A qualitative study of perceived barriers and facilitators to interrupting sedentary behavior among adults living with obesity

2.1 Research paradigm

To construct a rich understanding of the factors that influence sedentary behavior among adults with obesity, a critical realist approach was adopted. This qualitative approach focuses on the core concepts of experiences, events and causal mechanisms.³⁴ Experiences are defined as the perceptions of adults with obesity, events as the things that happen in the real world (e.g., SB), and causal mechanisms are the means that produce the events (e.g., factors resulting in SB).^{35, 36} Critical realism allows researchers to gain access to a complex social world of causal interactions through ‘richly textured accounts of events, experiences and underlying conditions or processes’.³⁷

2.2 Study design

Twenty-one semi-structured in-depth interviews with adults with obesity were conducted through May and June 2022. Adults with obesity are recognized by University College Dublin (UCD) Human Research Ethics Committee (HREC-LS-21-100) as a vulnerable population for research purposes; hence, individual interviews rather than focus groups were conducted to encourage openness and richness regarding the individual's lived experience. To broaden access to participation, interviews were conducted online via video-conferencing.

2.3 Participants and recruitment

To identify potential participants, a purposive sampling strategy targeting adults with current or past history of a BMI ≥35 kg/m² was employed. This cut-point, was chosen to investigate challenges associated with moderate or severe obesity, since BMI and severity of obesity are potentially associated with SB and consistently associated with reduced PA.¹⁴

Initially, GO’D invited the participation of the Irish Coalition of People living with Obesity (ICPO), an advocacy group which provides education, awareness and support to people living with obesity. Thereafter, the ICPO committee acted as gatekeepers by circulating leaflets advertising the study to members across a broad demographic range of age, gender, occupation and urban/rural residence. Subsequently, FC invited potential or actual participants to snowball the advert to further potential participants at their discretion. Inclusion criteria were adults (≥18 years) who self-identified as living with obesity, defined in the advert for the study as now or in the past a body mass index (BMI) ≥35 kg/m² which impacts health, wellbeing or enjoyment of life or activities. To gather valuable perspectives regarding SB associated with relapse or remission of obesity, participants who lost excess weight were included, even if their current BMI was ≤35 kg/m².

To determine that the sample size of 21 was sufficient to achieve the study aims, the principles of information power were applied including reflexive discussion among the research team during data collection. That is, the study aims were specific and relatively narrow (identify barriers and facilitators to interrupting SB in adults with obesity), a purposive, highly specific population was used, the interview was supported with established theory (TDF) which was applied flexibly to elicit an in-depth dialog, and reflexive appraisal for information power was conducted after every 3 interviews.^{38, 39} Thus, a minimum number of 12 interviews were planned. Interviews 19–21 contained no new information determining that the sample size was sufficient. Participants received a nominal voucher in line with the UCD reimbursement policy for public/patient participation in research.

2.4 Materials

An interview topic guide was developed using the Theoretical Domains Framework (TDF).^{26, 39} Additionally, non-TDF questions were included to richly contextualize perceptions about patterns of SB, how SB and obesity interplay, and ideas about interrupting SB.⁴⁰ The questions were open ended, and the interview style was flexible and reflexive to encourage the participants' expression through their own narrative. Prior to commencing the study, FC conducted two pilot interviews observed by GO’D. This resulted in amendments to some interview questions and inclusion of additional prompts to identify perceptions about the directionality of SB associations, causal mechanisms and the TDF domains. (Interview guide available in appendices Table S2).

2.5 Procedure

Potential participants who contacted FC via phone or email received an information sheet and a consent form for deliberation. FC answered any questions and once participants returned the signed consent form, they were sent a link to a secure online survey platform (Qualtrics), to collect demographic data prior to interview. FC conducted all the interviews. The mean duration of the interview was 48.0 min (SD = 7.6). FC documented reflective notes immediately following each interview.

2.6 Data analysis

Descriptive statistics were used to summarize the demographic data. Recorded interviews were transcribed verbatim, anonymized, then analyzed in Microsoft word and Microsoft Excel using reflexive thematic analysis (TA).^{41, 42} This type of analysis is aligned with the philosophical approach of critical realism which can be used to accurately explore the participant's empirical world, while engaging with underlying themes, concepts, and theory that can inform interventionist programs.⁴³ Salient phrases, sentences and paragraphs were inductively identified to develop first order codes from all transcripts. Following review and discussion with GO’D, CB and JM, FC continued the analysis to generate second order codes, returning to the raw data to enhance understanding. Codes with a shared pattern of meaning were grouped into candidate themes by FC. The research team then refined themes and subthemes by iterative discussion and collaboratively agreed and defined final themes. Each subtheme was then deductively mapped by FC to the TDF domains and COM-B. Any disagreement over domains was resolved through discussion with the other members of the research team.

3.1 Participant demographics

In total, 21 adults with obesity completed interviews. Participants included 15 females and six males, ranging in age from 31 to 64 years (mean = 48.9 years SD 10.8). Most participants (n = 19) scored ≥2 on the Edmonton obesity staging system (EOSS), which incorporates the physical, psychological, functional and quality of life impact of obesity.⁴⁴ The median EOSS score was 3. Mean ‘highest ever’ BMI was 55.5 kg/m² (SD 10.0) and mean ‘at interview’ BMI 42.0 kg/m² (SD 11.6). Four participants reported BMI <35 kg/m² at interview, while 13 had prior bariatric surgery. The mean total daily sitting time of participants was 471.0 min (SD 211.7) on a weekday and 387.0 min (SD 197.1) on a weekend day, self-reported using the International Sedentary Assessment Tool (ISAT).^{45, 46} Detailed information relating to participants' sedentary time and its domains is included in Table 1.

3.2 Interview results

Five key themes comprising 12 subthemes were generated from the patterned codes relating to barriers and facilitators to minimize/interrupt sedentary behavior in adults with obesity. These subthemes were mapped to the 14 domains of TDF and the COM-B. Table 2 provides an overview and Table S3 identifies barriers and facilitators (supporting information S1).

3.3 Theme 1 physical and mental wellbeing affects SB and the ability to move

Three subthemes are presented in relation to how physical and mental wellbeing influence participants' capability to interrupt SB and move more. Physical factors encompass both mechanics and pain and medical and metabolic factors.

3.4 Theme 2. Motivational readiness to change SB

This theme identifies participants' perceptions regarding internal and external motivators to minimize sedentary behavior and the readiness to actually change SB. Two subthemes are identified.

3.5 Theme 3. Roles, responsibilities and support for movement influence sedentary behavior

Participants described how their roles and responsibilities contributed to the development of their SB and influenced their ability to minimize SB. Familial/social responsibility, occupational and voluntary roles, including providing formal or informal support for others with obesity, were cited both as barriers and facilitators to minimizing SB. Three subthemes are identified.

3.6 Theme 4. Perceptions about weight bias and stigma influences SB

This theme relates to perceptions about negative attitudes, stereotypes, and stigmatizing experiences of living with obesity, which influence the willingness to minimize SB. Two subthemes are identified.

3.7 Theme 5. The environment and external factors influence SB

The majority of participants identified environmental factors which contribute to the development of SB or act as barriers or facilitators to reduce SB. Two subthemes are identified.

4.1 Physical and mental wellbeing

The most challenging perceived barriers to minimizing SB identified lay within the theme of physical and mental wellbeing, namely pain (attributed predominantly to inadequately or untreated musculoskeletal conditions), lack of energy (attributed predominantly to medical or metabolic conditions), and the impairment of mental wellbeing. Pain, lack of energy and reduced mental wellbeing have previously been indicated as barriers to PA and healthy lifestyle in adults with obesity^{47, 48} and cited as contributory to sedentary lifestyle for adults with obesity⁴⁹ while the number of co-morbidities was associated with increased sedentary time for adults with severe obesity.⁵⁰ Perceived poor physical functioning is also associated with seeking bariatric surgery versus lifestyle intervention for severe obesity.⁵¹ Moreover, mobility limitations, pain or discomfort, impairments in sleep or energy, and anxiety are reported to mediate the relationship between SB and depression.⁵² Similar to previous studies, participants experienced delayed, ineffective or lack of treatment, and lack of access to care for underlying medical or mental health conditions^{53, 54} which they perceived affected their ability to reduce their SB. This care gap precipitated a prolonged and significant deterioration in SB for many participants, associated with a decline in health, function, quality of life and obesity. This is an important consideration for intervention designers as it is likely that even when motivated and focused on behavioral change targets, adults with obesity may lack physical or psychological capability to engage in non-SB.

This study suggests that when adults living with obesity believe they lack the capability to change their SB, it could be considered a red flag in obesity care since they may already lack the physical or psychological capability to engage in adequate non-SB or may be on the precipice of a marked decline in their physical and/or mental wellbeing. In either case, clinical investigation or intervention may be warranted. A further challenge exists in identifying this red flag, since this stigmatized group may hide the extent of their SB, as revealed by a number of participants in this study. A recent study by Dolezal suggests that the experience of living with a health-related stigma is best characterized by shame anxiety or the chronic anticipation of shame, that is, fear of one's shameful secret, circumstances or personal history being discovered by a health professional.⁵⁵

It is also worth noting that while perceptions about physical and mental wellbeing revealed a lack of self-efficacy or confidence to change their SB, for most participants these beliefs about capabilities were based on an assumption that non-sedentary behavior is synonymous with physical activity, sport, or exercise. At an individual level, intervention components which target beliefs about capabilities, particularly self-efficacy, offer potential to interrupt SB, and have previously shown potential for physical activity engagement,⁵⁶ while a key component may be instruction on how to perform the behavior, a promising behavior change technique in the review of interventions to reduce sitting time by Gardner et al.²²

4.2 Motivational readiness

One of the most evident, and perhaps more easily addressed barriers to minimizing SB in this population is lack of knowledge, a barrier also reported in a recent systematic review of non-workplace SB interventions.⁵⁷ The knowledge deficit related to sedentary behavior, guidelines about SB, the negative consequences of SB, the independent health benefit to non-SB, as well as how to interrupt the behavior. Despite the lack of specific knowledge, similar to prior studies of workplace sitting time^{30, 32} participants were often aware that they were sitting too much, that too much sitting was not good and some expressed a willingness to change it. Participants were mostly unable to discriminate between being non-sedentary versus physically active, spoke almost exclusively about PA when asked about interrupting SB, and discounted short breaks in SB for example, comfort breaks or standing. However, some participants who described a value on mobility or belief that ‘all movement matters’ tended to participate in less SB or less prolonged SB, particularly in the home. This approach developed following periods of poor mobility or poor function due to health. A similar ‘value on mobility’ was recently reported for adults with osteoarthritis who perceived that the physical and psychological aspects of SB were interwoven with those of physical activity and who were trying to preserve mobility by keeping active.⁵⁸ This ‘value on mobility’ may be a particularly important maxim for adults with obesity during times of injury or when mobility has declined or is at risk of decline due to obesity related complications such as osteoarthritis.

Disconnecting non-sedentary behavior from physical activity may also be an important consideration for obesity care. Clinicians should tailor advice to adults with obesity regarding non-sedentary behavior versus physical activity as this may be an important management tool in the maintenance of function, mobility, and quality of life, particularly when pain or co-morbidity is present. Furthermore, systematic reviews suggest that interventions specifically designed to reduce SB show more promise to reduce SB²² or are more effective to reduce sedentary time⁵⁹ than PA interventions or combination interventions. Intervention designers should also include educational components, including various ways to interrupt/minimize SB and in various contexts. While ‘goal setting behavior’ may be a promising behavior change technique for SB interventions,⁶⁰ setting SB goals independent of weight loss may be important since participants tended to have less prolonged SB if their motivation to move was not for weight loss. Indeed, many adults with obesity hold unrealistic weight loss expectations, and when unsuccessful, unhealthy lifestyle behaviors including SB deteriorate.⁴⁹

4.3 Roles, responsibilities and support

Social and professional responsibilities tended to be prioritized over the participants' health or wellbeing, contributing to the development of habitual SB, unhealthy habits and weight gain, which is similar to prior research.⁶¹ Competing family responsibilities have previously been cited as a barrier to physical activity.^{17, 62} Appropriate social support tended to be perceived as a facilitator to minimizing SB, across all settings, which is similar to a recent study where individualized healthcare support, fellowship and peer support were perceived by participants as essential to the success of a lifestyle behavioral change self-management program for adults with obesity.⁶³ While lower levels of social support have previously been identified as a barrier to physical activity engagement for overweight and obese women,⁶⁴ lack of access to appropriate social support was identified in this present study as a barrier to interrupting SB. Intervention components which enable self-care while balancing competing responsibilities should be investigated for future SB interventions for adults with obesity. Positive encouragement and reinforcement, may enhance acceptability and adherence to SB guidelines for adults with obesity.

4.4 Weight bias and stigma

While weight bias and stigma experienced by adults with obesity is increasingly reported in the literature and contributes to poor health outcomes,^{65, 66} and feelings of guilt, embarrassment, shame and worthlessness,⁶⁷ it has also been reported to contribute to poorer lifestyle choices and increased sedentary time.⁵³ Almost all participants perceived bias or stigma as a barrier to interrupting SB with experience of negative emotions, prior negative experiences, or negative social influences acting as negative reinforcement. Similar to prior research^{54, 68-70} participants reported weight bias in all domains of life, social and physical activity avoidance due to weight bias and stigma^71-73 and experienced shame and humiliation while dining out.⁷⁴ Additionally, participants in this study revealed remaining sedentary, avoiding even basic comfort breaks while in public, in social settings, or on public transport due to fear of not fitting, embarrassment, weight bias, and stigma. This complex barrier will require the development of person-centered intervention components at multiple levels to address both internal and external biases. Therapeutic approaches which include self-compassion and self-acceptance may be indicated. Acceptance and commitment therapy has been indicated to help individuals to develop coping skills in other chronic conditions^{75, 76} and obesity acceptance and management,^{77, 78} while narrative inquiry and development of counter-narratives have the potential to assist adults with obesity to resist damaged social identities and demand respect, dignity, and fair treatment.⁷² However, a parallel approach to reducing societal weight bias and development of environments and policies which are accessible and inclusive for adults with obesity is essential.^78-80

4.5 The environment

Access to care for co-morbidities and specialist obesity care should be a priority for policy makers and public health providers since participants associated delayed care or lack of care with SB and poor health outcomes. In contrast, participants who had prior bariatric surgery tended to sit less, experience less pain and exerte less effort to move, particularly in the home and community environment, encountered fewer environmental barriers and experienced less weight bias. They also perceived an improved quality of life, and physical function. Although bariatric surgery results in small reductions in SB,^79-81 all participants who accessed bariatric surgery reported that the parallel support provided by engaging with a weight specialist service, which included behavioral, psychological and lifestyle components, was critical to sustained reductions in SB, as suggested in prior research.⁷⁹

An umbrella review of SB interventions found that, for adults with overweight or obesity, interventions targeting the physical environment are the most effective, followed by personal behavior interventions.⁸² By comparison, the results presented here suggest that both environmental and behavioral intervention components may be necessary to ensure that capability, opportunity and motivation exist for this population to minimize SB. Appropriate behavior change techniques such as action planning and self-monitoring delivered via mobile technology have the potential to enhance environmental interventions for adults with obesity.⁸³

Indeed, the WHO identifies that an obesogenic physical environment promotes sedentary behavior and reduces opportunities for physical activity⁸⁴ and many environmental interventions have been successful in increasing physical activity, particularly active transportation.⁸⁵ However, some participants in this study, those with less mobility or functional ability, felt further excluded from built and natural environments due to population level or inclusive initiatives. When developing population and policy interventions, consideration must be given to potential unintended consequences which could exclude vulnerable groups, such as adults with obesity, resulting in poorer health outcomes.