care, usual activities, pain, and anxiety or depression) and CORE (Clinical Outcomes in Routine Evaluation, a measure of psychological distress). However, data for the full sample were not available for each characteristic or each measure at each time point due to patients choosing not to disclose (e.g., ethnicity), patients being discharged from the service (planned or unplanned) or not having reached a particular milestone yet, and in some cases due to missing data.

Staff interviews

Interviews were conducted with seven members of the service and included the following roles: psychologist/ psychotherapist, dietitian/ nutritionist, and weight management advisors. Three female and four male colleagues participated in these interviews. These explored staff’s experiences of working with people with protected characteristics and sought to identify any skills gaps or training needs. The interviews were of 30–45 minutes’ duration and were recorded (with participants’ permission) and transcribed using Microsoft Teams. Interviews were analysed using a semantic level of thematic analysis ^[52] Patterns of ideas and meanings (themes) were sought across interviews using only minimal interpretation.

Focus groups with service users

One focus group and one semi-structured interview were conducted on Microsoft Teams with a total of three male participants (current or recently discharged patients). Recruitment and consent to participate was managed through the Weight Management Advisors. Five users returned the signed consent forms and were contacted to arrange a focus group. At this stage, one declined to participate. A focus group on Microsoft Teams was scheduled, however, due to non-attendance, a semi-structured interview was conducted instead with a single participant. A further focus group was arranged for the three remaining participants and two attended. In total therefore, three participants were involved, two in a focus groups and one in a semi-structured interview. All three were male, white and aged between 53 and 74 (mean = 65.7). A discussion guide was followed to encourage participants to share their experiences of barriers and facilitators to accessing and using the service. Inductive reflexive thematic analysis ^[53] was conducted on each of the corrected and anonymised transcripts, and the themes generated were then reviewed deductively through the lens of inequalities of access to form aggregated themes.

GP survey

Based on the analysis of referral data indicating that older adults and men were less frequently referred to the service, a nine-question survey aimed at GPs was constructed using LimeSurvey software and distributed electronically via NHS England/ Improvement networks to Primary Care Network (PCN) contacts in Derbyshire and Derby city. It remained live for seven weeks. This aimed to find out whether and what kind of specific difficulties GPs may experience in relation to referring these groups and sought their suggestions about how to make it easier to refer.

Equity of Access Quantitative Results

Women represent 71% of eligible referrals and 74% of starters, when both population and prevalence figures would predict a relatively even gender split, meaning that men are significantly under-represented in the service.

From an age perspective, 73% of eligible referrals are aged between 30 and 59 years old. In contrast, only 53% of the Derby and Derbyshire population fall within this age bracket. Once obesity prevalence by age group is factored in, the service sees a significantly higher number than expected of 30- to 49-year-olds, whereas adults aged 60 to 79 are under-represented.

Figures on ethnicity show that 92% of eligible referrals and starters are White British which is in line with the local population figures. Local population figures and prevalence would predict that around 3% of our patients would be Asian adults, yet this group only represents 1.5% of our eligible referrals and 2% of our starters, which would indicate that Asian adults are under-represented. However, considering the small sample size, these figures should be viewed with caution as they don’t meet the threshold for statistical significance.

Of the starters in our service, 32% have a disability that affects their mobility or gross motor capability, 14% are recorded as having a behavioural or emotional disability, whereas less than 0.5% have a learning disability. Whilst it was not possible to compare this to local population figures due to lack of data availability, national figures would indicate that people with learning disabilities could also be under-represented in our service.

Finally, more than half of both the eligible referrals (55%) and the starters in our service (55%) live in more deprived areas (with an IMD of 1 to 4), in contrast to 39% of the local population. IMDs range from 1 to 10, where 1 is the most deprived area and 10 is the least deprived. Obesity is more prevalent in areas of low IMD, however, when the data are adjusted for prevalence, patients from IMDs 1 to 4 are still over-represented in the service both at referral and as starters. Amongst the referrals, 26% are from the lowest two IMDs and only 12% are from the highest two. This difference is reduced slightly amongst starters where the lowest two IMDs represent 24% and the highest two represent 14%, which indicates that people from lower IMDs are less likely to take up a referral. In short, more patients from areas of increased deprivation are referred to and start in the service than local population and prevalence figures would predict.

Pathways & Outcomes Quantitative Results

Pathways

During the period of January 2018 to March 2022, 2,581 patients were referred to the T3 Weight Management service. However, around 17% of referrals were deemed ineligible (not progressed and no further data captured). Opt-in or -out data are not available for around 6% of the 2142 eligible referrals (which includes newly referred patients who may not have reached that decision point yet). Unless otherwise specified, the sample size is 2015 at baseline (opt-in analysis), 380 at 24 weeks and 108 at 52 weeks (outcome analysis).
Analysis shows that, consistent with the health equity audit results, men are significantly under-represented within the service. In addition, men are more likely to miss appointments (10% vs 4%) and are slightly more likely to experience unplanned discharge (29% vs 24%), whereas women are more likely to be discharged to bariatric surgery (26% vs 15%). Although there is some minor variation in opt-in rates across different age brackets, these relatively small differences across age groups do not suggest any age-specific barriers beyond the lower referral rates of older adults identified in the equity of access analysis. However, when data on age and gender are analysed together, they indicate that the proportion of men being referred increases with age whereas the proportion of women decreases with age (see Figure 1) and this trend carries through to the proportion of men and women that opt-in.

Figure 1: Referrals by sex/ by age

Data on ethnicity and opt-out (total sample 1815) show that dual heritage patients have the highest opt-out rate (n=59), however, given the small sample size for most ethnic groups, these figures should be viewed with caution. In terms of IMD, patients in the lowest decile are most likely to opt-out (30%) and patients in the highest decile are least likely to opt-out (15%). However, between these two extremes, the data do not appear to follow a linear pattern.

Weight loss outcomes

In terms of weight loss outcomes, on average, 2.7 BMI units were lost at 24 weeks and 4.0 at 52 weeks, indicating that on average, the longer someone is in the service, the more weight they will lose. Men lose more weight than women at 24 weeks, however BMI reduction at 52 weeks shows no significant gender bias (average BMI reduction of 4.1 for women and 4.0 for men). Age is not a barrier to successful outcomes, as older adults (60+) achieve higher than average BMI reduction at both 24 and 52 weeks. Younger adults (18-29) see the largest BMI reduction between 24 and 52 weeks, indicating that they may benefit from staying longer in our service. This appears to also be true of people from the areas of highest deprivation: at 24 weeks those in IMD 1 have a below average BMI reduction (2.2 vs 2.7 average) whereas at 52 weeks they have better outcomes than other groups (5.0 BMI reduction vs 4.3 average). The least deprived decile (IMD 10) has above average BMI reduction at both time points. Trends in other deciles are less clear. As people classed as White British ethnicity represent 89% of the sample, no reliable findings on variation by ethnic group can be reported.

Quality of life & wellbeing outcomes

Across all age groups and both sexes, quality of life scores (as measured by the EQ5-D) increase between 24 and 52 weeks in the service. However, women score higher on average at both time points and there is a linear relationship between age and quality of life, with older groups scoring lower than younger groups. Across all patients there is a reduction in average CORE (Clinical Outcomes in Routine Evaluation) score between baseline and 24 weeks and again between 24 and 52 weeks, meaning a reduction in psychological distress. Furthermore, the reduction from baseline to 24 weeks is bigger (-0.96) than between 24 and 52 weeks (-0.79). Age groups 30 to 59 have the largest average reduction in CORE score at 24 weeks, however this is overtaken by 18-29 year-olds at 52 weeks who see the largest change (from -0.68 at 24 weeks to -1.09 at 52 weeks). Women see a larger reduction in CORE score than men at both time points. Women see a bigger reduction between baseline and 24 weeks (-1.07) than between 24 and 52 weeks (-0.89), whereas men’s score reductions remain relatively similar at both time points (-0.63 at 24 weeks and -0.6 at 52 weeks). Both sexes see a large reduction in the lower range of scores between 24 and 52 weeks, suggesting improvements for those with the lowest scores. Less deprived groups have larger reductions in CORE scores than more deprived groups at 24 weeks. However, there are high levels of variation between the deciles which even out at 52 weeks.

Staff interviews

Staff described how they strive to deliver the service in a manner and format acceptable, understandable, and timely for each patient, in keeping with the personalised nature of the service. Participants tended to focus on challenges they had met and on what more could be done, showing awareness of their own and the service’s development needs vis-à-vis protected characteristics. Two summative themes were created:

How (well) do we work with present knowledge and skills?
What (if anything) do we need to work even better?

How well do we work with present knowledge and skills?

The interviews with staff demonstrate that their existing skills facilitate working with people with protected characteristics.

“Obviously, we don’t really know if there is something we should be doing differently, generally we get a rapport with the person, pick up the way they like to do things […] working in a very person-centred way.” (S7)

Regardless of job title, staff felt they had limited formal training on issues associated with protected characteristics but were experienced and pro-active in developing their knowledge on issues they perceived as important in clinical work. Most importantly, staff brought to work personal qualities such as sensitivity, empathy, positivity, and humour that facilitated the creation and maintenance of working alliances. They used clinical supervision and contact with peers to support their work.

Staff expressed confidence in working with patients with mobility comorbidities. The availability of a range of face to face and remote appointments (online, telephone) was reported as having improved access to T3 for patients with mobility issues. Learning disabilities were an area they felt less confident about, and they questioned their results when working with carers (employed carers in particular):

“I think it depends on the carer as to if they're really interested and motivated and to motivate the patient as well” (S1)

Most staff interpreted age as older adults (OA) and reported no real issues for this group, beyond accommodating physical disabilities and considering isolation.Although understanding of weight loss in relation to advancing age varied (e.g., sarcopenia: the loss of muscle mass with age), participants spoke of the need to improve focus on physical activity alongside eating habits to facilitate weight loss. They also highlighted the need to simplify information especially for patients who may have limited technological knowledge:

“the communication method is probably the biggest [adjustment]” (S6)

“Just feeling like […] they have someone to talk to about these things because sometimes people, you know, adults that stage in life can feel quite isolated.” (S6)

Concerns were shared about some younger adults’ understanding of the level of commitment to lifestyle changes required after bariatric surgery and suggestions were made that they should have a longer stay in T3 to fully assess their readiness for surgery:

“Young people are looking for a quick fix” (S5)
“I probably hold different beliefs around suitability” (S5)

Staff views about working with people of other ethnicities varied. Some spoke about adaptations required to improve services for this group, highlighting language issues such as the lack of availability of interpreters during lockdowns, the variable quality of interpretation, how phone appointments limited the amount of information available about both the patient and the interpreter, and the challenges of delivering behaviour change through interpreters:

“Because obviously you know you can't really hear the patient and you can't see them” (S2)

None of the participants had specific training on working with interpreters. In addition, interviewees recognised that the cultural aspects of food and the role of family life in weight management needed to be understood and managed:

“I believe there's always pastries on the table and it sounds like you just pick through the day and things like that and it's a big, strong cultural kind of family thing. So that's quite challenging.” (S1)

They also described religious beliefs, particularly Ramadan, as significant to their work due to the pattern of fasting and feasting. Although all participants stated having no formal training on this, they had sought out information to educate themselves.

“At the moment they're having to cope with things like Ramadan. So they're having to fast.” (S2)

“So I'm curious. I guess I'm curious about, you know, different people's religions and how that affects, impacts on them.” (S5)

Staff were acutely aware that they see more women than men and spoke of the reasons behind this such as different physiology, social roles, and media influence about gender in relation to weight. Some mentioned using a more fact-based approach with men.

“sometimes, men, it's the first time they've really ever thought about controlling their weight” (S3)

Working with transgender people was not perceived as presenting specific challenges as the guidance about weight loss remains the same.

In terms of socio-economic factors, staff report patients raising changes in eating habits or choosing healthier foods as a challenge, as they are perceived as more expensive than their usual food. They also noted the impact of precarious work and benefits on patients’ physical and mental health.

“She was trying to cut her down sugar. And she started to think about soya milk and almond milk. She found that she can't really have that because it's too expensive.” (S2)

In summary, the interviews demonstrated a good level of empathy, skills and awareness of adjustments needed in relation to protected characteristics.

What (if anything) do we need to work even better?

Participants considered how service delivery could be improved in relation to protected characteristics. Several suggestions were made around training and changes that would facilitate and improve their knowledge and practice.

Staff highlighted that adapted materials for people with visual and hearing impairments should be routinely available. They also felt they would benefit from more training in working with people with learning disabilities, especially when providing consultation working in collaboration with other services. Although training has been made available in this area, they don’t seem to recall or consciously apply it. They welcomed the supervisory support they received on this and expressed a desire for more systemic working.

“And I think a more systemic approach and supporting somebody you know, supporting the whole […] residential place.” (S4)

They felt that there was more scope to explore staff and patient assumptions and biases related to age, weight loss and bariatric surgery. Their responses also highlight a need for suggestions about appropriate or adapted physical activity and for the simplification of information and other interventions where appropriate (e.g., where use of technology may be challenging).

Staff expressed a desire for training in working with interpreters, particularly in terms of rapport building and effecting behaviour change, and for longer appointments to allow for translation. They also felt that they would benefit from understanding more about the challenges of religious fasting and exploring aspects of religious practice that may help weight management (e.g. prayer for emotional comfort).

“Now obviously I know the basics of Ramadan, but I'd probably I'd like to know more.” (S1)

Staff suggested working on ways of attracting more male patients to the service through the social normalisation of weight loss and bariatric surgery for men. Finally, their responses demonstrate the importance of support through regular clinical supervision embedded in the service.

Patient Focus Groups

The aim of the focus group and semi-structured interview were to investigate service users’ experiences of the T3 weight management service in terms of accessing and using the service, and to understand what barriers and facilitators might be contributing to inequalities. Inductive themes were generated from the focus group and from the semi-structured interview. These were then reviewed deductively through the lens of inequalities to generate three aggregated themes. Two aggregated themes that were present across both the focus group and the semi-structured interview highlight how the exercise of power can affect access: Stigma & power, and trust & power. In addition, a third theme that was only present in the focus group is represented here because of its importance in terms of inequalities of access: The role of gender.

Stigma and Power

The participants’ experience of stigma from both society and health professionals prior to their referral to T3 left them feeling frustrated and disempowered. They perceive GPs as reluctant to refer due to stigma, prejudice, or cost. Participants have felt superficially judged and dismissed because of their size by health professionals in the position of gatekeepers with the power to decide about their eligibility for referral. They felt that blame was placed on them for being obese.

“It’s the, it’s the tone and the disg-, the almost disgust that they [GPs] have with you. You know what I mean?” (Participant 1)
“And they [GPs] sit there in their chair… in their big leather reclining chair, and criticise me weight and you’re like…Really?” (Participant 1)
“I mean, who wants to go and be told by somebody after you’ve spent your lifetime… being told that you’re fat” (Participant 3)

Coping mechanisms were employed to deflect the threat of stigma and participants exercised their power by either dismissing the issue, using humour as a defence or highlighting external contributors to obesity as a way of reducing responsibility and avoiding judgement.

“You know, you go to the shops and they’re like, a bar of Galaxy, you know, like pound bar or, you know packet of four snickers or whatever for a pound, all that jazz, and it’s really cheap and easy.” (Participant 1)

In some cases these defences can be maladaptive and act as a barrier to confronting the issue of obesity and engaging with the solutions on offer. Participants’ unsuccessful attempts at weight loss have eroded their self-efficacy. However, a supportive and empathetic health professional can help break the deadlock and through mutual trust, understanding and encouragement, the support from T3 facilitated readiness for change.

“…what Doctor [X] said to me, you know, he says I can, I can help you, he says. But it is down to you. You’re in control of your body. What, what you put in, in your mouth is, it’s up to you. But I will do everything I can to make it easier for you.” (Participant 2)

Trust and power

The way power is exercised can affect the capital of trust. By exercising professional power in a facilitative way within the T3 service, trust was invited, and participants felt accepted and understood, thus allowing them to accept the need to change.

And even the psychologist (…) I was able to speak to [them] quite openly and [they] understood (Participant 1)

In this supportive working relationship, participants were able to create a narrative to make sense of their experience of weight gain and examine the extent of their responsibility and control without blame. The relationship empowered them, and they could exercise their newly accessed agency to make lifestyle changes. Both trust and empowerment were further reinforced as people started to experience positive results.

“I’m having to live with [the excess weight] but make the most of it and do what I can to try and get- I’ve got a target to get to.” (Participant 2)

However, stigma and barriers to access (barriers to a referral, waiting lists for bariatric surgery, or lack of access to medication) can undermine trust and the belief that either the health professional, the system or the institution have the participants’ best interests at heart. A deficit of trust built up through years of perceived prejudice can hinder the formation of a working relationship and stop the support being accepted. This created a barrier to enacting the recommendations from the service, which in turn had an impact on outcomes.

“but the bottom line is, you know, I can see that you haven’t got the data to work with. I mean, it’s just some, you know, it’s an awful thing to say, but it’s, almost it’s like a sham, innit, really?” (Participant 3)

Gender

Gender influences attitudes towards weight management. Participants highlighted that the media portray an idealised version of the male body which seemed unattainable and is in contrast with their day-to-day reality where “big” male bodies were increasingly common and therefore normalised. The participants’ euphemistic use of the word “big” can have both positive and negative connotations and particularly in a male context has associations with strength and power, suggesting that even as they recognised their weight as problematic, there was still some acceptance of their size.

“And I know, we see, we’re seeing sort of like increasingly big males you know, obese males, shall we say?” (Participant 1)

Implicitly and explicitly, the participants recognised that there was a greater tolerance of overweight and obesity for men than for women and suggest that women were more aware of their weight.

“How many times will a woman ask you, do you think I’m putting weight on against how many times will a man say do you think I’m putting weight on. They don’t broach that subject.” (Participant 2)

Whereas male pride can prevent men from raising the issue, women were perceived as much more comfortable discussing the topic, and weight management was seen as a female activity. Male gender acts as a barrier to acknowledging the issue and engaging with weight management, particularly for young men who are even more likely to underestimate or deny the issue. However, the role that age plays is a contradictory one. On the one hand, participants perceived that overweight is less of an issue for older men, whilst recognising that they were more receptive to weight management than their younger counterparts.

“But yeah, I think as we get older we, we do become more acceptable.” (Participant 2)

“Young men, males. Young males are like-, they’re invincible. You know, anybody young is invincible, but young males are invincible.” (Participant 1)

Participants felt that they wouldn’t have confronted the issue of their weight without being prompted by associated health issues that challenged their perception and highlighted their vulnerability.

GP Survey Results

Although the survey was distributed through PCN contacts in Derby & Derbyshire and remained live for seven weeks, only 9 attempts to complete the survey were registered, of which only two responses contain any data (one partially completed response and one full response). Conclusions cannot be drawn from such a small sample, other than perhaps seeing this response as symptomatic of primary care workload. However, the textual data does provide some indication of areas for improvement.

With regards to men, one participant commented on the limits of consultation time to conduct a conversation around weight management. Facilitators included patients being proactive and requesting referral, patients being open to discussing a referral for weight loss while consulting for other health conditions, and other health professionals preparing the patient for referral to weight loss services. However, one respondent felt that male patients did not wish to be referred to a specialist weight management service, and that patients’ motivation was compromised by delays in the referral system. Similar issues were highlighted regarding the referral of older adults. In addition, the physiology of aging was highlighted as an obstacle to weight loss. However, the scarcity of response limits the insights that can be inferred from the data.

This discussion will aim to briefly summarise the findings from the different elements of the service evaluation. These will then be reviewed in light of the current literature, starting with general barriers and facilitators, then socio-economic background, disability, gender, race and age, before considering the strengths and limitations of this evaluation.

General barriers and facilitators

The service can only be accessed through referral, mostly from primary care clinicians. Once referred, almost a quarter of patients choose not to take up the referral. Qualitative data from the focus group (albeit from a small sample) would indicate that whilst some GPs take the time to discuss and explain the referral, others do not, which is consistent with previous findings by Wallace et al. ^[6]. It is widely acknowledged that primary care is currently overwhelmingly busy ^[54–56] with pressure on consultation time. Indeed, the paucity of responses to the GP survey could be indicative of the workload pressures faced by primary care. Nonetheless, more work could be done with referrers to increase their understanding of the service, how they communicate about the service to patients, and make the referral process easier.

The focus group participants vividly describe their experience of stigma, which is not unique: a recent review indicates that weight bias and discrimination are prevalent across the media, education, workplaces and even public policy in the UK ^[57]. There is evidence that negative actions and attitudes from health professionals remain a barrier to discussing weight and accessing weight management services ^{[58, 59]}. There is also evidence that almost half of adults with overweight or obesity internalise weight stigma, particularly those with lower levels of education and income ^[60]. This internalised stigma can in turn lead individuals to believe that they are incapable or unworthy of achieving personal goals ^[61]. This raises interesting questions about how obesity stigma may exacerbate pre-existing inequalities.

Findings from the focus group indicate that patients felt understood, not judged, within the service, helping bring about change and influencing outcomes. This highlights the importance of the therapeutic or working alliance between patients and therapists ^[62]. Recent research has shown that the working alliance is relevant to a wide range of health professions, from physicians to physiotherapists ^{[63, 64]}. Further evidence has emphasised the role of empowerment which is achieved by therapists who actively work at reducing the power differential ^{[65, 66]}. Therefore, it could be argued that the way trust is generated, and power is exercised within the T3 service are essential to achieving positive outcomes for patients. The key relationship between Weight Management Advisor and patient highlights the importance of health professionals and weight management services in destigmatising obesity and creating a climate in which patients’ self-efficacy can be increased.

Socio-demographic factors

The quantitative data from this evaluation show inequalities in access, as lower IMD deciles are over-represented in our referrals, but more likely to opt-out. The data also show whilst the most deprived have below average outcomes at 24 weeks, this trend is reversed, and these individuals achieve higher-than-average BMI reductions at 52 weeks. This is in partial contradiction with Birch et al ^[11] whose systematic review indicates that people from higher socio-economic backgrounds had better adherence, lower attrition, and better outcomes after 12 or 18 months. In terms of understanding the reasons why individuals from more deprived areas would achieve lower results at first, participants in the staff interviews raised the issues faced by patients from lower socio-economic groups: precarious income and the affordability of healthy food, which is consistent with the literature ^{[10, 14]}. Similarly, Coupe et al. ^[17] cite challenges accessing leisure facilities and engaging in physical activities, the perceived and real cost of goal implementation, more complex social situations (e.g., caring responsibilities), literacy barriers, and possible lack of support from family members as barriers to engagement in weight management for people of lower socio-economic status.

Learning Disability

Less than half a percent of referrals into the service are for patients with a learning disability (LD), compared to more than 2% of the adult population in the UK ^[67]. In addition, people with LD are more likely to be living with obesity ^[68]. Existing literature identifies barriers that may be contributing to a lower-than-expected level of referrals to our service: these include communication challenges, lack of resources and perceived motivation issues with this patient population, as well as a lack of awareness of appropriate weight management services amongst GPs ^[23]. The staff interviews also identified patients with LD as an area of complexity, particularly working with support workers or employed carers who may have varying levels of motivation and be subject to frequent changes, issues which have been highlighted in previous research ^[23–25]. Communication challenges were also raised during staff interviews as well as the need to tailor communication. This is consistent with research conducted with people with LD who identified a lack of clear and accessible information as a barrier to weight management ^[23]. Finally, as patients are expected to engage with the programme for a minimum of 6 months, we need to ensure that people with LD have sufficient support to commit to that time period.

Gender

The data from this evaluation show that patients in the service are predominantly female. This finding does not appear to be unique to this service, as the under-representation of men in weight management has already been identified in previous literature ^{[26, 27, 69]}. According to our quantitative data, men represent less than 30% of referrals, which could indicate that GPs are more reluctant to refer men. This is consistent with findings from Tudor et al. ^[31], and with the results from the GP survey (which need to be viewed with caution given the limited response rate) highlighting GP perception that men are less receptive to weight management.

Furthermore, our quantitative evaluation also found evidence that men, and particularly young men, are less likely to opt-in when offered a referral. One potential explanation is that men are less likely to identify themselves as overweight ^[70]. Furthermore, men are less likely to identify the health risks associated with obesity but are more likely to recognise their weight as a risk as they get older ^[28]. This corroborates focus group participants’ views that women are more likely to be aware of their weight and act earlier and with the notion of young men’s sense of “invincibility” as a barrier to engaging with weight issues. Social norms are likely to influence men’s perceptions of weight and Gray et al. ^{[71 p.2]} argue that increased body size is associated with “muscularity and masculinity”. However, research would indicate that men can be motivated to lose weight after being reminded of their vulnerability by a health issue or after being labelled obese by a health professional ^{[29, 30]}.

The focus group participants’ description of weight management as a female domain is consistent with Robertson et al.’s ^[30] review findings that weight loss programmes can be perceived as a feminine activity. The staff interviews also highlight a perception that men are more focused on practical aspects, which also has parallels with Robertson et al.’s findings that men preferred fact-based interventions. It may be beneficial for T3 services to be aware of this potential gender difference and of findings by Wyke et al. ^[33] around the importance of physical activity, and to consider whether individual goals may need to be adjusted for male service users.

However, it should not be overlooked that those men who do opt-in to the service are on average as successful as their female counterparts, which is consistent with findings from a commercial weight management program study by Tudor et al. ^[31]. These findings therefore highlight the need to address men’s awareness of the health implications of obesity, to raise awareness that the service is suitable for men, and to encourage them to proactively raise the issue with their GP.

Race/Ethnicity and Religion

The quantitative data show that patients in this service are predominantly white, in line with the local population, and hint at an under-representation of Asian patients, although this is not statistically significant. However, the prevalence data used in the analysis doesn’t apply the ^[35] guidelines of a lower obesity threshold for Asian adults (which this service works to) and further analysis is needed to understand the impact of this revised threshold. Several recent studies have shown that people from ethnic minorities are likely to have lower trust in medical institutions, linked to experiences of discrimination within healthcare settings ^{[39, 40, 72]}, although Jaiswal ^[73] argues that medical mistrust is a phenomenon that can affect any marginalised or stigmatised group. Previous weight management studies amongst South Asian populations ^{[74, 75]} have shown that recruitment of participants was significantly more successful when conducted through the local community than through GPs. This would indicate that to improve access amongst minoritized ethnic populations, outreach into the community may be required.

Staff brought up the challenges of working with interpreters and how they worked to overcome these. Previous reviews have highlighted how nurses expressed similar concerns around accuracy and confidentiality with both formal and informal interpreters as well as a lack of knowledge on how to work most effectively with interpreters ^[76], and how personal qualities such as sensitivity, empathy and cultural humility are key to creating a relationship across language barriers ^[77]. Staff also recognised the need to develop a greater understanding of how cultural and religious practices might impact a patient’s journey through the service. Service users’ appetite for interventions that are culturally appropriate has been highlighted in previous research across different ethnic minorities ^{[36, 78]} and is supported by research showing increased engagement in weight management interventions when these were tailored to reflect different diets and commonly used foods ^[79].

Age

Adults over 60 are under-represented in referrals and as starters in the service. As indicated in the literature, this could be driven by a combination of health professionals’ reluctance to refer and a lack of interest or engagement from older adults. Focus group participants acknowledged a contradiction that being overweight became more acceptable as they got older yet that older men were likely to be more receptive to help offered by a health professional. The quantitative data show that referral and opt-in rates increase with age for men, but decrease for women, and the reasons for this may need further exploration. These findings are supported by Jackson et al. ^[47] which indicates that being overweight was perceived as more acceptable for older adults, but not to the extent that they were unmotivated by weight loss, and that older adults would welcome weight management support from health professionals but perceive this to be lacking. Walter et al. ^[80] found that physicians in Germany held the belief that preventative care such as weight loss was less relevant for older adults as they expected these patients to be resistant to lifestyle changes, and the respondent in our GP survey perceived older patients as unwilling to discuss their weight and reluctant to be referred. Furthermore, Gill et al. ^[44] state that concerns around sarcopenia may have wrongly contributed to a lack of focus on obesity in older adults in clinical practice, despite the significant health benefits of weight loss combined with physical activity for this population. GP workload may further disadvantage older adults as the need to focus on a single issue per consultation may limit opportunities to discuss weight for older adults who are more likely to have other comorbidities ^[81]. Indeed, the issue of comorbidities was raised during staff interviews as an added complexity with older adults.

The quantitative outcome data show that EuroQol scores (a measure of quality of life), decline with age. This is not specific to this service but is consistent with UK population norms ^[82]. Although scores mprove between 24 and 52 weeks for all age groups, these remain consistently lower than the population norms, possibly reflecting the impact of obesity on quality of life, often mediated by chronic pain and reduced mobility ^[83]. The issue of mobility in older adults was also raised during staff interviews, as a barrier to physical activity. Given the importance of avoiding sarcopenia in older adults, further consideration should be given on how this patient group can be encouraged to engage in physical activity.

Once barriers to access have been overcome, older adults have a higher-than-average BMI reduction at both 24 and 52 weeks. Overall, these findings highlight the need to address health professionals’ perceptions of the appropriateness and effectiveness of older adult referrals.

Finally, under 30s have the biggest BMI reduction of any age group between 24 and 52 weeks, as well as the biggest improvement in CORE mental health scores between 24 and 52 weeks. The reasons for the improvement in results in the second half of the T3 journey for this population are not understood and warrant further investigation. However, these findings would indicate the importance of keeping this age group in the service for longer.

Intersectionality

Finally, it is worth considering the potentially intersectional additive impact of socio-economic status, and protected characteristics. Doherty et al. ^[24] raise the issue of limited income as a barrier to weight loss for people with LD and Jaiswal ^[37] argues that medical mistrust is a phenomenon that could affect any marginalised or stigmatised group. It is therefore important that weight management services continue to be mindful of the impact of combined weight stigma, poverty stigma as well as the stigma and medical mistrust that may be associated with any existing protected characteristics.

Strengths & Limitations

A key strength of this service evaluation is that it attempted to achieve a 360-degree understanding of the service from the perspective of referrers, patients and staff. It also combined qualitative and quantitative data to ensure a fuller understanding. However, the extent to which that 360-degree understanding was achieved was undoubtedly limited by small sample sizes of the focus group and the low response on the GP survey. Small sample sizes for ethnic groups meant we were unable to ascertain an understanding of any differential access or outcomes by ethnicity. The absence of reliable data about referrers’ perceptions of and requirements from the service remains a gap in our knowledge that may benefit from future investigation.

Furthermore, whilst this T3 service measures outcomes at 24 and 52 weeks, no data are available on the long-term outlook for patients within the service. Future research should also focus on understanding the perspective of people with protected characteristics who are eligible and would benefit from our service but have not accessed it.

This evaluation has highlighted that despite staff’s efforts to meet the need of every individual, inequalities remain. The causes of these inequalities are complex and multi-factorial, and many of them are societal and structural rather than specific to the service. This evaluation has shown that older adults, men and possibly ethnic minorities face barriers to accessing the service and that the most deprived show poorer outcomes at 24 weeks. However, it has also demonstrated how, when referred and engaged with the service over time, positive outcomes can be achieved for men, older and younger adults, and the most deprived. These findings are unlikely to be unique to this service, and recommendations for practice include training for staff (e.g., on working with interpreters or people with LD), trying to keep certain patients engaged with service for longer lengths of time, and working with GPs to increase their understanding of the service.

Ethics approval and consent to participate:

A service evaluation, defined as a study in which the systematic collection and analysis of data is used to judge the quality or worth of a service or intervention, providing evidence that can be used to improve it, and conducted by internal members of staff within the service being evaluated does not require ethical approval. However, an ethics and risk evaluation was conducted before the project was initiated, and informed consent was obtained from all participants in the qualitative research in a process that adhered to British Psychological Society guidelines on research with human participants.

Full-guidelines-for-Best-Practice-in-the-Ethics-and-Governance-of-Service-Evaluation-Final02.pdf (nihr.ac.uk)

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to confidentiality of NHS data sets.

Competing interests

Caroline Savidge was at the time of the evaluation the Service Lead for the Tier 3 Weight Management service being evaluated. The other authors confirm that they have no competing interests.

Funding

Funding was received from NHS England and from Derbyshire Community Health Services NHS Foundation Trust (where the evaluation took place).

Authors' contributions

Caitlin Sorrell was responsible for the collection and analysis of qualitative data and the write-up of the service evaluation. Grace Brough was responsible for quantitative analysis of the data. Caroline Savidge was responsible for supervision of the project from inception to write-up. Both Grace Brough and Caroline Savidge provided editorial input for the written document.

Acknowledgements

The Tier 3 weight management service would like to thank NHS England/ Improvement for funding this evaluation.

The authors are also grateful to Manya Merodoulaki, Ayoola Ajibola, Andrew Turvey, Esther Owuna, Chibuzo Obinyelaku, Rebecca Symes, and participating patients and GPs for their valuable contribution.

Batterham, R. Health Inequalities and Obesity. Health inequalities and obesity | RCP London (accessed May 2022).
World Health Organization. Regional Office for Europe. European Regional Obesity Report 2022 2022. https://apps.who.int/iris/handle/10665/353747 (accessed March 2023)
NHS Digital. Health Survey for England 2019 Retrieved from Health Survey for England 2019 [NS] - NHS Digital (accessed March 2023)
Power M, Doherty B, Pybus K, Pickett K. How Covid-19 has exposed inequalities in the UK food system: The case of UK food and poverty 2020;2. https://doi.org/10.35241/emeraldopenres.13539.1.
Stephenson J, Haywood A, Bond M, Gillibrand W, Bissell PP, Holding EE, et al. Health‐related outcomes in patients enrolled on surgical and non‐surgical routes in a weight management service 2022;5. https://doi.org/10.1002/hsr2.501.
Wallace D, Myles P, Holt R, Van-Tam JN. Evaluation of the ‘Live Life Better Service’, a community-based weight management service, for morbidly obese patients 2015;38:e138. https://doi.org/10.1093/pubmed/fdv103.
Hassan Y, Head V, Jacob D, Bachmann MO, Diu S, Ford J. Lifestyle interventions for weight loss in adults with severe obesity: a systematic review 2016;6:395. https://doi.org/10.1111/cob.12161.
Brown TJ, O’Malley C, Blackshaw J, Coulton V, Tedstone A, Summerbell C, et al. Exploring the evidence base for Tier 3 weight management interventions for adults: a systematic review 2017;7. https://doi.org/10.1111/cob.12204.
National Institute for Health Research: Providing weight management programmes for people living with obesity. https://evidence.nihr.ac.uk/how-local-authorities-can-reduce-obesity/report/providing-weight-management-programmes/ (accessed July 2022)
Holmes J. Tackling Obesity, The role of the NHS in a whole-system approach. vol. 52. Elsevier BV; 2021.
Birch JM, Jones RA, Mueller J, Mcdonald MD, Richards R, Kelly MP, et al. A systematic review of inequalities in the uptake of, adherence to, and effectiveness of behavioral weight management interventions in adults 2022;23. https://doi.org/10.1111/obr.13438.
Government Equalities Office. The Equality Act. 2010. Easy Read: The Equality Act - making equality real - GOV.UK (www.gov.uk) (accessed October 2022)
Office for Health Improvement & Disparities. Obesity Profile. 2021. Obesity Profile - Data - OHID (phe.org.uk) (accessed October 2022)
Marmot M, Goldblatt P, Allen J, Boyce T, Mc Neish D, Grady M, et al. Fair Society, Healthy Lives. 2010. (The Marmot Review). Institute of Health Equity. Retrieved from https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review
Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. vol. 368. England: BMJ Publishing Group LTD; 2020. https://doi.org/10.1136/bmj.m693.
Sport England. Active Lives Adult Survey November 2021-22 Report. 2022. Active Lives Adult Survey November 2020-21 Report (sportengland-production-files.s3.eu-west-2.amazonaws.com) Accessed October 2022
Coupe N, Cotterill S, Peters S. Tailoring lifestyle interventions to low socio-economic populations: a qualitative study 2018;18. https://doi.org/https://doi.org/10.1186/s12889-018-5877-8.
NHS Digital. Health and Care of People with Learning Disabilities. 2021.
Melville CA, McGarty A, Harris L, Hughes-McCormack L, Baltzer M, McArthur LA, et al. A population-based, cross-sectional study of the prevalence and correlates of sedentary behaviour of adults with intellectual disabilities 2018;62:60–71. https://doi.org/10.1111/jir.12454.
Ranjan S, Nasser JA, Fisher K. Prevalence and potential factors associated with overweight and obesity status in adults with intellectual developmental disorders 2018;31:29–38. https://doi.org/10.1111/jar.12370.
Association of UK Dieticians. Weight management for people with learning disabilities 2021. https://www.bda.uk.com/resource/weight-management-for-people-with-learning-disabilities.html (accessed August 2022).
Weir E, Allison C, Ong KK, Baron-Cohen S. An investigation of the diet, exercise, sleep, BMI, and health outcomes of autistic adults 2021;12. https://doi.org/10.1186/s13229-021-00441-x.
Doherty AJ, Jones SP, Chauhan U, Gibson JME. Healthcare practitioners’ views and experiences of barriers and facilitators to weight management interventions for adults with intellectual disabilities 2019:1067–77. https://doi.org/10.1111/jar.12596.
Doherty AJ, Jones SP, Chauhan U, Gibson JME. Eating well, living well and weight management: A co-produced semi-qualitative study of barriers and facilitators experienced by adults with intellectual disabilities 2020;24:158–76. https://doi.org/10.1177/1744629518773938.
Spanos D, Hankey CR, Boyle S, Koshy P, Macmillan S, Matthews L, et al. Carers’ perspectives of a weight loss intervention for adults with intellectual disabilities and obesity: a qualitative study 2013;57:90–102. https://doi.org/10.1111/j.1365-2788.2011.01530.x.
Stubbs RJ, Morris L, Pallister C, Horgan G, Lavin JH. Weight outcomes audit in 1.3 million adults during their first 3 months’ attendance in a commercial weight management programme 2015;15. https://doi.org/10.1186/s12889-015-2225-0.
Booth HP, Prevost AT, Gulliford MC. Access to weight reduction interventions for overweight and obese patients in UK primary care: population-based cohort study 2015;5: e006642. https://doi.org/10.1136/bmjopen-2014-006642.
Gregory CO, Blanck HM, Gillespie C, Maynard LM, Serdula MK. Perceived health risk of excess body weight among overweight and obese men and women: Differences by sex 2008;47:46–52. https://doi.org/10.1016/j.ypmed.2008.01.008.
Archibald D, Douglas F, Hoddinott P, Van Teijlingen E, Stewart F, Robertson C, et al. A qualitative evidence synthesis on the management of male obesity 2015;5. https://doi.org/10.1136/bmjopen-2015-008372.
Robertson C, Archibald D, Avenell A, Douglas F, Hoddinott P, Van Teijlingen E, et al. Systematic reviews of and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men 2014;18. https://doi.org/10.3310/hta18350.
Tudor K, Tearne SL, Jebb SA, Lewis AL, Adab P, Begh R, et al. Gender differences in response to an opportunistic brief intervention for obesity in primary care: Data from the BWeL trial 2020;11. https://doi.org/10.1111/cob.12418.
Hunt K, Mccann C, Gray CM, Mutrie N, Wyke S. “You’ve got to walk before you run”: Positive evaluations of a walking program as part of a gender-sensitized, weight-management program delivered to men through professional football clubs. 2013;32:57. https://doi.org/10.1037/a0029537.
Wyke S, Hunt K, Gray CM, Fenwick E, Bunn C, Donnan PT, et al. Football Fans in Training (FFIT): a randomised controlled trial of a gender-sensitised weight loss and healthy living programme for men – end of study report 2015;3. https://doi.org/10.3310/phr03020.
Witty KR, White A. Tackling Men’s Health Evaluation Study, Final Report April 2020. 2010.
WHO Expert Panel. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. 2004;363:157–63. https://doi.org/https://doi.org/0.1016/S0140-6736(03)15268-3.
Iqbal H, West J, Mceachan RRC, Haith‐cooper M. Exploring the obesity concerns of British Pakistani women living in deprived inner‐city areas: A qualitative study 2022;25:1821. https://doi.org/10.1111/hex.13527.
Jaiswal J, Halkitis PN. Towards a More Inclusive and Dynamic Understanding of Medical Mistrust Informed by Science 2019;45:79. https://doi.org/10.1080/08964289.2019.1619511.
Benkert R, Cuevas A, Thompson HS, Dove-Medows E, Knuckles D. Ubiquitous Yet Unclear: A Systematic Review of Medical Mistrust 2019;45:86. https://doi.org/10.1080/08964289.2019.1588220.
Allington D, McAndrew S, Duffy B, Moxham-Hall V. Trust and experiences of National Health Service healthcare do not fully explain demographic disparities in coronavirus vaccination uptake in the UK: a cross-sectional study 2022;12:e053827. https://doi.org/10.1136/bmjopen-2021-053827.
Paul E, Fancourt D, Razai M. Racial discrimination, low trust in the health system and COVID-19 vaccine uptake: a longitudinal observational study of 633 UK adults from ethnic minority groups 2022;115:439–47. https://doi.org/10.1177/01410768221095241.
Peralta M, Ramos M, Lipert A, Martins J, Marques A. Prevalence and trends of overweight and obesity in older adults from 10 European countries from 2005 to 2013 2018;46:522–9.
Donini LM, Busetto L, Bischoff SC, Cederholm T, Ballesteros-Pomar MD, Batsis JA, et al. Definition and Diagnostic Criteria for Sarcopenic Obesity: ESPEN and EASO Consensus Statement 2022;15:321. https://doi.org/10.1159/000521241.
Han TS, Tajar A, Lean MEJ. Obesity and weight management in the elderly 2011;97:169–96. https://doi.org/10.1093/bmb/ldr002.
Gill LE, Bartels SJ, Batsis JA. Weight Management in Older Adults 2015;4:379. https://doi.org/10.1007/s13679-015-0161-z.
Waters DL, Ward AL, Villareal DT. Weight loss in obese adults 65years and older: A review of the controversy 2013;48:1054. https://doi.org/10.1016/j.exger.2013.02.005.
Newberry C, Dakin G. Nutrition and Weight Management in the Elderly 2021;37:131 https://doi.org/10.1016/j.cger.2020.08.010.
Jackson SE, Holter L, Beeken RJ. ‘Just because I’m old it doesn’t mean I have to be fat’: a qualitative study exploring older adults’ views and experiences of weight management 2019;9. https://doi.org/10.1136/bmjopen-2018-025680.
Feilzer YM. Doing Mixed Methods Research Pragmatically: Implications for the Rediscovery of Pragmatism as a Research Paradigm 2010;4:6–16. https://doi.org/10.1177/1558689809349691.
Allemang B, Sitter K, Dimitropoulos G. Pragmatism as a paradigm for patient‐oriented research 2021;25:38. https://doi.org/10.1111/hex.13384.
Bradbury H, Lifvergren S. Action research healthcare 2016;29:269–74. https://doi.org/10.1177/0840470416658905.
O’Cathain A. 29. Mixed Methods Involving Qualitative Research. London: SAGE Publications Ltd; 2010. https://doi.org/10.4135/9781446268247.n30.
Braun V, Clarke V. Using thematic analysis in psychology 2006;3:77–101. https://doi.org/10.1191/1478088706qp063oa.
Braun V, Clarke V. Thematic analysis: a practical guide. London: SAGE; 2022.
Limb M. Long NHS waits and rising living costs are harming people’s health, show ONS data 2023;380:479-p479. https://doi.org/10.1136/bmj.p479.
Salisbury H. Helen Salisbury: E-consultations are increasing the GP workload 2021;375:n2867. https://doi.org/10.1136/bmj.n2867.
Rimmer A. Doctors call for cap on GP workload 2018;361:k2810. https://doi.org/10.1136/bmj.k2810.
Brown A, Flint SW, Batterham RL. Pervasiveness, impact and implications of weight stigma 2022;47:101408. https://doi.org/10.1016/j.eclinm.2022.101408.
Flint SW, Hudson J, Lavallee D. UK adults’ implicit and explicit attitudes towards obesity: a cross-sectional study 2015;2. https://doi.org/10.1186/s40608-015-0064-2.
Holt G, Hughes D. A study using semi‐structured interview and Delphi survey to explore the barriers and enabling factors that influence access and utilisation of weight management services for people living with morbid obesity: A patient and professional perspective 2021;34:215–23. https://doi.org/10.1111/jhn.12832.
Puhl RM, Himmelstein MS, Quinn DM. Internalizing Weight Stigma: Prevalence and Sociodemographic Considerations in US Adults 2018;26:167. https://doi.org/10.1002/oby.22029.
Corrigan PW, Bink AB, Schmidt A, Jones N, Rüsch N. What is the impact of self-stigma? Loss of self-respect and the why try effect 2016;25:10–5. https://doi.org/10.3109/09638237.2015.1021902.
Flückiger C, Del Re AC, Wampold BE, Symonds D, Horvath AO. How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis 2012;59:10. https://doi.org/10.1037/a0025749.
Pinto RZ, Ferreira ML, Oliveira VC, Franco MR, Adams R, Maher CG, et al. Patient-centred communication is associated with positive therapeutic alliance: a systematic review 2012;58:77. https://doi.org/10.1016/s1836-9553(12)70087-5.
Fuertes, JN, Toporovsky A, Reyes M, Osborne JB. The physician-patient working alliance: Theory, research, and future possibilities 2016;100:610–5. https://doi.org/10.1016/j.pec.2016.10.018.
Eigeland J, Jones L, Sheeran N, Moffitt R. Critical physician behaviours in the formation of a good physician-patient relationship : Concept mapping the perspective of patients with chronic conditions 2022:198–205.
Noyce R, Simpson J. The Experience of Forming a Therapeutic Relationship from the Client’s Perspective: A Metasynthesis 2018;28:281–96. https://doi.org/10.1080/10503307.2016.1208373.
Mencap. Research and Statistics 2023. https://www.mencap.org.uk/learning-disability-explained/research-and-statistics (accessed March 2023).
NHS Digital. Health and Care of People with Learning Disabilities. Retrieved from Microsoft Power BI Accessed 2021.
Pagoto SL, Schneider KL, Oleski JL, Luciani JM, Bodenlos JS, Whited MC. Male Inclusion in Randomized Controlled Trials of Lifestyle Weight Loss Interventions 2012;20:1234–9. https://doi.org/10.1038/oby.2011.140.
England PH. Patterns and trends in adult excess weight. 2021. https://fingertips.phe.org.uk/profile/national-child-measurement-programme/data#page/13/ (accessed October 2022).
Gray CM, Hunt K, Mutrie N, Anderson AS, Leishman J, Dalgarno L, et al. Football Fans in Training: the development and optimization of an intervention delivered through professional sports clubs to help men lose weight, become more active and adopt healthier eating habits 2013;13. https://doi.org/10.1186/1471-2458-13-232.
Williamson LD, Smith MA, Bigman CA. Does Discrimination Breed Mistrust? Examining the Role of Mediated and Non-Mediated Discrimination Experiences in Medical Mistrust 2019;24:791–9. https://doi.org/10.1080/10810730.2019.1669742.
Jaiswal J. Whose Responsibility Is It to Dismantle Medical Mistrust? Future Directions for Researchers and Health Care Providers 2019;45:188. https://doi.org/10.1080/08964289.2019.1630357.
Bhopal RS, Douglas A, Wallia S, Forbes JF, Lean MEJ, Gill JMR, et al. Effect of a lifestyle intervention on weight change in south Asian individuals in the UK at high risk of type 2 diabetes: a family-cluster randomised controlled trial 2014;2:218. https://doi.org/10.1016/s2213-8587(13)70204-3.
Douglas A, Bhopal RS, Bhopal R, Forbes JF, Gill JMR, Lawton J, et al. Recruiting South Asians to a lifestyle intervention trial: experiences and lessons from PODOSA (Prevention of Diabetes & Obesity in South Asians) 2011;12:220. https://doi.org/10.1186/1745-6215-12-220.
Gerchow L, Burka LR, Miner S, Squires A. Language barriers between nurses and patients: A scoping review 2021;104:534–53. https://doi.org/10.1016/j.pec.2020.09.017.
Robertshaw L, Dhesi S, Jones LL. Challenges and facilitators for healthcare professionals providing primary healthcare for refugees and asylum seekers in high-income countries: A systematic review and thematic synthesis of qualitative research 2017;7:e015981. https://doi.org/10.1136/bmjopen-2017-015981.
Ngongalah L, Rankin J, Heslehurst N, Rapley T. Pre- and Post-Migration Influences on Weight Management Behaviours before and during Pregnancy: Perceptions of African Migrant Women in England 2021;13:1667. https://doi.org/10.3390/nu13051667.
Coupe N, Cotterill S, Peters S. Enhancing community weight loss groups in a low socioeconomic status area: Application of the COM‐B model and Behaviour Change Wheel 2022;25:2043. https://doi.org/10.1111/hex.13325.
Walter U, Flick U, Neuber A, Fischer C, Hussein RJ, Schwartz FW. Putting prevention into practice: qualitative study of factors that inhibit and promote preventive care by general practitioners, with a focus on elderly patients 2010;11:68. https://doi.org/10.1186/1471-2296-11-68.
Atella V, Piano Mortari A, Kopinska J, Belotti F, Lapi F, Cricelli C, et al. Trends in age-related disease burden and healthcare utilization 2018;18. https://doi.org/10.1111/acel.12861.
Janssen MF, Szende A, Cabases J, Ramos-Goñi JM, Vilagut G, König HH. Population norms for the EQ-5D-3L: a cross-country analysis of population surveys for 20 countries 2019;20:205–16. https://doi.org/10.1007/s10198-018-0955-5.
Taylor VH, Forhan M, Vigod SN, McIntyre RS, Morrison KM. The impact of obesity on quality of life 2013;27:139–46. https://doi.org/10.1016/j.beem.2013.04.004.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
03 Sep, 2024
Editor assigned by journal
03 Sep, 2024
Submission checks completed at journal
03 Sep, 2024
First submitted to journal
28 Aug, 2024

You are reading this latest preprint version

An Exploration of Health Inequalities in a Tier 3 Specialist Weight Management Service

Status:

Version 1

Abstract

Figures

Background

Obesity and socio-economic background

Obesity and learning disabilities

Obesity and gender

Obesity and ethnicity

Obesity and age

Methods

Equity of Access Quantitative Demographic Analysis

Pathways and Outcomes Quantitative Analysis

Staff interviews

Focus groups with service users

GP survey

Results

Equity of Access Quantitative Results

Pathways & Outcomes Quantitative Results

Staff interviews

How well do we work with present knowledge and skills?

What (if anything) do we need to work even better?

Patient Focus Groups

Stigma and Power

Trust and power

Gender

GP Survey Results

Discussion

General barriers and facilitators

Socio-demographic factors

Learning Disability

Gender

Race/Ethnicity and Religion

Age

Intersectionality

Strengths & Limitations

Conclusion

Declarations

Ethics approval and consent to participate:

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

References

Additional Declarations

Status:

Version 1