The lived experience of patients with obesity at a metropolitan public health setting

The rising prevalence of obesity, defined as abnormal or excessive fat accumulation that presents a risk to health is a key challenge for healthcare systems internationally [1]. Obesity is measured using the body mass index (BMI) (weight in kilograms divided by the square of height in metres), with a BMI of 30 or more considered obese [1]. Obesity is a risk factor for multiple diseases, and is associated with increased hospitalisation rates and healthcare costs [2]. People with obesity require a specialised care approach during hospitalisation due to their size, body habitus and compounding comorbidities. Although the effects of obesity have been well documented in terms of morbidity and mortality, less is known about what it is like to live with this complex and chronic disease [3], particularly in the context of being in hospital. Previous research has demonstrated that obesity stigma and weight bias occur in the general community generally [3], and in the hospital setting [4]. Navigating such complexities can negatively impact on a person’s care experience. In addition, there is limited understanding of important factors in care delivery while in hospital for people living with obesity. This makes it difficult to develop patient-centred, effective models of care which meet the needs of people living with obesity in hospital.

Positive patient experiences are known to be associated with improved patient safety and clinical effectiveness [5]. Conversely, negative patient experiences can lead to avoidance of care, mistrust of healthcare professionals and poor engagement in treatment for patients with obesity [4]. There is also strong evidence that people with obesity have poorer health outcomes in a range of patient groups [6‐9]. This is attributable to the physiological impact of being obese and subsequent the lack of quality of care. This increased risk of suboptimal outcomes and lack of understanding makes it difficult to identify the most important factors for delivery of safe, effective, and high-quality care for these patients.

Most of the current literature regarding care of people living with obesity while in hospital is based on clinical opinion rather than being informed by lived experience or scientific evidence. The aim of this study was to bridge this gap by exploring the lived experience of people with obesity admitted to hospital. The findings will inform future service improvement for people with obesity requiring hospital-based care related to any aspect of their health.

This study utilised a qualitative methodology and employed Interpretative Phenomenological Analysis (IPA) to explore the research question. IPA aims to explore ‘lived experience’ and how people make sense of it, via first person subjective accounts [10]. It is based on the assumption that human beings are “constantly engaged in the process of interpreting their experiences and such interpretations are necessary for them to reach an understanding of the events or experiences that mark their life” [11]. In healthcare, the lived service experience of consumers can be of great value in driving service improvement that is relevant to their needs, and inclusive of their perspectives.

The majority of participants were men (n = 6), and the mean age was 51 years (± 14, 25 – 73). The mean BMI (57.4) met the criteria for morbid obesity (greater than or equal to 40) [22] with the mean weight of participants was 158 kg (± 25.8, 109 - 194). The mean length of hospital admission for participants was 29.6 days, which exceeds the average length of stay of 5.3 days for emergency admissions to Australian public hospitals [23]. Reasons for admission were not specifically related to obesity, with the most common reason being complex orthopaedic issues (n = 3), followed by lower limb cellulitis (n = 2). Participant characteristics are provided in Table 2.

Three themes were identified within the data: 1) meeting physical care needs of people with obesity on hospital wards, 2) interpersonal interactions between patients and healthcare professionals, and 3) the psychosocial impact of living with obesity in the hospital setting. Notably, all participants initially indicated that their overall service experience was positive but were able to describe and elaborate on negative or challenging aspects as the discussion wore on, highlighting the benefit of in depth conversation.

The findings of this study captured lived experiences of people living with obesity during hospitalisation and provide critical new insights into their experiences. Our findings identified that the key themes for people living with obesity on hospital wards were meeting physical care needs, interpersonal interactions with healthcare professionals, and the psychosocial impact of being obese in the hospital setting. These data should be used to inform innovative care models, given the identified differences in priorities and perspectives between healthcare professionals and patients living with obesity [25]. The themes identified provide direction to drive service improvements in this patient cohort, who experience higher than average length of stay and currently report service experiences which are inappropriate to their needs and potentially damaging to their wellbeing.

A key priority for people living with obesity in hospital was timely provision of equipment to meet their personal needs, which has also been found in previous studies [26]. Planned approaches to ward transfers and systems to facilitate timely sourcing of equipment are needed to streamline this process and may require internal stock reviews or ready access to external suppliers. Previous research has also found patient comfort is compromised when specialised equipment is designed simply as scaled up versions of standard equipment [27]. Larger equipment is also often more expensive; however, the findings here emphasise the potential impact low-cost items (including simple assistive technology, gowns, and continence aids) can have on patient experience. Lack of adequate facilitators for mobility was another common experience, which may also contribute to negative experiences and poorer health outcomes. For example, delays to being able to sit out of bed in a suitable chair is in opposition to best practice inpatient care and increases the risk of hospital associated deconditioning [28]. This barrier also exacerbated a perceived loss of independence, causing a negative impact on health and wellbeing. The often-repeated recommendation of providing access to independently propelled electric wheelchairs reflects a desire by patients to self-manage their participation in meaningful activities whilst hospitalised. It also highlights a specific opportunity for improvement in patient experience and potentially medical outcomes. Additionally, infrastructure that supported best care for people with obesity clearly positively impacted on their lived experience of hospital admission. Previous literature suggests that the physical environment in healthcare settings should allow for a range of body types [29]. Without provision of accessible and supportive built environments, people living with obesity are unable to fully participate in care and may choose (as one participant did) to disengage from treatment completely. The design of hospital environment must therefore consider adequate circulation space, access options and the equipment to accommodate people with obesity in future hospital builds. Retrofitting existing infrastructure is another option but is more costly and often results in a less successful design outcome than universal design from the beginning [30].

Unsurprisingly, the theme of interpersonal interactions was also identified and highlighted negative experiences during hospitalisation. The critical influence of communication on patient experience was repeatedly highlighted as important by participants, who perceived a lack of empathy and feeling ignored. This builds on previous literature in primary care settings, which describe the negative experiences of people living with obesity accessing, or trying to access, healthcare [3]. These previous studies detail a lack of respect and compassion and use of inappropriate language by health care providers. Obesity is a stigmatised and gendered disease which can further impact the relationship between patients and healthcare professionals via implicit or explicit discrimination that impedes patient engagement with treatment [31]. It has been shown that obesity stigma and weight bias is endemic in healthcare settings [32]. Although negative interpersonal interactions described by our participants were not always specifically related to obesity, some data provided evidence of obesity stigma in the hospital setting. In addition, positive interpersonal interactions help people overcome difficult moments in stressful situations such as healthcare [33]. Previous research describes “moments of care” as short-lived, prosocial interpersonal interactions between healthcare consumers and medical staff which significantly contribute to improved experience [33]. This suggests the patient experience may be enhanced by generic cultural improvement which could include small and specific behaviour change such as positive facial expressions and introducing oneself by name. A focus on improving the quality of interpersonal interactions in the hospital setting, particularly though role modelling may assist in reducing discrimination. Healthcare professionals can be role models for tackling discrimination against people with obesity [34]. Teamwork is also critical in this patient cohort that often require specialised equipment and devices, a tailored ergonomic approach and multiple staff to meet care needs [26]. Therefore, supporting staff to develop skills to meaningfully engage with people with obesity may positively impact patient experience.

Obesity is known to be associated with a significant psychosocial burden [35]. This study demonstrated that hospitalisation had a substantial negative impact on emotional and mental wellbeing for people living with obesity. People reported feeling like a burden to staff who were providing care and identified stress related to delays in care delivery. Research has shown that staff perceive inpatients with obesity as passive participants in their care [36], however other studies have shown that people with obesity have a willingness to contribute to care provision that is often overlooked [37]. Of note, people living with obesity often have self-developed solutions to manage self-care that could be well utilised in the hospital setting [38]. Engagement of the patient is critical for patient centred care and should be prioritised by for healthcare professionals. This also presents a strategy to address the identified negative psychosocial impact. Some participants also identified that hospital admission led to self-reflection around weight gain and the subsequent impact on health and wellbeing. They identified their admission was an opportunity to address weight loss and those that did receive support reported this as a positive experience. However, it is not known whether all participants received weight loss support. It is known that healthcare professionals can feel unprepared to provide support with weight loss [34]. This research provides further support for previous suggestions to provide healthcare professionals with specific education to both reduce weight bias and obesity stigma and enable them to support patients in the treatment of obesity and its associated complexities [37]. If staff can build trust through good communication and rapport with people living with obesity when they are in hospital, we may be able to better help engage from a psychosocial perspective to help increase capacity for self-management of their weight. Further research into design of training models to achieve effective health professional education is required.

This study provides a robust investigation of this topic not otherwise represented in the current literature, using a rigorous methodological approach. The sample is representative of hospitalised people with obesity, and includes diverse genders, ages, and reasons for admission. Most participants were morbidly obese with a BMI of greater than or equal to 40, however BMI could not be calculated for two participants due to unknown height. While recruitment targeted acutely admitted inpatients, their experiences included aspects of their entire patient journey, including acute and subacute settings, and post-hospital discharge services. The participants were recruited from a hospital setting with limited specifically designed rooms for people with obesity, and significant infrastructure differences from other sites within the healthcare service. Despite the limitation of being restricted to one public health service, this study therefore included experiences of contrasting settings. The pre-existing initiatives around care for people with obesity at the organisation provided an avenue for recruitment and may also be a platform to implement changes suggested to improve patient experience and ultimately care outcomes. Interviews were guided by a specially designed interview schedule informed by previous research. As such, participant responses and themes identified are likely to align with existing evidence, however this may have restricted the breadth of information gathered.

This study explored the lived experience of people with obesity admitted to a metropolitan public healthcare service. Findings demonstrate that meeting physical care needs, enhancing interpersonal interactions and understanding and addressing psychosocial impact most significantly influence patient experience. Timely provision of equipment to meet the specialised needs of these patients and consideration of the design of infrastructure was most important, hence should be a key consideration in the redesign of models of care and infrastructure. An emphasis on the basic principles of care provision, coupled with improved understanding of specific needs for people with obesity are also suggested. Role modelling to address obesity stigma and weight bias and enabling healthcare professionals to better support weight loss are likely to positively influence patient experience. The use of consumer engagement strategies would prove beneficial to the development of obesity specific models of care, to ensure better experiences and outcomes for all patients with obesity.