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Patients’ bariatric expectations

Patients’ expectations of bariatric surgery ‘unrealistic’

The study used a modified photovoice methodology incorporating photography, semi-structured individual interviews and framework analysis techniques
Many participants in this study emphasised their fear of being refused what they perceived to be life-changing surgery if they did not change their behaviour or manage comorbidities, and they were determined to show the commitment required.

A study by researchers from Sheffield, UK, has reported the expectations and experiences of patients in England who have been referred for bariatric surgery. They found that there are several factors that influence patients’ expectations of surgery, although “these expectations were not always realistic.” The paper, ‘Expectations and patients’ experiences of obesity prior to bariatric surgery: a qualitative study’, published in the journal BMJ Open, said that the study demonstrates the importance of weight management services assessing and modifying patient's expectations as appropriate.

The study team from Sheffield Hallam University and the University of Sheffield, sought to understand the experiences and expectations of people seeking bariatric surgery in England and identify implications for behavioural and self-management interventions. The aim was to help inform the commissioning and delivery of weight management services that provide the required preparation for patients prior to bariatric surgery. The study was conducted in areas served by two hospital-based, bariatric surgery, MDTs in the north of England from August 2012 to April 2013.

They recruited 18 patients (14 females), 16 had been to tier 3 community obesity services with access to dieticians, obesity nurses, talking therapists and general practitioners (GP). Three others were referred directly from a primary care physician, as their area did not have a tier 3 service.

The study used a modified photovoice methodology incorporating photography, semi-structured individual interviews and framework analysis techniques. According to the authors, “Photovoice is a participative research approach traditionally used in a community context where participants take photographs to illustrate their experiences of the issue of concern and the meanings they hold for participants.”

The photovoice tasks and interview schedule were developed through consultation with the MDTs, patient and public involvement with previous bariatric surgery patients, and relevant literature. Photovoice tasks were given to participants prior to the interviews. Participants were given prompts on what the photographs could include such as exploring life as an obese person, the decision to be referred for the surgery, preparation for surgery and expectations of how life will change after the surgery. The resultant photographs were used as prompts in the interview.

Results

The findings were reported under three broad headings: the negative experience of obesity, experience of weight management services, and expectations of normality.

The combination of photographic and interview data revealed how profound the impact of obesity was on the participant’s emotional well-being and quality of life. For some people, this was so marked that they described their life as not worth living and surgery was considered by all participants to be the last resort. Over half the participants said that without surgery they may as well be dead or would not have long left to live.

Participants who suffered from weight-related comorbidities that required multiple medications found this polypharmacy burdensome and constricting, and also impaired their quality of life.

Employed participants described work as having a positive effect on self-esteem, in comparison unemployed participants described how their weight and associated poor health prevented them applying for, or staying at work, further reducing their self-esteem.

Participants described how family members did not understand their position and appeared to judge or blame them for their obesity and related health problems. Their families did not understand their weight struggles, and viewed the surgery as an easy or soft option. Prior to being referred to specialist obesity services, participants identified that healthcare professionals had also been judgemental regarding their weight. This lack of understanding from the healthcare profession and of those closest to them meant that participants felt increasingly marginalised from networks they regarded as their support.

Interestingly, the researcher found that once patients had realised that funded surgery was a possibility, they became fixed on the notion of it as the only solution to their obesity. All participants who attended tier 3 weight management services commented that they were delivered in a non-judgemental way. This compared favourably with participants’ contact with other health professionals in other settings where they recalled feeling blamed because of their obesity and related health conditions.

Many participants in this study emphasised their fear of being refused what they perceived to be life-changing surgery if they did not change their behaviour or manage comorbidities, and they were determined to show the commitment required.

Unrealistic expectations of surgery were reported by all participants including improved health and an eradication or reduction in comorbidities, and improved relationship with health professionals.

Overall, the study:

  • Supports previous findings in terms of the extent of bariatric surgery patients’ psychological and physical morbidity.
  • Showed how the impacts of obesity play out in everyday lives, creating low self-esteem, social avoidance and poor quality of life prior to different types of bariatric surgery, thereby exacerbating unrealistic aspirations for postoperative normality.
  • The majority of the participants rejected the notion that excess skin would be a problem for them and did not anticipate that excess skin would obstruct their journey to ‘normality’.

The outcomes also indicated that some participants saw surgery as a tool to change their eating behaviour rather than relying on their will power, suggesting a naivety regarding postoperative lifestyle change and a rejection by the patient that they need to change their eating behaviours post-surgery. Furthermore, the study also showed that it was important that patient are given the opportunity to identify and access the support they require to manage expectations, so they can identify factors that may impede progress, and access support in maintaining healthy eating behaviour.

“The importance of providing behaviour change and self-management support is also emphasised, and this support needs to take into account the impact of stigmatisation and shame if positive outcomes are to be maximised following surgery,” the paper concludes. “Future research examining post-surgery will be useful to determine the extent to which expectations of the procedure and future life are met, and to develop and evaluate the required interventions.”

To access this paper, please click here

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