Eighteen participants in total were recruited and interviewed as part of this research. The characteristics of each participant are described in Table 1. The average age of participants was 46-years and the majority had, or were planning to undergo, a gastric bypass procedure.
Table 1: Participant characteristics
Participant No
|
Sex (M/F)
|
Age (years)
|
Surgical
Procedure
|
Pre- / Post- operative
|
Time since surgery (months)
|
1
|
F
|
29
|
Gastric bypass
|
Post
|
24
|
2
|
F
|
55
|
Sleeve gastrectomy
|
Post
|
12
|
3
|
F
|
54
|
Gastric band
|
Post
|
18
|
4
|
F
|
50
|
Sleeve gastrectomy
|
Post
|
24
|
5
|
M
|
46
|
Undecided
|
Pre
|
-
|
6
|
F
|
52
|
Gastric bypass
|
Post
|
9
|
7
|
F
|
61
|
Gastric bypass
|
Post
|
4
|
8
|
M
|
51
|
Gastric band
|
Post
|
24
|
9
|
F
|
39
|
Sleeve gastrectomy
|
Pre
|
-
|
10
|
M
|
40
|
Gastric bypass
|
Pre
|
-
|
11
|
F
|
31
|
Gastric bypass
|
Post
|
24
|
12
|
F
|
51
|
Gastric bypass
|
Post
|
24
|
13
|
F
|
58
|
Gastric bypass
|
Post
|
24
|
14
|
F
|
50
|
Gastric bypass
|
Pre
|
-
|
15
|
F
|
59
|
Gastric bypass
|
Post
|
24
|
16
|
F
|
29
|
Gastric bypass
|
Post
|
12
|
17
|
M
|
26
|
Sleeve gastrectomy
|
Pre
|
-
|
18
|
F
|
52
|
Gastric band
|
Pre
|
-
|
The analysis revealed that participants had particular needs and desires, relating to support, throughout their bariatric surgical journey. Four overarching themes were developed from the data, relating in particular to the capability and functionality of technologies to: 1) provide tailored content and support, 2) facilitate self-monitoring and goal-setting, 3) deliver information in an accessible, trusted, and usable manner, and 4) meet information-seeking and engagement needs for patients undergoing bariatric surgery (demonstrated in Figure 1). We explore these four themes, illustrating perspectives and suggestions with direct interview quotes, within this patient-informed piece of work.
Providing tailored content and support
When asked about how digital technologies could best be designed for patients undergoing bariatric surgery, interviewees expressed opinions about what information should be provided, how this information should be tailored, how specific features could be designed, and their visions of what their ‘ideal’ supportive intervention would look like.
It was deemed important that the content and support patients received from the technology was specific to bariatric surgery. One pre-operative participant described how “the support packages should be tailored to the people rather than the procedure” (participant 14), explaining how patients “can lose our hair, end up with excess skin, and need to be on life-long supplements” and how this is “the kind of stuff” that they need support with throughout the journey of surgery and beyond. Another participant explained how it would have been helpful to know that “after a normal operation you’d be able to eat whatever to build up your energy levels again quite quickly… but you can’t do that with bariatric surgery, you physically can’t eat things immediately post-surgery” so “you’d need it specifically to advise on the bariatric recovery in that case” (participant 3). There appeared to be an unmet need relating to tailored, educational- and informational-based support for this cohort.
With regards to the content of the technology, discussions centred on dietary-focused forms of support. Patients’ suggestions and desires ranged from the inclusion of “options of what I could have for a snack” (participant 5) and “something with a meal plan available” (participant 9), to designing “an app with recipes on it” so patients could “keep coming back to it” for healthier meal options (participant 5). Patients favoured prescriptive approaches to content when it came to describing ‘ideal’ technology-enabled support, stating that the intervention should tell them what to do and what to “stick to” (participant 8). One pre-operative patient suggested the integration of features such as “a list of what you’re not allowed to eat anymore” would be most helpful so they could “easily keep away from it (unhealthy foods)” in a bid to “keep on track” with their anticipated weight-loss (participant 14). Some participants stated that immediately following surgery, they wished for stricter support mechanisms delivered via digital technologies, especially to support them in adjusting to their new post-operative lifestyle and dietary intake. One participant discussed that “in the first couple of weeks (following surgery), we need to be told what to do, what exactly to do… like what to eat and what to avoid” (participant 9).
A number of participants considered it important that technology content also focused on the wider elements of healthy lifestyle support, including increased physical activity and reduced in alcohol intake: “If you called it a ‘lifestyles package’ for after bariatric surgery then you can mention things like diet but also (alcohol) drinking and exercise” (participant 9). Patients demonstrated awareness that positive behaviour changes in these areas also contributed to bariatric surgery success, with one participant specifically discussing how they were “trying to look for better choices – like a better choices app” to support their journey (participant 5).
Another participant described how building reminders and prompts into the technology could promote positive health behaviours. The tone and content of these prompts were perceived to be important, combining messages of monitoring and activity with motivational statements. The same participant described how patients should be given control over the technology settings so they could decide on the correct tone for them.
“I would want something to just give you little reminders – maybe even “have you been weighed this week?”, “have you been for a walk?”, “don’t let yourself slip”, things like that. But erm, nothing too forceful… Not the whole powered sort of, gym messages, like “get up fatty!” (laughs)” (Participant 10)
A post-operative patient reflected that, regardless of the technology delivery method used, “the most important thing is that you’re not left alone after the operation… (as) there’s so many unknowns [sic]” (Participant 11). Instead, calling for tailored, digital support to be on hand throughout the whole surgical journey to provide reassurance to patients both pre- and post-operatively.
Facilitating self-monitoring and goal-setting
Both pre- and post-operative participants reflected on the usefulness of self-monitoring and goal-setting functionalities, so as to help track progress throughout the surgical journey. One participant felt it would be useful to self-monitor “calories… and nutritional information” in food when adjusting to new meal plans (participant 14), with another participant describing the usefulness of “comparison photos” that could be uploaded to an app to “see how much of a difference there has been” (participant 15), or having “graphs to track” their weight-loss over time (participant 7). The suggestions for digital self-monitoring to support in this way appeared to acknowledge the determination of this cohort in striving for surgical success.
Self-monitoring features were also discussed in association with motivation and emotional-investment in the surgical journey, where one participant described how observing “how much (weight) you’ve lost” can “keep people’s spirits up” (participant 15). Another participant explained how automated messages of “congratulations” were encouraging and “if it calculates your BMI going down as well, I think that would be a really good motivational tool” (participant 7). Patients recognised how technology could encourage and ‘push’ them to undertake positive health behaviours, like physical activity.
One participant described how wearable technology enticed them “into doing more steps or exercise” (participant 1), with another referring to gamification features, with different ‘levels’ of increased difficulty for patients to work through, to encourage engagement with the technology.
“I'd want it to have different levels too - like the first month, the second month, unlocking the next bit... Then it’s all there for you and you can keep going back and checking on the app… I can know I’m on track then.” (Participant 14)
When it came to engaging with the surgical journey, one participant described the common post-operative pitfall of getting “so hung up on what we’re eating and whether it’s right or wrong” (participant 11). Instead, they recognised the benefit that could come from setting “daily goals about exercise” to “give us something else to think about… and work towards” to achieve optimal post-operative outcomes (participant 11). The same participant reflected on how goal-setting would have widened their personal knowledge of “what to do after” surgery, meaning they were able to “recover better” (participant 11). Another participant drew on personal experiences with the “NHS Patient Access app” (participant 7), suggesting the inclusion of specialist-bariatric advice, linking “the full app to your NHS number so it’s all personalised”, and using the home screen with “tabs at the bottom for specific stuff… like graphs to track (your progress)” (participant 7).
Some participants also discussed the value of sharing their data with healthcare professionals and the increased sense of motivation and accountability to “break those (bad) habits” (participant 10) when knowing someone else was “keeping an eye” (participant 11). Another participant felt that shared monitoring could act as a reassurance-mechanism for patients, where they weren’t being left to “fend for themselves” in the run up to surgery or as soon as the surgery was over (participant 4). A sense of shared responsibility for the success of surgeries was discussed when considering healthcare professional-led monitoring. One participant supported the inclusion of shared-monitoring capabilities so that both patients and healthcare professionals can “notice if they’re slipping” off the post-surgical diet, implying that patients alone may not be able to recognise bad habits re-forming.
Delivering information in an accessible, trusted and usable manner
All participants offered suggestions on technology delivery methods and how they would like the intervention to be available to them, including via phone-based applications (apps), online forums, and the use of social media platforms like Facebook. The majority of participants discussed that their preferred delivery method would be accessible through their smartphone via an app, with one patient explaining “practically everyone knows how to use a phone for stuff now. Everything’s on it... So, if you could put an app on there, I reckon that’s the best way” (participant 15). Other participants also reported how frequently they used their phones and how people rarely “go anywhere without it”, offering the potential for ongoing engagement even “if I’m out for the day or away on holidays or whatever, I can still log in” to use it (participant 14). Many interviewees desired a delivery system that was “nice and clear” (participant 3), with one remarking they did not want another “dry or crisp NHS website”, instead preferring a “modernised” app or discussion page (participant 4).
As an alternative delivery method, some participants reported being members of bariatric groups on Facebook. A few participants reported social media and Facebook to be an acceptable delivery format, offering familiarity and reassurance: “I use Facebook all the time… it’s amazing” (participant 9). However, participants also questioned the reliability of information posted on Facebook, describing it as “obviously everyone’s own experiences, but it might not necessarily be the safest” (participant 11). One participant described how some of the posts they had read were “full of nonsense” and so he got rid of his account. In his view, “an app would be better” as he “would probably trust it (the content) more than Facebook” (participant 5). Furthermore, another drawback of Facebook was how one “need[ed] to scroll back to find the information”, whereas an app could contain “a specific folder or tab so you could go back to it (information)” (participant 9). Other participants described their positive experiences of ‘closed’ groups with smaller numbers of individuals. One female patient discussed a private WhatsApp group which contained five other post-operative patients and felt that the ““how are you all doing?” messages” (participant 4) were helpfully shared amongst themselves. This indicates that some post-operative patients might find it helpful to surround themselves with like-minded individuals.
Many participants highlighted how information needs to be quick and easy to locate, with one participant suggesting it should be kept “all together in one place” (participant 9) and another describing how “that way you can keep coming back to the information any time you wanted to, rather than looking for the leaflets they gave us” (participant 5). Another participant described organising the information with “tabs at the bottom (of the screen) for specific stuff” like “appointments for follow ups” (participant 7).
Previous technology use was considered alongside accessibility and information provision. One participant described usability as something that depends “on your character. I’m not very techno-loving or anything, but I’d give it a go (laughs)” (participant 6). Some participants discussed usability from the perspective of others, particularly older family members. One interviewee considered her 63-year old mother, describing how “she can use Google now, but it’s took a long time to get her to do that [sic]. But then again, my husband’s Dad, he’s 73 and he would definitely use digital stuff”. Interestingly, she also appreciated that usability “is a bit dependent on the person too, not just their age” (participant 9). Some interviewees viewed usability in the same context as familiarity, and referred to strategies to overcome this through the use of patient education.
Another participant offered suggestions of how to design the technology so that users of all literary-abilities could engage, through the use of ‘happy’ or ‘sad’ faces, or colours, for instance.
“I’ve met a lot of people that can’t read or write... you could do happy face, sad face, whatever… Or amber colour for not advisable, red for bad or danger, green for good” (Participant 12)
Meeting patient information-seeking and engagement needs
With regards to using a form of digital technology for support, participants shared varying opinions about when it would be of most benefit. This benefit appeared to relate to (a) the timing of intervention implementation on the surgical journey (for example, seeking pre-operative information or post-operative reassurance) and (b) the timing of engagement with technologies (for instance, the value of interventions offering functions of ‘real-time’ use and ‘ad hoc’ use).
When considering their implementation within the surgical journey, some participants believed pre-operative digital support would be useful in helping to acquire knowledge about the upcoming surgery “it’s an operation at the end of the day and you’re changing your insides so I think it’s important to fully know (about) it” (participant 10), and their preparedness for it “at least you know what to expect, what is coming either before or after the procedure, and what to do” (participant 9). After struggling with their own surgical outcomes, one participant suggested a potential role of pre-operative digital support relating to the psychological preparation ahead of surgery. They discussed how pre-operative interventions could better educate patients and meet information-seeking needs, as well as manage post-operative weight loss expectations: “if something could teach me like how to expect, what to expect after (the surgery), it might have helped… ‘cause I thought the weight loss would be much faster and I look no different now” (participant 3). Similar thoughts were raised by other participants, with one participant explaining how it “would be really useful to have a map or plan to know what’s going to happen, and when, so we know it’s a full process for us to refer to and not panic” (participant 4). Another suggested designing “a checklist… like all part of your own bariatric package” where you could “tick off each bit” when it was achieved (participant 3). Patients may find benefit from seeing the phases of the journey and understanding what was going to happen next.
Interviewees recognised the value of real-time information seeking in the initial post-operative period, for instance: “‘cause, say you were standing in the supermarket and you thought “oh I could really fancy that, but I don’t know if I’m allowed it”, then you’d be able to look it up and see if you can have it or not. That would be really practical and handy” (participant 14) and “I think if you could make something that had a meal plan we could access straight after the surgery… rigidly… what to stick to for the first few weeks, then that would be good [sic]” (participant 5). In a cohort required to change their lifestyle behaviours, even before having the surgery, perhaps technologies delivering short-term descriptive support would be beneficial.
Participants also considered technologies playing a role in terms of long-term support. Interviewees recognised that engagement with technologies would likely be higher in the initial post-operative period “once you’ve had it (surgery), you’re in it, and probably will need the information there and then…” (participant 10), but that each participant’s engagement needs will change, the further along their post-surgical surgery they are. Being able to engage with the technology again, when needed, was deemed important: “it might be something where it (intervention usage) tails off a bit, once you start getting the hang of things, what to eat, how much you can tolerate and stuff. But also, if anything happened and I wanted to ask questions, then I picture being able to use it as and when” (participant 14).
Two participants (one pre- and one post-operative) acknowledged that technologies could play a role in complementing current practice to improve patient support between annual follow-up appointments. One post-operative participant explained that “once you got a few months in it was more “well, I’ll see you in 12 months unless you have problems” and that's not supportive enough”. They believed there to be benefit from continued technology-enabled engagement throughout this time, specifically linking with a healthcare professional for ad hoc advice:“if I’d had more contact with the dietician, digitally, I could maybe have stayed on track better” (participant 11). Recurring messages of prescriptive and descriptive approaches, where post-operative participants appear to cede complete control over their journey and outcomes, perhaps demonstrates a lack of belief that they can make and sustain positive behaviour changes on their own. One pre-operative participant perceived the value of ongoing support from technologies in a more self-determined manner: “I want to make sure I get it (dietary intake) right. I want to avoid any complications and give myself the best chance of success”. They went on to describe their ideal technology-enabled support system, combining technology alongside face-to-face appointments, stating: “I think using tech and still having the (face-to-face) appointments will give me as much support as I need” (participant 5).
Of all the participants interviewed, only one recommended implementing an intervention that spanned both the pre- and post-operative periods. This patient was 2-years post-surgery and their views combined those of pre- and post-operative patients, as discussed above, and described how supportive ‘boosts’ from the technology continued on a long-term basis could help to promote positive behaviours: “from the minute you decide to go through with it (surgery), you probably would benefit from having something there just for peace of mind… definitely (implementing) from the start, but also so they can keep using it after (surgery) too for those little boosts and support” (participant 16).