Socioeconomic Disparity and Bariatric Surgery Outcomes: A Qualitative Analysis

Abstract

INTRODUCTION: Disparity in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. Reasons for these disparities are unknown. Our objective was to identify socioeconomic barriers to weight loss after bariatric surgery. METHODS: We performed semi-structured interviews with bariatric surgery patients and providers from April to November 2020. Participants were asked to describe their postoperative experiences within 3 clinical areas: dietary habits, physical activity, and follow-up care. Purposeful sampling was used to recruit similar numbers of patients within low vs high SES and “optimal” vs “suboptimal” weight loss groups. Low SES patients were defined as having Medicaid within 3 years of operation. Patients with “optimal” weight loss had obtained ≥50% excess weight loss at their most recent clinic visit. Interview data were coded by team members using Directed Content Analysis based on the domains in Andersen’s Behavioral Model of Health Services Use and Torain’s Surgical Disparities Model. Codes pertaining to patient-level behaviors were included in the analysis. RESULTS: Twenty-four patients (median of 4.1 years postoperatively; mean age 50.6 ± 10.7 years; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss at the patient level related to 5 areas (Table 1): (1) limited health literacy; (2) challenging employment environments; (3) limited income; (4) unreliable transportation; and (5) unsafe/inconvenient neighborhoods. Table 1. - Socioeconomic Barriers to Weight Loss after Bariatric Surgery Barrier Description 1. Limited health literacy Patients with less formal education needed more training/teaching regarding recommendations for diet, physical activity, and postoperative care. 2. Challenging employment environments Patients who had physically demanding jobs or multiple jobs struggled to follow dietary, physical activity, and follow-up care recommendations. 3. Limited income Lower-income patients: (a) had a difficult time affording supplements and vitamins; (b) skipped meals or relied on cheaper convenience food options/unhealthy options at food pantry; (c) did not have access to affordable fitness centers; (d) did not have reliable internet access for virtual follow-up meetings; (e) struggled with gas money and co-pays, which prevented their attendance at follow-up meetings. 4. Unreliable transportation Patients who did not have reliable transportation were restricted by bus routes to obtain healthier foods. Public transportation or insurance-provided transportation (eg, scheduled service driver) was often unreliable. 5. Unsafe/inconvenient neighborhoods Grocery stores in disadvantaged neighborhoods carried fewer healthy options. Patients in these neighborhoods struggled to have groceries delivered to their homes because of fear of theft. These neighborhoods were often unsafe for exercising or did not have sidewalks. CONCLUSION: Numerous socioeconomic barriers to weight loss exist for bariatric surgery patients. Interventions targeting these factors are needed to support patients, particularly those who are socioeconomically disadvantaged.