INTRODUCTION
Despite being at higher risk for chronic disorders, the South Asian population remains largely under-represented in clinical and applied health research or service design,1,2 and is less likely to access or be referred to relevant services compared with the white population.3 This adds to the multiple disadvantages faced by some ethnic minority communities.4
Mainstream research practices that elicit the participation of the majority population can sometimes exclude minority populations because the nature of the methods used are not always culturally appropriate.5 Given the prevalence and consequences of overweight/obesity in the South Asian population in the UK, it is important to identify strategies for raising the issue of overweight/obesity with this group, although there is little evidence on raising this sensitive issue with patients generally.
Patient and public involvement
The role of the public and patients in research and service redesign as co-producers of health has been highlighted, but descriptions and discussions of the processes are often limited.6,7 Studies have shown that using the appropriate approaches can aid participation and involvement of different communities8,9 in order to inform healthcare services, research, policies, and practice.
From the patient’s perspective, fear of obesity-related stigma by others including healthcare professionals (HCPs) and previous experience of obesity-related discrimination10,11 may result in people with weight problems failing to seek health care.12 Furthermore, a mismatch between how healthcare professionals and patients make sense of the causes, consequences, and solutions of overweight and obesity13 will lead to barriers in communication. For this reason, appropriately developed public and patient involvement (PPI) activities as a method of research are required for seldom heard groups.14
Therefore, it is especially important that when the issue is raised with people that societal prejudices are not reaffirmed, and that raising the issue has the desired outcome where the person is receptive and positively engaged. To address these fears, we carried out a PPI activity in Birmingham, UK to explore with representatives two key aspects with respect to the South Asian population. First, to explore who should raise the issue of overweight/obesity with South Asian people, and secondly, how it should be raised.
PROCESS
This work was conducted as the PPI14 element in preparation for a study to develop interventions to address overweight/obesity among the South Asian population and to develop services best suited to promote uptake. The feedback on which this article is based was obtained from a total of 24 South Asian PPI representatives, who took part in three discussion group sessions in Birmingham to identify and discuss the factors that need to be taken into account when developing strategy.
EVIDENCE COLLATED FROM PPI DISCUSSION GROUPS
GPs: responsibility, relationship, and status
While representatives acknowledged the role of family and community in raising the issue of excess weight, there was a consensus that GPs are the most appropriate HCPs to raise the issue. GPs were considered the most important first point of contact for people looking for health-related advice and were in a position to make referrals to other services that people would otherwise be unable to access. The patient–GP relationship was also perceived as significant if it was underpinned by mutual respect and cultural sensitivity, because it was more likely to lead to a productive discussion either initiated by the GP or by the patient. A strong relationship with GPs was often associated with more frequent visits and familiarity (Box 1 [a]). However, overly informal approaches were viewed with suspicion as they threatened the professional credibility of both the GP and any information conveyed.15
PPI session results: themes and comments
| a) GPs | |
| Responsibility |
|
| Relationship |
|
| Status |
|
| b) ‘Soft’ versus ‘hard’ approach |
|
| c) Alternative approach |
|
| d) Differences | |
| Sex |
|
| Cultural |
|
| Physical |
|
| e) Patient empowerment |
|
| f) Mis(use) of phrases |
|
‘Soft’ versus ‘hard’ approach
PPI representatives distinguished between ‘soft’ (subtle or indirect approach) and ‘hard’ (direct) approaches. There was no consensus on which was the preferred approach. However, it was suggested that in the absence of familiarity between patient and GP, the issue ought to be raised using a ‘soft’ approach (Box 1 [b]).
Alternative approaches
Representatives in all three groups explored other methods of raising the issue that did not involve face-to-face interaction. Many felt that, due to the social stigma attached to overweight/obesity, some people will be ‘in denial’ and resistant to information on weight loss and exercise.16 Suggestions were made for the issue to be raised holistically in relation to good health in general as well as discussing the social, economic, and psychological implications of poor health (Box 1 [c]).
Sex, cultural, and physical differences
The patient’s sex was seen as playing a role in the decision about how the topic should be introduced. Women were thought to be more sensitive to having the issue raised as opposed to men because of the societal pressures and media attention on body shape and image for women (Box 1 [d]). The sex of the GP was also considered important as it was suggested that an HCP of the opposite sex to the patient talking about weight would be a source of embarrassment and shame and likely to prevent engagement. The body size and weight of the HCP was also identified as a factor influencing the receptiveness of the patient. Information given by HCPs who are themselves overweight was seen to be less credible, although some representatives believed that the fact that the HCP was struggling with weight themselves might lead to a more empathetic approach. It was suggested that raising the issue could be couched in the HCP’s own experiences, or the experiences of those close to them, so that patients do not feel as if they are being singled out.
Patient empowerment
Discussions took place about patient autonomy and choice. While representatives believed in the value of patients receiving information about risks to health and possible weight management strategies, they felt that patients needed to make their own decisions about whether or not they wanted to discuss their weight during a consultation. Given that people have some insight into body size and weight, patients should be encouraged to raise the issue proactively; however, representatives agreed that this would not be appropriate for all. The importance of a positive relationship with practice staff in general was reiterated (Box 1 [e]).
Terminology
Using appropriate terminology should also be considered when raising the issue. Many PPI representatives were in favour of the term ‘healthy’ as opposed to ‘overweight’ or ‘obese’ and preferred HCPs discussing health in general terms as opposed to using specific terms, which may lead their patient to feeling offended (Box 1[f]). While avoiding offence was considered easier in established relationships, initiating a dialogue opportunistically is also important, although a more indirect approach was favoured.
CONCLUSION
The responses elicited highlight the importance of cultural sensitivity in initiating a meaningful dialogue between patients and GPs about health issues related to excess weight.
Using a PPI activity to elicit useful information and suggestions on raising the issue of overweight and obesity in the South Asian community has minimised the mistrust and power differentials that exist between researchers and research participants.17 A PPI activity can empower representatives to participate ‘with’ research and other aspects of applied health without being researched ‘on’. This notion of being subjects of research is what often leaves people disconnected and not wanting to take part.18 Similarly, this form of approach where GPs work ‘with’ patients in understanding their needs and practicalities will also be useful in service delivery in primary care.
Engaging South Asian patients in research or service design activities is not straightforward, primarily because commonly used recruitment or educational strategies do not reflect the concerns of South Asian communities. However, if they have no voice in shaping the agenda, the allocation of resources for services and research for minority communities will not reflect their needs.
Creative strategies for involvement of under-represented groups need to be developed because these groups are not necessarily ‘hard to reach’4 or difficult to engage, but rather the approaches and methods used need to be culturally sensitive, inclusive, and appropriate. The interactions patients have with their HCPs are a crucial first step in initiating dialogue, which is especially important in relation to a sensitive health problem such as overweight/obesity.
Notes
Funding
This work was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2014
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