Can you see me? Participant experience of accessing a weight management programme via group videoconference to overcome barriers to engagement

Abstract Background Engagement with conventional weight management group programmes is low. Objective To understand participant experience of accessing an adapted programme via videoconference. Participants Adults with obesity (BMI ≥ 35kg/m2), referred to an NHS Dietetics service in Wales, were offered a group videoconference weight management programme as an optional alternative to in‐person groups. Thirteen participants (mean age 48.5 ± 20.2 years, 8 female) recruited to two videoconference groups were interviewed. Study design A Registered Dietitian delivered a behavioural programme using Skype for Business in 10 sessions over 6 months. Participants joined the groups from any Internet‐connected device with a webcam. Participant perspectives were audiorecorded in one‐to‐one, semi‐structured interviews. Interviews were transcribed verbatim and thematically analysed using self‐determination theory as a theoretical framework. Results Ten themes were identified, three relating to service engagement and seven relating to behaviour change facilitation. Key themes in engagement included ‘reduced burden’, described as saving time and travel and ‘reduced threat’ as participants perceived joining a group from home as less daunting compared to attending in‐person. Despite reporting some initial technical difficulties with establishing video and audio connection, participants described beneficial peer support although not physically with other group members. Conclusion Accessing a group weight management programme via videoconference may be the preferred option for some participants, overcoming some of the barriers to access to standard in‐person programmes, particularly in rural areas. Participants are able to experience peer support via videoconference. During the COVID‐19 pandemic, weight management programmes could utilize videoconference groups to continue to provide support.


| BACKG ROU N D
Since 1975, worldwide obesity has nearly trebled, now affecting 650 million people, 1 and in Wales 24% of adults live with obesity. 2 Obesity is associated with reduced disability-free-life-years and increased risk of co-morbidities such as diabetes, heart disease, cancer and osteoarthritis. 3 More recently, obesity has been associated with increased severity of coronavirus symptoms. 4 Expert dietetic and behavioural counselling, as part of a structured programme with intensive follow-up, can help people with obesity to achieve modest but clinically significant weight loss of 5kg or more. 5 Evidence suggests that group-based interventions may be more effective in facilitating weight change than individual interventions. 6 The challenge, however, is that engagement with conventional, in-person behavioural weight management programmes is known to be low. 7 In a large multicentre trial of primary care referral to a group behavioural weight loss programme in England, only 6.5% of invited patients took up the offer. 8 In Scotland, 34% of patients referred to a weight management service attended the first session. 5 In Wales, approximately one in three people live in a rural area.
Due to extended travel distances and comparatively poor public transport in rural areas, accessing services can be more time consuming, deterring some patients from utilizing health services. 9 In a phenomenon described as 'distance decay' in rural residents, there is a decreasing rate of service use with increasing distance from services. 10 Rural patients are less likely to have the opportunity to exercise choice in health care. 11 Disparities in accessing care are especially relevant in weight management where participants need to access numerous sessions for support with health behaviour change. 12 Harnessing the potential of digital technology to empower people to take greater control of their health and well-being is of importance in Wales and internationally. 13 Meta-analyses of studies using eHealth interventions and mobile apps to promote weight loss have demonstrated significantly greater weight loss than controls. [14][15][16] Evidence suggests that the addition of personalized or human interaction improves engagement with eHealth 14,17 and studies have shown that greater engagement is associated with greater weight loss. [18][19][20][21] A systematic review of a variety of group therapy and health education telehealth group programmes reported that groups delivered by videoconference are feasible and can potentially improve the accessibility of group interventions. 22 Banbury et al 22  Recent studies have suggested that short-term weight loss outcomes are at least as good as standard interventions when lifestyle programmes, including diet and exercise coaching, are delivered via videoconference. 3,[23][24][25] Offering the option of accessing weight management programmes via videoconference could improve access to services and mitigate the travel and environmental costs of conventional in-person services. 26 Indeed, videoconferencing requires, at most, 7% of the total energy of an in-person meeting. 27 Participant acceptability, or satisfaction with, one-to-one videoconference weight management interventions, has been investigated in adults living in rural areas and in postpartum women. 12 Autonomy can be described as the psychological need to experience self-direction and personal endorsement in the initiation and regulation of one's behaviour. The internalization of behaviour regulation is the process of taking in an idea, and transforming it into one's own. 31 Autonomy satisfaction can be recognized in personal ownership of action. 32 Competence refers to the need to be effective. In this context, competence describes a person's confidence in mastering healthy eating or skills to overcome challenges to changing eating behaviours. Promoting competence involves helping participants to experience mastery of change. 33 Relatedness is the need to establish attachments with other people. The hallmarks of relatedness satisfaction are feeling socially connected and being actively engaged in both the giving and receiving of care to other people.. 32,33 A concern regarding videoconference interventions is that, without authentic in-person interaction, interpersonal connection might be diminished, groups may not fulfil relatedness needs, and consequently, this could jeopardize behaviour change initiation. 34 The aim of this study was to qualitatively investigate participants' perceptions of a group weight management programme, delivered via videoconference. Specifically, in order to understand: • the acceptability of this digital approach for participants in a health setting.
• the impact of remote delivery on behaviour change facilitation, especially participants' perceptions of relatedness or peer support.

| Participants
Study ethical approval was granted by Wales Research Ethics Committee 5 on 26/11/2018. Participants were adults (≥18 years old) digital, obesity, rural health, self-determination theory, videoconference, weight management with BMI 35-45kg/m 2 . Potential participants (n = 89) were referred by primary care, secondary care or self-referral for weight management to an NHS Dietetics Service in Wales. For study inclusion, participants were required to be able to access an Internet-connected device with camera and microphone in a private area of their choice, each week, at the time of the scheduled group. Exclusion criteria were pregnancy and known eating disorder disclosed at screening.
Participants were offered the opportunity to enrol on the study intervention, a group videoconference programme, as an optional alternative to usual treatment. Only participants who chose to attend the videoconference intervention (n = 14) were enrolled on the study. Potential participants who did not respond to the invite or who chose to attend an in-person programme were not interviewed.
Participant flow is shown in Figure 1, and baseline characteristics of interviewed participants are shown in Table 1. Mean age of interviewed participants (n = 13, 5 male) was 48.5 ± 20.2 years, and mean BMI was 39.3 ± 2.9kg/m 2 .

| Intervention
The study intervention was adapted from a dietitian-led weight management face-to-face group programme (usual care) into a format suitable for email and videoconference delivery. At screening, participants provided written informed consent prior to commencing the study. Participants were asked to sign up to ground rules to facilitate effective group interaction and confidentiality, including accessing the video groups from a private area, free from disturbance. A test connection was made with each participant before joining the group F I G . 1 Participant flow diagram programme to ensure audio and video connection. The programme was delivered to two groups between March and November 2019, using Skype for Business, by the first author, a registered Dietitian experienced in facilitating group weight management programmes.
Participants accessed the groups from their own devices, usually from home, via the Internet. Participants used a variety of devices including desktop computers, laptops, tablets and smartphones.
The materials and content were based on an adaption of the in-house NHS KindEating weight management group programme.
The programme was based on NICE guidelines for lifestyle weight management services and delivered using a motivational interviewing communication style. 35,36 The programme provided eight weekly sessions followed by review sessions at 4 and 6 months. The interactive sessions covered different aspects of weight management including education on healthy eating and increasing physical activity, and employed the following behaviour change techniques: goal setting, problem solving, action planning, reviewing behaviour goals, self-monitoring of behaviour, self-monitoring of outcomes of behaviour, social support, instruction on how to perform behaviour, social comparison, behaviour substitution, habit formation, habit reversal, credible source and comparative imaging of future outcomes. 37 Local service evaluation showed that conventional delivery of the programme led to an average weight loss of 4.42kg at 6 months. To adapt the programme for remote delivery, hands-on activities were converted to visual activities. Interaction during remote delivery was predominantly limited to discussion, and small group discussion used in the traditional programme was replaced with whole group discussion. Written information and visual materials were sent by email the week before each session. Participants accessed reliable weighing scales from home and emailed their weekly weight records to the facilitator. Mean self-reported weight loss for videoconference programme completers was comparable to the conventional programme.

| Data collection and analysis
Participant experiences and perspectives of the study intervention were recorded in one-to-one videoconference or telephone semi- Transcripts were initially analysed inductively to identify themes. In order to enhance understanding of how the intervention facilitated behaviour change, themes relating to behaviour change were deductively categorized within the theoretical framework of SDT.

| RE SULTS
Participants' (n = 13) experiences and perspectives of the weight management videoconference intervention are reported below with behaviour change facilitation themes described within the context of the SDT model of health behaviour change. Figure 2 illustrates TA B L E 1 Socio-demographic and medical characteristics of interviewed participants (n = 13) Co-morbidities (participants with more than one co-morbidity are counted more than once) Osteoarthritis 6 Depression/anxiety 5 the ten key themes as a process of service engagement to behaviour change facilitating weight loss. Participants have been assigned gendered pseudonyms.

| Service engagement
The following themes relating to engagement were identified. Probably would have continued to try and lose weight on my own, probably unsuccessfully…I had been referred before, but before the Skype sessions were an option and I couldn't get to any of the in-person ses-

| Reduced threat
The remoteness of using videoconference had the advantage of feeling less daunting or stressful for people with more introverted personalities. It therefore seemed less threatening. Participants also benefitted from the added reassurance of being in familiar surroundings, in the comfort of their own homes, providing feelings of security. Participants also implied that the perceived confidentiality afforded by accessing a programme from their own home may be seen as a way of reducing the threat of exposure to the stigma and discrimination associated with obesity.

| Behaviour change facilitation
In order to provide a clearer theoretical understanding of the role of this intervention in facilitation of behaviour change, themes relating to effectiveness were organized into the domains of autonomy, competence and relatedness, identified in SDT as leading to enhanced self-motivation.

| Relatedness
Three themes relevant to relatedness were identified. Participants described how they felt connected to other group members, how they identified with other participants and felt supported by them.

| Autonomy
Themes of increasing personal responsibility and decision ownership were identified as relevant to autonomy.

Personal responsibility
Some participants started out hoping for an external solution (or even, in some cases, intervention from a higher power) but gradually took a more autonomous approach.

| Competence
The themes of learning new strategies and comparing oneself favourably with others were identified as influencing competence satisfaction amongst participants.

| Service engagement
This study provides insights into the experiences of participants in engaging with a group weight management service via videoconference. Potential barriers to engagement with conventional group weight management programmes were described by participants.
For these participants, the option of accessing a programme via videoconference sufficiently reduced the barriers to allow them to access support when they would otherwise have been unable, or chosen not, to do so.
Participants found that accessing the programme via videoconference reduced the burden on them in terms of travel, time, cost and employment disruption. These burdens associated with the requirement to travel to attend a centre can be particularly exaggerated in rural areas. Burden has been identified as an important component in acceptability of healthcare interventions. 39 In a systematic review, intervention accessibility was identified as a facilitator in uptake of weight management programmes, 40 and, in a feasibility study, McVay et al 41 also identified practical factors as being important in the initiation of behavioural weight loss interventions. Women participating in a one-to-one postpartum weight management programme via video consultation in Australia similarly reported preferring the convenience and reduced logistical challenges of accessing a service from their own home. 28 Reduced threat was also identified by participants as an important factor in facilitating access. Participants perceived that communicating with the group remotely was less daunting or intimidating than attending an in-person group. They also perceived that accessing a programme from their own home afforded increased confidentiality, suggesting this may be seen as a way of reducing the threat of exposure to the stigma and discrimination known to contribute to avoidance of health care by people living with obesity. 42 A report by Public Health England identified stigma as a barrier to uptake of group weight management services, 40 and 15% of respondents in a USA survey (n = 3008) reported embarrassment as a barrier to seeking help. 43 Thus, remote participation offers an important potential means of overcoming these barriers.
Almost all participants encountered some form of technical problems with the connection. In all but one case these problems were resolved by troubleshooting between the facilitator and participant before the first session, or they were not considered sufficiently significant to prevent participation. suggests that, when an in-person alternative is available, the majority would prefer this. However, when there is no alternative option available, the uptake is likely to be higher.

| Behaviour change facilitation
The results suggest that autonomy was supported by encouraging ownership of decisions regarding behaviour change goals. No evidence was found to suggest that delivering the programme remotely thwarted the support for autonomy. Indeed, the findings mirror those from a qualitative evaluation of a face-to-face programme where participants reported that facilitator delivery style was important in supporting their choice of set goals. 47 Though participants described learning new strategies to manage their eating behaviour, it is interesting to note that much of the perceived increase in competence reported by videoconference participants was as a result of interaction with other group members, rather than from information provided by the facilitator. An important factor was favourable comparison with others, so that finding one was more competent in a certain behaviour, especially having the opportunity to share suggestions with others, was a powerful means of promoting feelings of mastery of change. This contrasts with the findings of Battista et al, who found that in a face-to-face lifestyle intervention programme, participants reported that particular 'tools' provided by the facilitator were most important in promoting competence. 47 It is feasible that the adaption of hands-on activities to visual activities and discussion reduced the memorability of practical aspects of the remotely delivered programme.
It has been established that groups can act to support weight management intervention delivery, and therefore behaviour change, but to realize this potential, participants need to experience a meaningful sense of social connection to other participants within the treatment group, so that they experience a shared social identity. 48 A recent systematic review of qualitative evidence on service users' perspectives in weight management programmes found that service users were emphatic that supportive relationships, with service providers or weight management programme peers, are the most critical aspect of weight management programmes. 49 Participants are more likely to adopt behaviours and values promoted by those with whom they feel connected. 30 The need to feel a sense of belonging is important in fostering internalization, and the need to feel understood impacts on openness to information. Fostering participant relatedness in lifestyle intervention programmes is also important in increasing the likelihood of behaviour change maintenance. 47 Discovering whether or not people were able to feel this sense of connection with other group members, and thus benefit from the peer support afforded by a group programme, even when they were not physically in the same place, was an important aspiration for this research.
Participants in this study generally reported that they had been able to relate effectively to other participants, with some expressing a preference for interacting in this way, perceiving that videoconference afforded the opportunity for more honesty and openness. One participant highlighted the benefit of 'facing' other group members on the screen, rather than sitting beside them in a physical meeting in fostering better relationships. There are limitations in using this mode; for instance, it is not possible for members to have casual one-to-one conversations with other group members with whom they identify more strongly. However, despite the limitations, participants generally felt they all had something in common and were 'in the same boat'.
They found other group members with whom they identified, and felt they were able to be supported, share ideas and learn from each other.

| Implications for future research and practice
This research has taken on new relevance as requirements for social distancing during the COVID-19 pandemic have focussed attention on new models of care that avoid face-to-face contact. 50 It has been proposed that offering this alternative mode of access may help to reduce health inequalities related to rurality. 12 However, there is a concern that in harnessing digital technology to overcome existing inequalities in access to health care, we might, inadvertently, in- Running groups remotely would allow the potential for groups to be convened on the basis of gender, language preference or condition rather than geographical location.

| Strengths and limitations
The first author delivered the programme and conducted participant experience interviews. This approach had the advantage of allowing the researcher to build rapport with participants and thus may have facilitated the collection of richer qualitative data. Conversely, this approach may have introduced bias as participants may have been less inclined to report negative experiences or appear critical.
A major limitation of the study was that it did not capture the views of potential participants who did not respond to the invitation to access the programme, or those who chose to access the service via in-person groups, as only those consenting to participate in the programme via videoconference were interviewed. Further research should explore the perspectives of those who chose not to engage with videoconference groups.

| CON CLUS IONS
Delivering a weight management group programme via videoconference is feasible and may be the preferred option for some participants. Data from our small sample suggested that participants can still benefit from peer support despite not being physically in the same place. Offering this mode of access as an option may assist potential participants to overcome some of the barriers to access to standard in-person programmes, particularly in rural areas. Strong information technology support will be required if group videoconference services are to become routine practice in the NHS. Further research should evaluate the effect of offering videoconference services on health inequalities and investigate if offering this alternative access option increases overall engagement. During the COVID-19 pandemic, weight management programmes could utilize videoconference groups to continue to provide support.

ACK N OWLED G EM ENTS
The authors would like to thank all the participants who shared their experiences, Noelle Cooper and Helen Hamer for initial advice on use of videoconferencing, Jared Stammers for technical advice and Sion Williams and Professor Emeritus Kevin Hylton for assistance with thematic analysis.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest regarding this research.

DATA AVA I L A B I L I T Y
Data available from the authors upon reasonable request.