Bariatric surgery stigma from the perspective of patients: A scoping review.

AIMS: To explore the experiences and consequences of bariatric surgery stigma from the perspective of bariatric surgery patients and to identify knowledge gaps in the literature. DESIGN: A scoping review. DATA SOURCES: Studies published between December 2002 and January 2022 were identified from the following databases: PubMed, Web of Science, PsycINFO and MEDLINE. REVIEW METHODS: We screened 3092 records and included 28 studies. Findings were grouped thematically using the health stigma discrimination framework. RESULTS: Patients experienced several types of stigmas, including perceived, experienced, anticipated and internalized stigma, related to undergoing bariatric surgery. Patients were confronted with negative comments and judgement from others when they disclosed their decision to have surgery or when they revealed that they had undergone surgery. These experiences led to conflicts in the decision-making process, such as delaying the choice for surgery, seeking surgery abroad or opting out. Patients who internalized stigma often reported feelings of shame and embarrassment for choosing surgery and felt the need for secrecy or selective disclosure. Stigma experiences were influenced by gender and differed between different subgroups of patients. CONCLUSION: The stigma surrounding bariatric surgery has detrimental consequences for eligible individuals and bariatric surgery patients. However, the evidence from patients' perspective remains limited. More research into patient's experiences is needed to improve patient care and further educate healthcare professionals. In addition, to better understand the nature and implications of bariatric surgery stigma, future research should be founded on stigma theories and distinguish between the different types of stigmas. IMPACT: This scoping review contributes to a better understanding of the implications the stigma surrounding bariatric surgery has for bariatric surgery patients before and after surgery. The knowledge generated by this review can inform improvements in the education and management of people living with obesity and bariatric surgery patients. REPORTING METHOD: The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. PROTOCOL REGISTRATION: A protocol was not registered for this scoping review.

The positive impact of a care-physical activity initiative for people with a low socioeconomic status on health, quality of life and societal participation: a mixed-methods study.

BACKGROUND: Overweight and obesity rates are increasing worldwide, particularly among people with a low socioeconomic status (SES). Care-physical activity (care-PA) initiatives may improve participants' lifestyles and thereby lower overweight and obesity rates. A two-year care-PA initiative specifically developed for citizens with a low SES, X-Fittt 2.0, was offered free of charge to participants, and included 12 weeks of intensive guidance and sports sessions, and 21 months of aftercare. Here, we study the impact of X-Fittt 2.0 on health, quality of life (QoL) and societal participation using a mixed-methods design. METHODS: Questionnaires and body measurements were taken from 208 participants at the start of X-Fittt 2.0 (t0) and after 12 weeks (t1), one year (t2) and two to three years (t3). We also held 17 group discussions (t1, n = 71) and 68 semi-structured interviews (t2 and t3). Continuous variables were analysed using a linear mixed-model analysis (corrected for gender, age at t0, height, education level and employment status at the different time points), while we used descriptive statistics for the categorical variables. Qualitative data were analysed using a thematic analysis. RESULTS: Body weight was significantly lower at all three post-initiative time points compared with the baseline, with a maximum of 3.8 kg difference at t2. Body Mass Index, waist circumference, blood pressure and self-perceived health only significantly improved during the first 12 weeks. A positive trend regarding paid work was observed, while social visits decreased. The latter might be explained by the COVID-19 pandemic, as lockdowns limited social life. Furthermore, participants reported increased PA (including sports) and a few stopped smoking or drinking alcohol. Participants mentioned feeling healthier, fitter and more energetic. Additionally, participants' self-esteem and stress levels improved, stimulating them to become more socially active. However, the participants also mentioned barriers to being physically active, such as a lack of money or time, or physical or mental health problems. CONCLUSIONS: X-Fittt 2.0 improved the health, QoL and societal participation of the participants. Future initiatives should take into account the aforementioned barriers, and consider a longer intervention period for more sustainable results. More complete data are needed to confirm the findings.

Care-physical activity initiatives in the neighbourhood: study protocol for mixed-methods research on participation, effective elements, impact, and funding methods.

BACKGROUND: In the Netherlands, people with a low socioeconomic status (SES) live approximately 6 years less and are less engaged in physical activity (PA) than high SES citizens. This contributes to the persistent health inequalities between low and high SES citizens. Care-PA initiatives are deemed effective for stimulating PA and improving health and participation among peoples with a low SES. In those initiatives, multiple sectors (e.g. sports, health insurers, municipalities) collaborate to connect primary care and PA at neighbourhood level. This study focuses on two Dutch municipalities that aim to invest in Health in All Policies (HiAP) and care-PA initiatives to improve the health of people with low SES. The aim is to gain insight into (1) the short-term (3 months) and long-term (1 year) outcomes of participating in care-PA initiatives for low SES citizens in terms of health, quality of life, and societal participation, (2) the effective elements that contribute to these outcomes, (3) the direct and perceived societal costs and benefits of care-PA initiatives, and (4) alternative ways to fund integrated care, prevention, and care-PA initiatives at neighbourhood level. METHODS: The study will be built on a mixed-methods design guided by action research to continuously facilitate participatory processes and practical solutions. To assess outcomes, body measurements and questionnaires will be used as part of a pre-test/post-test design. Focus groups and interviews will be conducted to gain an in-depth understanding of outcomes and action elements. Action elements will be explored by using multiple tools: concept mapping, the logic model, and capacity mapping. Direct and perceived societal costs will be measured by administrative data from healthcare insurers (before-after design) and the effectiveness arena. An alternative funding model will be identified based on literature study, expert meetings, and municipal workshops. DISCUSSION: Initiatives addressing multiple factors at different levels in an integral way are a challenge for evaluation. Multi-methods and tools are required, and data need to be interpreted comprehensively in order to contribute to a contextual insight into what works and why in relation to HiAP and care-PA initiatives.

Exercise self-identity: interactions with social comparison and exercise behaviour.

Possible interactions among exercise self-identity, social comparison and exercise behaviour were explored in a sample of 417 undergraduate students (mean age = 21.5, SD = 3.0; 73% female). Two models were examined using self-report data; (1) a mediation model which proposed an association between social comparison and exercise behaviour mediated by exercise self-identity and (2) a moderation model proposing an association between exercise behaviour and self-identity moderated by social comparison. Results of the mediation analyses revealed partial mediation of the social comparison--exercise behaviour relationship by self-identity in females. Results of the moderation analyses revealed in males a significant interaction of social comparison with exercise behaviour in the prediction of self-identity - the positive association between exercise behaviour and exercise self-identity showed only significant among male students who believed to exercise equally much or less than peers. Possible explanations and implications for exercise promotion are discussed.

Stigma Toward Bariatric Surgery in the Netherlands, France, and the United Kingdom: Protocol for a Cross-cultural Mixed Methods Study.

BACKGROUND: Bariatric surgery is an effective procedure for the treatment of obesity. Despite this, only 0.1% to 2% of eligible individuals undergo surgery worldwide. The stigma surrounding surgery might be a reason for this. Thus far, no research has systematically studied the nature and implications of bariatric surgery stigma. The limited studies on bariatric surgery stigma are often conducted from the perspective of the public or health care professions and either use small and nonrepresentative samples or fail to capture the full essence and implications of the stigma altogether, including attitudes toward patients and perpetrators of the stigma. In addition, studies from patients' perspectives are limited and tend to address bariatric surgery stigma superficially or implicitly. Finally, the extent to which cultural factors shape and facilitate this stigma and the experiences of patients have not yet been researched. OBJECTIVE: This study aimed to explore the perceptions, experiences, and consequences of bariatric surgery stigma from the perspective of the public, health care professionals, and patients before and after bariatric surgery. Furthermore, although the concept of stigma is universal, every society has specific cultural norms and values that define acceptable attributes and behaviors for its members. Therefore, this study also aimed to explore the extent to which cultural factors influence bariatric surgery stigma by comparing the Netherlands, France, and the United Kingdom. METHODS: This paper describes the protocol for a multiphase mixed methods research design. In the first part, we will conduct a scoping review to determine the current knowledge on bariatric surgery stigma and identify knowledge gaps. In the second part, semistructured interviews among patients before and after bariatric surgery will be conducted to explore their experiences and consequences of bariatric surgery stigma. In the third part, surveys will be conducted among both the public and health care professionals to determine the prevalence, nature, and impact of bariatric surgery stigma. Surveys and interviews will be conducted in the Netherlands, France, and the United Kingdom. Finally, data integration will be conducted at the interpretation and reporting levels. RESULTS: The study began in September 2020 and will continue through September 2025. With the results of the review, we will create an overview of the current knowledge regarding bariatric surgery stigma from patients' perspectives. Qualitative data will provide insights into patients' experiences with bariatric surgery stigma. Quantitative data will provide information related to the prevalence and nature of bariatric surgery stigma from the perspective of the public and health care professionals. Both qualitative and quantitative data will be compared for each country. CONCLUSIONS: The findings from this study will lead to new insights that can be used to develop strategies to reduce bariatric surgery stigma and improve access, use, and outcomes of bariatric surgery. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/36753.

Citizen preferences regarding the public funding of projects promoting a healthy body weight among people with a low income.

Overweight and obesity are a growing problem, especially among people with a low income. Policymakers aspire to alleviate this problem by implementing publicly funded projects. This study has three aims: 1) to explore citizen preferences regarding the public funding of projects promoting a healthy body weight among people with a low income, 2) to identify whether such preferences differ between citizens with a low income and those with a higher income, and 3) to identify the reasons underlying these preferences. We conducted a Participatory Value Evaluation (PVE) among 1053 Dutch citizens to achieve these aims. In an online choice experiment, respondents were asked to advise on the implementation of eight different projects that encourage a healthy body weight among citizens with a low income, with a total resource constraint of 100,000 euros. The projects were 1) lifestyle coaching including sports, 2) lifestyle coaching without sports, 3) local sports coach, 4) fruit and vegetable boxes, 5) bariatric surgery, 6) improving the living environment, 7) courses on healthy lifestyles, and 8) sports vouchers. We used the "Multiple Discrete-Continuous Extreme Value" model to estimate the preferences of respondents towards these eight projects. Fruit and vegetable boxes and sports vouchers were the most popular projects, while bariatric surgery was least popular. Respondents with a low income tended to spend less of the budget than respondents with a higher income. Respondent arguments for the choices they made were qualitatively analysed using inductive content analysis. They often mentioned the value judgements 'importance', 'healthiness' and 'usefulness', as well as project costs and efficacy, as reasons for their decisions. Policymakers could use the results to ensure their decisions on the allocation of public funding to projects that encourage a healthy weight among people with a low income are aligned with citizen preferences.

Effective elements of care-physical activity initiatives for adults with a low socioeconomic status: A concept mapping study with health promotion experts.

In care-physical activity (care-PA) initiatives, primary care and sports are combined to stimulate PA among adults at risk of lifestyle related diseases. Preliminary results from Dutch care-PA initiatives for adults with a low socioeconomic status (SES) indicate a decrease in participants' body weight and an improved quality of life, however, the elements that make these initiatives successful are yet to be identified. In total, 19 Dutch health promotion experts participated in our concept mapping (CM) of the effective elements of care-PA initiatives for adults with a low SES. The experts identified 111 effective elements of these initiatives, which were grouped into 11 clusters, focusing on: 1) approaching participants within the care-PA initiative, 2) barriers experienced throughout the initiative, 3) long-term implementation, 4) customizing the care-PA initiative to the target population, 5) social support, 6) structure and guidance, 7) the professionals within the care-PA initiative, 8) the accessibility of the care-PA initiative, 9) targeted behaviour and progression, 10) recruitment and administration, and 11) intersectoral collaboration. CM was useful for creating a valuable overview of these effective elements. Our results could be used to improve the development and implementation of future care-PA initiatives for adults with a low SES.

The Association between leisure time physical activity and smoking in adolescence: an examination of potential mediating and moderating factors.

BACKGROUND: Although physical activity has been associated negatively with smoking in adolescence, the association is not well understood. PURPOSE: This study examines the relationship between adolescents' leisure time physical activity and smoking behavior, while considering BMI, weight concern, sense of coherence, and physically active self-concept as potential mediating and moderating variables. METHOD: Data were obtained through a postal survey among 3,940 Danes aged 16 to 20. Bivariate and multivariate logistic regressions were performed to identify significant associations as well as mediating and moderating effects. RESULTS: In the bivariate model, leisure time physical activity was negatively associated with smoking; adolescents who were active at least one hour per week were up to half as likely to smoke as inactive adolescents. In the adjusted model, however, the association disappeared. Further analyses revealed that physically active self-concept acted both as a mediator and as a moderator of the studied relationship. CONCLUSION: The data suggest that participation in leisure time physical activity is indeed inversely associated with adolescent smoking, but only when physical activity is perceived as an important part of the self. Hence, interventions designed to promote physical activity among youth may also aim to boost physically active self-concepts.

Youth crowds and substance use: the impact of perceived group norm and multiple group identification.

The impact of group identity on adolescent tobacco, alcohol, and marijuana use was examined through a postal survey. The study included adolescents who identified with 1 subgroup (n = 1425) as well as adolescents who identified with 2 (n = 895) or 3 (n = 339) subgroups. The results showed that identification with the pop, skate/hip-hop, techno, and hippie subgroups was associated with higher risks of substance use, whereas identification with the sporty, quiet, computer nerd, and religious subgroups was associated with lower risks. Perceived group norm mediated the group identity-substance use relationship. Furthermore, identification with multiple groups with corresponding norm increased norm-consistent substance use, whereas identification with multiple groups with opposing norms reduced normative behavior. Implications for health promotion are discussed.

Co-ordinated action between youth-care and sports: facilitators and barriers.

In the Netherlands, youth-care organisations and community sports clubs are collaborating to increase socially vulnerable youths' participation in sport. This is rooted in the idea that sports clubs are settings for youth development. As not much is known about co-ordinated action involving professional care organisations and community sports clubs, this study aims to generate insight into facilitators of and barriers to successful co-ordinated action between these two organisations. A cross-sectional study was conducted using in-depth semi-structured qualitative interview data. In total, 23 interviews were held at five locations where co-ordinated action between youth-care and sports takes place. Interviewees were youth-care workers, representatives from community sports clubs, and Care Sport Connectors who were assigned to encourage and manage the co-ordinated action. Using inductive coding procedures, this study shows that existing and good relationships, a boundary spanner, care workers' attitudes, knowledge and competences of the participants, organisational policies and ambitions, and some elements external to the co-ordinated action were reported to be facilitators or barriers. In addition, the participants reported that the different facilitators and barriers influenced the success of the co-ordinated action at different stages of the co-ordinated action. Future research is recommended to further explore the role of boundary spanners in co-ordinated action involving social care organisations and community sports clubs, and to identify what external elements (e.g. events, processes, national policies) are turning points in the formation, implementation and continuation of such co-ordinated action.

A Systematic Review of Life Skill Development Through Sports Programs Serving Socially Vulnerable Youth.

PURPOSE: Despite the strong belief in sports programs as a setting in which socially vulnerable youth can develop life skills, no overview exists of life skill development in sports programs serving this youth group. Therefore, the present systematic review provides an overview of the evidence on life skill development in sports programs serving socially vulnerable youth and, insofar as it was investigated in the included studies, of the conditions conducive to life skill development in these sports programs. METHOD: Potentially relevant studies published during 1990 to 2014 were identified by a search in 7 electronic databases. The search combined terms relating to (a) sport, (b) youth AND socially vulnerable, and (c) life skills. Eighteen of the 2,076 unique studies met the inclusion criteria. RESULTS: Each included study reported that at least 1 life skill improved in youth who participated in the studied sports program. Improvements in cognitive and social life skills were more frequently reported than were improvements in emotional life skills. Only a few of the included studies investigated the conditions in the studied sports programs that made these programs conducive to life skill development. CONCLUSIONS: Sports programs have the potential to make a difference in the life skill development of socially vulnerable youth. This conclusion needs to be treated with some caution, because the studies experienced many challenges in reducing the risk for bias. Several alternative research strategies are suggested for future studies in this field.

How norms work: self-identification, attitude, and self-efficacy mediate the relation between descriptive social norms and vegetable intake.

BACKGROUND: The current studies aim to show that descriptive social norms influence vegetable intake and to investigate three potentially underlying processes (self-identification, attitude, and self-efficacy). METHODS: In two studies, descriptive social norms regarding vegetable intake were manipulated (majority vs. minority norm). Study 1 investigated both the relation between baseline vegetable intake and self-identification, attitude, and self-efficacy, as well as the effect of the norm manipulation on vegetable intake over a one-week period. Study 2 investigated potential mediation of the effect of the manipulation on vegetable intake intentions through self-identification, attitude, and self-efficacy. RESULTS: Study 1 showed that the proposed mediators were related to a baseline measure of vegetable intake. Moreover, in participants identifying strongly with the norm referent group, majority norms led to higher vegetable consumption than minority norms. Study 2 showed that the direct effect of the social norm manipulation on vegetable intake intentions was partly mediated by self-identification, attitude, and self-efficacy. CONCLUSIONS: These studies shed first light on processes underlying the effect of descriptive social norms on health behavior. A norm describing the behavior of a salient social group leads people to identify more with, have more positive attitudes toward, and feel more self-efficacious regarding that behavior.