Introduction
A recent study of primary healthcare services utilization found that patients with obesity had almost one and a half times more visits with their primary care physician than patients without obesity (Twells et al., Reference Twells, Bridger, Knight, Alaghenhbandan and Barrett2012). Utilization rates provide information about the amount of contact a patient has with their physician; however, these do not provide information about the quality of these visits. Such information is needed to better understand factors that facilitate engagement in primary health care. Patient engagement, grounded by the principles of patient-centered care, is characterized by promoting patient involvement in decision making, providing sufficient time to discuss issues related to promoting health or treating a health condition and providing opportunities to ask questions about treatment recommendations (Health Council of Canada, 2012). Patient outcomes associated with engagement in primary health care include increased participation in health-promoting behaviors, such as disease prevention and screening, improved self-efficacy for self-management of health conditions (Hibbard et al., Reference Hibbard, Stockard, Mahoney and Tusler2004; Coulter and Ellins, Reference Coulter and Ellins2007) and improved satisfaction with care (Osborn and Squires, Reference Osborn and Squires2012).
The physician–patient relationship can impact a patient's engagement in primary health care. Research in the area of bias, discrimination and obesity found that healthcare providers, even those who work in the area of obesity, reported negative attitudes toward patients with obesity (Puhl and Brownell, Reference Puhl and Brownell2001; Schwartz et al., Reference Schwartz, Chamblis, Brownell, Blair and Billington2003; Brown et al., Reference Brown, Thompson, Tod and Jones2006; Forhan and Law, Reference Forhan and Law2009). A recent study of physicians providing primary care to patients with obesity reported an inverse relationship between a patient's body mass and the respect of physicians toward their patients (Huizinga et al., Reference Huizinga, Cooper, Bleich, Clark and Beach2009). Another study of over 620 primary care physicians found that over 50% of participants viewed patients with obesity as awkward and non-compliant with one-third of the sample further characterizing these patients as lazy and weak with respect to will power (Foster et al., Reference Foster, Wadden, Makris, Davidson, Sanderson, Allison and Kessler2003).
In addition to, and perhaps enhanced by weight bias, patients with obesity report barriers in the physical environment that limit access to health care. These include seating in the waiting areas, poorly fitting gowns and blood pressure cuffs (Forhan et al., Reference Forhan, Law, Vrkljan and Taylor2010). Such barriers are cited by patients with obesity as reasons for delaying or forgoing preventative services including screenings for breast, cervical and colorectal cancers (Drury and Lois, Reference Drury and Lois2002; Reidpath et al., Reference Reidpath, Crawford, Tilgner and Gibbons2002; Mitchell et al., Reference Mitchell, Padwal, Chuck and Klarenbach2008).
Inadequate knowledge about obesity care and management has been identified as another barrier that caused patients to be reluctant to seek care or to follow through with recommendations made by practitioners (Brown et al., Reference Brown, Thompson, Tod and Jones2006). A report published by the Health Council of Canada (2012) provided tips for physicians on how to redesign their service around patient needs and for patients on how to be more involved in their care. These universal strategies may benefit patients who resemble the general patient population but it is not known whether such strategies will meet the needs of patients with obesity.
No studies to date have explored factors that contribute to engagement in primary health care for patients with obesity from the patient perspective. A better understanding of the primary healthcare experience for these patients is needed particularly with the increase in prevalence of obesity and the demand for primary healthcare services.
The purpose of this qualitative study was to understand patients’ perceptions of the barriers and facilitators of engagement in their health care in a primary care setting.
Methods
The Hamilton Health Sciences and McMaster University Research Ethics Board approved this study. Adult patients with a minimum body mass index (BMI) of 30 kg/m2, who were registered with an academic family health team, were invited to participate in an interview through posters located in waiting and patient treatment areas of the clinic. The family health team is located in a large city in Ontario, Canada and is associated with two large teaching hospitals. The core healthcare team consists of a family physician, family medicine residents and a nurse practitioner. A registered dietitian and occupational therapist are also available for consultations. Of the twenty patients who volunteered to participate in the study, 15 patients agreed to be contacted for an interview. One of these patients cancelled the interview due to an illness in the family and three people did not return calls from the researcher to schedule an interview leaving a final sample of 11 participants. Participants completed a semi-structured interview focusing on their perceptions of the barriers and facilitators to patient engagement. The main questions asked of participants were: (1) Please describe what it is like to be a patient with obesity at this clinic. (2) What is it about this clinic that keeps you coming back? (3) What, if any, factors at this clinic interfere with you getting the care you want or think you need? A study investigator (MF) who was not affiliated with the family health team conducted the interviews. Parking expenses or cost associated with public transit was provided.
Interviews were audiotaped and transcribed verbatim. The experiences of being a patient with obesity in primary health care were analyzed using conventional content analysis (Hsieh and Shannon, Reference Hsieh and Shannon2005). The analysis began with the independent review and coding of three transcripts by each of the investigators. Then the investigators met to develop an initial coding scheme. The investigators used the coding scheme to independently code two more transcripts. Following review of these transcripts, the investigators developed a final coding scheme and the six remaining transcripts were analyzed independently. The investigators met on two occasions to reconcile any differences in coding. An iterative analysis occurred and recruitment continued until saturation of the data had been reached. A final step in the analysis was a review of the codes for the purpose of identifying themes related to patients’ perceptions of factors that contributed to their engagement in primary health care.
Results
Eight women and two men participated in face-to-face interviews and one man participated in a telephone interview. Interviews averaged 33 min (range 21–49 min). Participants had a mean age of 44 years (range 19–64-year old) and a mean BMI of 40.8 kg/m2 (range 30–45 kg/m2).
The overarching theme of engagement in primary health care included sub-themes with content labeled as facilitators or barriers to engagement in primary health care. Themes and illustrative participant quotes are summarized in Table 1.
Table 1 Summary of themes and corresponding participant quotes
Facilitators to engagement
Availability of resources
The availability of resources for the management of obesity was identified as important for engagement of patients in their primary health care. These included resources specific to the management of obesity-related health concerns and resources aimed at helping individuals to lose weight.
Importance of the relationship
Participants described several factors that promoted the sharing of information with a provider including trust and respect. Participants stated they were more likely to follow through with treatment recommendations when they had developed trust with their healthcare provider. As in many large family health teams, patients do not always see the same provider at each visit. Having repeated contact and interaction with the same provider was identified as important. The length of time available from the provider was identified as central to establishing a relationship and thought to demonstrate concern for the participant.
Meaningful communication
Participants described helpful ways in which the provider communicated with them about their overall health and obesity. Providers who explained the connection between specific health concerns and body weight in a way that was meaningful to patients provided motivation for participants to engage in health behavior change.
Barriers to engagement
Feeling judged
Participants described carrying pre-conceived thoughts about health providers’ beliefs and attitudes toward persons with obesity with them to their visits. Although these thoughts were not always directly triggered by an experience with the family health team, the thoughts accompanied the participants to every clinical visit. A number of participants described believing that they knew what the provider was thinking even though these thoughts were not validated by what the provider said to them. These feelings had a negative impact on engagement in primary health care by limiting the information they would share with the healthcare provider. This included reluctance to stating the purpose of their visit or having their body weight measured or recorded. Participants also described a belief that their physician would attribute all of their health concerns solely to their obesity. This was identified as a barrier to exploring any factors beyond obesity that may be the cause of their health concern.
Lack of privacy
Privacy was perceived as an important component of care particularly when providers were gathering information about a patient's weight. Participants described feeling self-conscious and embarrassed when the scale was in an open area. Another privacy-related concern was the requirement to identify the purpose of the visit when phoning to make an appointment. Although participants understood the importance of such information in order to book adequate time for the visit and to enter a billing code, they described being reluctant to disclose to the booking agent that they wanted to discuss their obesity with their provider.
Poor communication
Aspects of communication identified as barriers to engagement in primary health care included use of language that implied a level of understanding by providers about living with obesity. Participants described feeling as though providers assumed what it was like living with obesity and this lead to a reluctance to share information. Participants described feeling as if their obesity was ignored as a health concern and that this was an indication that it was not an important issue to be addressed. The way in which a care provider reacted in situations where medical equipment such as blood pressure cuffs did not fit a patient also created a barrier to patient engagement.
Limited care provider knowledge about obesity
Participants described an overall sense that most physicians did not have the training or knowledge to work with patients who have obesity despite the fact that it may be raised as a health concern.
Discussion
This is the first study in which patients with obesity in a primary care setting were asked directly about their experiences with general care and not focused on weight loss treatment. Participants identified trust, respect, contact with the same provider and knowledge about their health status in the context of their daily lives as key elements to feeling engaged in their care. Such expectations are essential factors for patient-centered care and are not unique to patients with obesity (Belle Brown et al., Reference Belle Brown, Stewart, Weston and Freeman2003).
Disparity in primary healthcare experiences occurred when participants perceived that providers had pre-conceived notions about patients with obesity and attributed all health concerns to their body weight. Participants wanted to avoid being weighed or sharing their weight with the provider in an effort to shift the focus away from body weight and onto the exploration of specific health concerns for which the visit was scheduled. Participants who wanted to focus on obesity-related concerns perceived a lack of knowledge on behalf of the provider about obesity and its treatment. This finding is consistent with studies that found physicians acknowledged their limited competence and/or interest in addressing obesity in primary healthcare settings (Leverence et al., Reference Leverence, Williams, Sussman and Crabtree2007; Tham and Young, Reference Tham and Young2008) and by patients with obesity who reported being unsatisfied with obesity specific care provided by their primary care physician (Wadden et al., Reference Wadden, Anderson, Foster, Bennett, Steinberg and Sarwer2000). Sensitivity with respect to gathering information about a patient's body weight or having equipment that fits an obese body was identified in this study as a unique issue. Recommendations to address such issues have been made in a guide for bariatric practitioners but could also be considered for use by primary healthcare practitioners (Freedhoff and Sharma, Reference Freedhoff and Sharma2010).
Limitations
Some of the positive findings in this study may result from a volunteer bias. Those patients who have had negative primary care experiences may not access their primary care providers or volunteer to participate in the study. This study took place in a family practice center in which medical residents may have provided direct patient care under the supervision of a primary care physician. We did not collect data on the role of the care provider and duration of the appointment. It is possible that contact with the medical resident resulted in longer appointment times due to consultations with physician supervisors and could have influenced patient perceptions of care. As in all qualitative studies, the intent is not to generalize results from this to all patients with obesity seeking primary health care.
Conclusion
This study provides information about the conditions necessary for patients with obesity to engage in primary health care. Although expectations for patient-centered care are not unique to this population, sensitivity and privacy is required when gathering information about a person's body weight. Having medical equipment designed for obese bodies is recommended for patients to feel comfortable and valued in the primary care environment. Future research is needed to explore the extent to which interventions aimed to promote patient-centered care meet the needs of patients with obesity. Knowledge about and uptake of effective strategies to enable engagement in primary health care for patients with obesity has the potential to contribute to health promotion and chronic disease prevention for this high-risk population.
Acknowledgments
This research was supported by the Canadian Institutes of Health Research (CIHR) Strategic Training Program-Transdisciplinary Understanding and Training on Research-Primary Health Care (TUTOR-PHC).
