Views of patients with obesity on person‐centred care: A Q‐methodology study

Abstract Introduction To better accommodate patients with obesity, the adoption of a person‐centred approach to healthcare seems to be imperative. Eight dimensions are important for person‐centred care (PCC): respect for patients' preferences, physical comfort, the coordination of care, emotional support, access to care, the continuity of care, the provision of information and education, and the involvement of family and friends. The aim of this study was to explore the views of patients with obesity on the relative importance of the dimensions of PCC. Methods Q methodology was used to study the viewpoints of 21 patients with obesity on PCC. Respondents were asked to rank 31 statements about the eight dimensions of PCC by level of personal significance. Using by‐person factor analysis, distinct viewpoints were identified. Respondents' comments made while ranking were used to verify and refine the interpretation of the viewpoints. Results Five distinct viewpoints were identified: (1) ‘someone who listens in an unbiased manner’, (2) ‘everything should run smoothly’, (3) ‘interpersonal communication is key’, (4) ‘I want my independence’, and (5) ‘support for myself and my loved ones’. Viewpoint 1 was supported by the largest number of respondents and explained the most variance in the data, followed by viewpoint 3 and the other viewpoints, respectively. Conclusion Our findings highlight the need for tailored care in obesity treatment and shed light on aspects of care and support that are most important for patients with obesity. Patient Contribution Our sample consisted of patients. Patients were also involved in the development of the statement set through pilot testing.


| INTRODUCTION
Over the past four decades, the global prevalence of obesity has nearly tripled. 1,2 The World Health Organization defines obesity as an excessive accumulation of body fat that poses a threat to health. 3 Living with obesity seriously impairs physical and psychosocial functioning, resulting in a reduced quality of life. 4 Obesity also increases the risk of developing other serious health conditions, such as type 2 diabetes, cardiovascular diseases, several types of cancer, and many other diseases. 5 Consequently, obesity, and especially severe obesity is associated with increases in healthcare utilization and expenditures, as well as substantial societal costs due to productivity losses. 6,7 Although many health institutions have recognized it as a chronic disease, 8 healthcare systems seem poorly prepared to meet the needs of patients living with obesity. Clinical guidelines for the treatment of these patients are often too simplistic, focusing merely on weight loss instead of the improvement of overall health and well-being. 9 As a result, individual circumstances, including contributing factors and underlying diseases, are often overlooked. 10 Furthermore, patients with obesity often experience weight-related stigma and discrimination in healthcare, which can affect the quality of their care and their treatment outcomes. 11,12 For instance, some healthcare professionals view patients with obesity more negatively than other patients and spend less time treating them. 13 Healthcare professionals may also be insufficiently equipped or educated to perform standard medical procedures on patients with obesity. 14 To better accommodate patients with obesity, the adoption of a person-centred approach in which care is tailored to the individual and individuals' preferences, needs, and values are respected seems to be imperative. 15 Person-centred care (PCC) can be seen as a paradigm shift in healthcare that has been gaining broad support with the increasing interest in the quality of care. 16,17 The Picker Institute distinguishes eight dimensions that are important for PCC: respect for patients' preferences, physical comfort, coordination of care, emotional support, access to care, continuity of care, the provision of information and education, and the involvement of family and friends. 18,19 An overview of these dimensions can be found in Table 1. PCC has been associated with improved patient outcomes in various healthcare settings, 26 including the provision of care to patients with obesity. 27 However, the relative importance of the different aspects of PCC seems to vary among patient groups. 28,29 Although aspects of care that may be important specifically for patients with obesity have been identified, the significance of the eight dimensions of PCC for patients with obesity has not been assessed. Gaining insight into the aspects of PCC that are most important to this patient group is a vital step toward improved care provision, and consequently improved quality of care and patient outcomes. Thus, the aim of this study was to explore the views of patients with obesity on the relative importance of the dimensions of PCC.

Patients' preferences
Treating patients with dignity and respect and demonstrating sensitivity to their preferences, needs and values. When treating patients with obesity, a focus on overall quality of life, rather than the achievement of weight loss alone, is important. 20 Physical comfort Physical comfort should be supported, in the case of obesity by offering pain management if needed and attending to problems with physical activity. Buildings should be comfortable and provide enough privacy. Specifically, a lack of privacy during weight assessment has been identified as a barrier to the engagement in care of some patients with obesity. 21 Coordination of care Coordination and integration of care among healthcare professionals within organizations is critical. All professionals should be well informed, and each patient should have a primary contact person.
Emotional support Living with obesity is associated with a great psychosocial burden, and patients with obesity may experience issues such as depression, anxiety, stigma and discrimination. 22 Access to care Includes quick and easy appointment scheduling, accessible buildings and access to adequate medical equipment. Not all currently used medical equipment is designed to accommodate patients with larger bodies, which may restrict quality of care and contribute to stigmatization of patients with obesity. 23 Continuity of care Includes smooth transitions between healthcare providers and the transferring of relevant patient information between organizations. As patients with obesity often deal with comorbid conditions, several providers in primary and specialty care settings may be involved in their care. 24 Information and education Patients should receive appropriate information and education about all aspects of their care. Accumulating evidence links low health literacy to excess body weight. 25 To support patients with obesity to be in charge of their own care, the provision of understandable information and education is essential.

Family and friends
The involvement of family and friends may also play an important part in caring for patients with obesity, as family members and friends may act as caregivers or contributors to the disease. When applicable, PCC also involves paying attention to the roles of loved ones in obesity treatment.
2 | METHODS To examine the views of patients with obesity on what is important for PCC, the mixed-method Q methodology was used. Q methodology may be best described as an inverted factor analytic technique for the systematic study of subjective viewpoints. 30 Q-methodology research aims to identify and discern views on a specific topic, rather than determine the prevalence of these viewpoints. In a Q-methodology study, respondents are asked to rank a set of statements about the study subject. Using by-person factor analysis, in which the respondents are treated as variates, distinct viewpoints are identified. Q methodology has been used to examine the views of patients and professionals, such as patients with multimorbidity, 28 those with end-stage renal disease, 29 and professionals and volunteers providing palliative care, 31 on what is important for PCC.

| Respondents
As our goal was to obtain a wide breadth of views on what is important for PCC for patients with obesity, we recruited respondents varying in terms of gender, age, educational background, marital status, and health literacy. Eligible patients were over the age of 18 years and had body mass indices (BMIs) of at least 40 kg/m 2 , which defines severe obesity. This obesity threshold was chosen because it is associated with the most healthcare utilization and greatest health risks. 5,6 Practitioners working in the internal medicine departments of four hospitals in the area of Rotterdam, the Netherlands, informed patients about the study. In the Netherlands, access to nonurgent hospitals or specialty care requires a referral from a general practitioner (GP). 32 Recruitment through hospitals thus ensured that respondents were familiar with both specialty and primary care (e.g., GP visitation), characteristic of care provision for patients with severe obesity. 6,24 Data collection took place between April and October 2021. Twentysix eligible patients gave consent to be contacted to receive detailed study information and schedule an appointment. Of the 26 patients that were contacted, 3 were unable to schedule appointments and 2 could not be reached by the researcher. This led to the inclusion of 21 patients in the study, which is a typical sample size for a Q-methodology study. 30

| Statements
To capture the full range of possible views on a specific topic, the statements in a Q-methodology study should have good coverage of the subject of interest. 30 The eight dimensions of PCC provided by the Picker Institute were used as a conceptual framework for this study. 18,19 First, statements from previous studies in which the same framework was used to investigate the views of patients or professionals on what is important for PCC were collected. 28,29,31 Further statement selection was informed by various sources covering the care and support needs of patients with obesity, such as scientific articles 23,33 and clinical guidelines, 34 Table 2. Because no substantial change was made to the statement set, the pilot data were included in the analyses conducted for this study.

| Data collection
Data collection took place in an online environment using video conferencing software; the process lasted approximately 60 min per respondent. One researcher guided the respondents' ranking of statements. All sessions were audio recorded with respondents' informed consent. First, the respondents answered basic demographic questions and filled in the Set of Brief Screening Questions (SBSQ) as an assessment of health literacy. 35 Low health literacy was defined as an average SBSQ score of 2 or lower. Next, the respondents were asked to carefully read the statements about aspects of PCC, displayed on the screen one by one in random order using the HtmlQ software, 36 and to sort them into 'important', 'neutral', and 'unimportant' piles. The researcher then asked the respondents to rank the statements in each pile according to their personal significance using a forced sorting grid with a scale ranging from +4 (most important) to -4 (most unimportant; Figure 1). While ranking, the respondents were encouraged to speak out loud about their views; after completing the ranking, they were asked to elaborate on their placement of the statements. All comments made by the respondents during and after the ranking process were transcribed verbatim.

| Statistical analysis
To identify distinct viewpoints on what is important for PCC for patients with obesity, the rankings of the 21 respondents were intercorrelated and subjected to by-person factor analysis using the PQMethod software. 37 Clusters in the data were identified using

| RESULTS
Twenty-one respondents completed the ranking ( as much as possible and to expand what is possible to do myself'. Although these respondents seek independence, they value knowing where to go for care and support after treatment highly (statement 24, +4). They are willing to take the lead, provided that they know where they can go for support. Respondent 4 stated 'That

| LIMITATIONS
Several potential limitations of this study should be considered. First, the sample of patients recruited for this study may seem to be small.
However, it meets the requirements of Q methodology 30 and is similar to those of other studies. 28,47 Furthermore, consultation of the literature revealed no evidence of a missing viewpoint. Additionally, the viewpoints identified in this study were recognized by a professor of obesity and stress research who is involved in the treatment of patients with obesity and indicated that no viewpoint was missing, based on many years of clinical experience. Furthermore, the representation of the male perspective in this sample might be limited due to the male-to-female ratio. However, a similar ratio is seen in patients seeking obesity care. 48 Second, at the start of the data collection period, respondents could only participate online due to COVID-19 pandemic precautions. Although we later offered the opportunity for face-to-face participation, this approach may have led to the underrepresentation of individuals with low health literacy, for whom digitalization can be a barrier to engagement. 49 However, the views of individuals with low health literacy are represented in this study, as four respondents met this criterion. patients may benefit greatly from a high level of emotional support, while others will respond better to care and support that is centred around patient education or self-management.