LGBT Health Volume 2, Number 2, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/lgbt.2014.0082
Aging, Weight, and Health Among Adult Lesbian and Bisexual Women: A Metasynthesis of the Multisite ‘‘Healthy Weight Initiative’’ Focus Groups Samantha Garbers, PhD,1,2 Cheryl McDonnell, PhD,3 Sarah C. Fogel, PhD,4 Michele Eliason, PhD,5 Natalie Ingraham, MPH,6 Jane A. McElroy, PhD,7 Anita Radix, MD, MPH,8,9 Suzanne G. Haynes, PhD10
Abstract
Purpose: Adult lesbian and bisexual (LB) women are more likely to be obese than adult heterosexual women. Achieving a healthy weight reduces health risks and improves quality of life, but the evidence based on successful weight interventions is limited. To inform a national initiative, a metasynthesis (a form of qualitative metaanalysis) of focus group data was conducted to gather lesbian and bisexual womens’ perspectives. Methods: Analysis used de-identified transcripts and narrative reports from 11 focus groups guided by different semi-structured discussion guides with 65 participants from five locations. A literature search was conducted to identify existing themes in published literature and unpublished reports. Results: Six key themes were identified: aging; physical and mental health status; community norms; subgroup differences; family and partner support; and awareness and tracking of diet and physical activity. Participants expressed feeling unprepared for age-related changes to their health and voiced interest in interventions addressing these issues. Their perspectives on community acceptance of body size shifted as they aged. Participants cited age, class, race, ethnicity, sexual identity, and gender expression as potential characteristics that may influence participation in interventions. Families were both a barrier to and a facilitator of health behaviors. Awareness and tracking of dietary habits, stressors, and physical activity levels emerged as a theme in more than half of the groups. Conclusion: An unsolicited, overarching theme was aging and its influence on the participants’ perspectives on health and weight. Interventions should be tailored to the needs, goals, and community norms of LB women. Key words: aging,
bisexual, health promotion, lesbian, obesity, weight.
Introduction
O
besity and being overweight are associated with adverse health conditions in women, including diabetes, coronary artery disease, joint pain, some cancers, and reduced quality of life.1,2 Additional evidence shows that weight varies by sexual orientation, with several reports indicating that adult lesbian and bisexual women are more likely
to be obese than adult women who identify as heterosexual.3–6 In the 2013 National Health Interview Survey (the first to include a question on sexual orientation), 37 percent of adult women who identified as gay or lesbian and 41 percent who identified as bisexual were obese, compared with 28 percent who identified as straight or heterosexual.6 In light of the public health costs of obesity in general7 and identified disparities in obesity prevalence by sexual orientation, the
1
Research & Evaluation Unit, Public Health Solutions, New York, New York. Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, New York. 3 The CDM Group, Bethesda, Maryland. 4 School of Nursing, Vanderbilt University, Nashville, Tennessee. 5 Department of Health Education, San Francisco State University, San Francisco, California. 6 Lyon-Martin Health Services, San Francisco, California. 7 Department of Community & Family Medicine, University of Missouri, Columbia, Missouri. 8 Department of Medicine, New York University, New York, New York. 9 Callen-Lorde Community Health Center, New York, New York. 10 Office on Women’s Health, U.S. Department of Health & Human Services, Washington, D.C. 2
176
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
U.S. Department of Health and Human Services Office on Women’s Health funded five projects to develop and test community-based Healthy Weight Initiatives for Lesbian and Bisexual Women. Achieving a healthy weight8,9 has been shown to reduce health risks10–14 and improve quality of life,15 but the evidence base on what makes weight interventions successful in the general population is limited by participant attrition and a lack of generalizability of findings,16–21 and the fact that only one intervention has been conducted specifically with lesbian and bisexual women.22 Recent reviews suggest that weight interventions must be tailored to the individual, ideally with community input.10,23,24 Individual and structural barriers to achieving and maintaining optimal health, including health behaviors, self-efficacy, body image, and limited mobility, have been reported among adult women, but only a few studies have addressed lesbian and bisexual women.25–28 However, previous qualitative studies of lesbian and bisexual women have identified issues specific to this community, including a focus on health rather than on weight loss; the importance of social support; minority stress and isolation; generational differences; lesbian community norms regarding the acceptability of larger bodies; and the impact of stress on wellness.29–32 Focus groups were convened at five geographic locations across the country to gather lesbian and bisexual women’s specific perspectives on topics relevant to the national initiative such as health behaviors, barriers and factors that promote exercise and healthy eating, participant recruitment strategies, and the preferred content and delivery of the interventions. A thematic synthesis was conducted to add to the literature
177
reflecting lesbian and bisexual women’s perspectives. This metasynthesis, a form of qualitative meta-analysis, counteracts documented challenges in recruiting sufficient numbers of lesbian and bisexual women for participation in research, by bringing together data from multiple focus groups.33–35 Methods Recruitment
Four out of five funded institutions contributed de-identified transcripts from separate focus groups for joint analyses. Eleven focus groups were conducted from January to April 2013 at five geographic locations: Washington, D.C.; San Francisco, Oakland, and Santa Rosa, California; and Columbia, Missouri. The Institutional Review Board (IRB) at each institution approved the protocols and materials. Eligibility criteria included being age 40 and over, currently female identified (regardless of sex assigned at birth), and identifying as lesbian or bisexual. Two sites had additional inclusion criteria: body mass index ‡ 27.5 according to self-reported height and weight (Site C) or ‘‘at risk for weight-related health problems’’ (Site B). Primary data collection
Each focus group was guided by one to two moderators using different semistructured discussion guides: The planned discussion topics, summarized in Table 1, (full list in Supplementary Data: Focus Group Discussion Guides), expanded on themes identified in previously published studies of health, weight loss, physical activity, and diet among lesbian and
Table 1. Topic Areas Included in Focus Group Discussion Guides Group General Topics About Health and Healthy Weight
1
2
Definitions and feelings about health and being healthy Interactions with providers regarding weight, nutrition, exercise, and health Current health habits (nutrition, exercise, stress relief) Support and motivation for health and health habits Barriers and challenges to staying healthy (nutrition, exercise, other) Sources of information on health, nutrition, and exercise Relationship between health and weight
x x
x x
x x
x
Lesbian and Bisexual-Specific Topics
1
2
Provider understanding of health needs of lesbian and bisexual women Specific health needs and concerns of lesbian and bisexual women Cultural differences in lesbian and bisexual women communities Attitudes and messages about weight in lesbian and bisexual women communities Raising awareness of health issues in lesbian and bisexual communities
x
Intervention-Specific Topics
1
Interest in and feedback about intervention components, topics, and structure Recruitment and messaging to promote intervention
x
3
4
5
6
7
8
9
10
x
x
x
x
x
x
x
x
x
x
x
x
x
x x
x x
x x
x x
x x
x x
4
5
6
7
8
9
10
x
x
x
x
x
x
x
x
x
x
x
x
x
11 x
x
3
x
x x x
11
x x x 2
3
4
5
6
7
8
9
10
11
x
x
x
x
x
x
x
x
x
x
x
178
GARBERS ET AL.
bisexual women (Appendix 1).29–32 (Supplementary data is available online at www.liebertpub.com/lgbt.) Each focus group was audiotaped; de-identified verbatim transcripts and narrative reports were used for analysis. This qualitative analysis of de-identified secondary data was deemed exempt from review by the IRB at the Healthy Weight Initiative Coordinating Center. Literature search and identification of initial themes
Consistent with methodology for metasyntheses, a literature search was conducted to identify existing themes.36 Articles were considered that: explored health, healthy weight, weight loss, exercise, and diet and/or physical activity; were published in English between January 2003 and December 2013; included adult lesbian and/or bisexual women; and used qualitative data. The lead author conducted the search. To ensure conceptual saturation,36 and for consistency with search terms used by Bowen and Balsam,36,37 a search of two electronic databases—PubMed and SCOPUS (health science/social science/humanities)—was conducted using the search terms: lesbian OR bisexual OR (sexual minority AND women); health OR healthy; weight OR weight loss OR exercise OR diet OR physical activity OR fitness; and qualitative OR focus group OR interview. From the 27 articles identified, we excluded studies that did not: include adult lesbian or bisexual women (n = 14); present findings separately by gender and sexual orientation (n = 1); address definitions of health, healthy weight, diet, or physical fitness or activity (n = 3); or include qualitative data (n = 5). This process yielded four eligible peer-reviewed manuscripts. We reviewed the bibliographies for each reference cited in the four published papers and found three additional unique papers, which yielded seven published articles.31,38,39 Finally, the four unpublished reports summarizing the focus group findings written by the facilitators were included, for a total of 11 original sources of data for thematic synthesis. The first author conducted the theme identification using existing literature, with confirmation and refinement by the second author. Any subheading within a section labeled ‘‘Results’’ or ‘‘Findings’’ was incorporated as a theme, as was any text within a conceptual map or table.36,40 The themes identified in the 11 underlying studies (listed in Appendix 1) became the initial codes for analysis of the transcripts. Coding
Two independent coders conducted line-by-line coding. Coding agreement was determined after completion of each transcript. Discrepancies in coding were resolved through consensus. Newly identified themes were proposed at the conclusion of each transcript review. If the new themes were agreed upon by the two coders, a new code was added in NVivo qualitative data analysis software (QSR International Pty Ltd., Version 10, 2012). Iterative coding was conducted: when any new theme was identified, previously reviewed transcripts were recoded. Conceptual saturation was achieved by the fourth transcript, and no new themes were identified in the remaining transcripts.36 After final review, agreement was 99 percent and kappa was 0.76, representing substantial to excellent agreement.41 Concept mapping
After completion of transcript coding, linkages between themes were identified by running NVivo-based matrix code
FIG. 1.
Conceptual map of the six identified key themes.
queries. Concept mapping (Figure 1) was used to represent the linkages among the identified themes.42 This approach enabled us to identify relationships across the focus groups as the evidence was synthesized.36,42 Methods to improve validity and reliability
Methods to maximize trustworthiness of the analysis (validity) included the following: credibility, the extent to which findings reflect the experience of participants, was enhanced by drawing themes from multiple underlying studies, using broad literature search terms, and providing verbatim transcription;43,44 authenticity, an awareness of the subtle differences between the voices of all participants,45 was improved by using matrix codes to identify rare or atypical themes;43 and matrix coding for both negative and positive attitudes facilitated identification of contradictory findings.45 A lengthy audit trail outlining the methods for identifying themes was used to enhance reliability (consistency).46 Results Focus group participants
A total of 65 women (aged 38 through 80) participated in the 11 focus groups (Table 2). In total, 14% of participants were Black or African American, 8% Hispanic or Latina, and 9% Asian, Native American, or an unspecified race other than White. Findings
Six key themes were identified in this analysis: aging, physical and mental health status, community norms, subgroup differences, family and partner support, and awareness and tracking of eating and physical activity. Key themes were identified based on frequency of coding, their applicability
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
179
Table 2. Summary of Focus Groups and Sample Characteristics (n = 65) Site
Focus Group Recruitment/ Setting(s)
Group Number
A
Clinical & Community
1
B
Community
C
Clinical & Community
D
Community
Month and Year
Moderator (n)
n
Age Range
March 2013
2
9
38*–61
2 3
January 2013 January 2013
1 1
8 6
51–61 46–72
4 5 6
February 2013 March 2013 March 2013
1 1 2
7 2 5
62–80 40–45 40–65
7
March 2013
1
4
40–55
8
April 2013
2
7
40–65
9
April 2013
1
5
40–65
10
April 2013
1
4
40–65
11
March 2013
1
8
41–59
Racial/Ethnic White (n = 6) Non-White (n = 3) White (n = 8) White (n = 3) Latina (n = 1) Native American (n = 1) Black (n = 1) White (n = 7) White (n = 2) Latina (n = 2) White (n = 2) Asian (n = 1) White (n = 3) Black (n = 1) White (n = 3) Black (n = 2) Latina (n = 2) Black (n = 3) White (n = 2) White (n = 3) Black (n = 1) White (n = 7) Black (n = 1)
*One participant, age 38, was included as a key stakeholder.
to informing the interventions, and the extent to which our findings uncovered new insight beyond the existing literature. Each of these key themes had a coding frequency of more than 50 times and was discussed in at least half of the groups. Three of the six key themes were identified in all 11 groups: physical and/or mental health status, community norms, and subgroup differences. The themes of aging and family influences were mentioned in 10 groups and awareness and tracking in six groups. Two key themes—aging, and awareness and tracking— were not previously identified in the literature. Several themes previously identified in the literature were confirmed: preference for interventions that focus on promoting health and on the ability to participate fully in life rather than on weight loss only;29,31,37 cultural norms within lesbian communities that are accepting of larger body types;29,32,38,47,48 and, importance of social support and group structures in initiating and maintaining healthy behaviors.29–32,37,38,47,48 Aging
Aging was not a planned discussion topic in any of the groups, and was not identified as a theme in the published or unpublished reports, yet the theme emerged in 10 of the 11 groups. Many participants cited aging as a key determinant of health and wellbeing and, in many cases, as a source of stress.
‘‘When I hit 40, my health started going downhill in a big way.’’ (Group 2) ‘‘You get old and people don’t want to hire you even though you got degrees and experience.. I did find myself sometimes wondering, ‘Is it because I’m older? Is it because I’m a lesbian?’ It’s hard not to internalize that. That’s one of my stressors.’’ (Group 9)
Health changes related to increased age and menopause (including apparent changes in metabolism and inability to control weight gain) were a specific concern cited in most of the groups. Many expressed feeling unprepared for age-related changes to their health and voiced an interest in an intervention to directly address these issues. ‘‘I am pretty healthy.but I have a lot of complaints, and that includes weight issues. I just need others to talk about health. I don’t really talk about the aches and pains and changes and things that make me hate the way I look, and all that stuff about aging.’’ (Group 3) ‘‘Once your body goes through changes some of the stuff you do doesn’t apply anymore. So telling me you should change your eating habits or exercise.doesn’t help me. (It doesn’t) tell me.why you suddenly gain all this weight when you’re 50.’’ (Group 1)
Physical and mental health status ‘‘I think once you get to our age, there’s just no way of avoiding the fact that you’re falling apart.. It’s one thing after another. It’s like keeping up an old car.’’ (Group 4)* *Group discussion topics are reviewed in Table 1 and the Supplementary Data: Focus Group Discussion Guides. Composition of groups is summarized in Table 2.
Most participants defined health as the absence of physical and mental health conditions that impair quality of life. For many, health conditions (including stroke; diabetes; limited mobility due to pain, arthritis, or disability; or depression) limited their ability to engage in physical activity. At the same time, excess weight was perceived as one of many
180
GARBERS ET AL.
factors that impacted health, sometimes creating a ‘‘snowball effect’’ (Group 10) when considered in the context of medical conditions.
gret the amount of time I spent under that belief that I could be healthy at any size, because I’m not sure that’s sustainable as you age.’’ (Group 1)
‘‘We’re all at the particular age where we just want to be able to get around and feel good.. I think that when you carry more weight.with the joints and everything else, it does limit your activity. It limits my activity. I’m looking.to (not) be incapacitated and having to be in a wheelchair— all that kind of stuff.’’ (Group 8)
‘‘Like, the stuff on TV doesn’t really affect me a whole lot these days. And when I was younger, it really would. But I would like to feel healthy, I would like to not have pain. When it gets right down to it, I would like to be able to move with more grace and stuff like that. I’d like to feel better in my body.. I think in our community, there is a wider range of acceptance, and that’s nice. There’s extremists, too, because really, when you have a huge amount of weight, and you have diabetes, and you have knee surgeries, it’s kind of like, come on, that’s not good either.’’ (Group 3)
‘‘I want to feel good inside and out.. There are certain measurements that I’m really looking for—my fasting blood sugar right now is too high.. I’d like to reduce pain, physical pain.. And then there’s mood stuff.the anxiety and stress. So there’s.mind and body. I’d like to.feel better inside. And then the body part, I’d like to feel better, you know, more alacrity getting out of bed. Not going, ‘Ouch!’ ’’ (Group 3)
Community norms
Several groups initiated discussions about lesbian community norms around body size and size acceptance. There was agreement that such social influences had an impact on health behaviors in both positive and negative ways. Community acceptance of body size differences was mentioned in many groups as a source of support, particularly in younger years and during the coming out process. These norms were viewed as being in opposition to the images of thinness that, ‘‘the mainstream media pushes (in terms of) what health should look like’’ (Group 11). Yet, in almost all groups, participants cited a need for ‘‘balance,’’ recognizing health problems that can result from heavier weight. ‘‘It kind of is the double-edged sword.. There is this Madison Avenue image of what you’re supposed to look like.and I think that the fat activist community within women’s/lesbian community is really important for redefining that and saying there’s not just one way to be beautiful, and you don’t have to feel like crap about yourself because you don’t fit into this size 10 or 12. And then, at the same time, it kind of can start to go too far, where you do kind of put blinders on and don’t pay attention to the signals in your body and, you know, don’t make changes that are better for your health, like movement, eating healthy foods, things like that. So it’s sort of an interesting balance that I think needs to be struck there.’’ (Group 2) ‘‘If you can be overweight and you can be still healthy, and your body’s OK with that, then cool. But, if it’s not, then it’s not really your bowing down to what popular culture will tell you about your weight is. It’s really that you’d like to walk without a cane (or) you don’t want to be diabetic.. There’s a certain point where yes, (it’s) good to accept yourself and validate yourself, and know that you’re a good person, (that) you’re worthy of people loving you and caring about you. But, then sometimes it gets taken a little too far.’’ (Group 8) ‘‘It’s tricky, it’s that whole fat-phobic thing we live in, the whole balance of.(being) a feminist and person who cares about everybody’s rights, and then at the same time, not let that tilt me into someone with really bad health.’’ (Group 11)
Participants often noted a shift as they aged in their perception of the effect of such community norms about body size, weight, and health. ‘‘I felt like when I saw women getting older, I saw more and more problems—not just problems of aging, but problems of aging compounded by weight for me—this was my truth. I re-
Subgroup differences
Participants cited age, class, race, ethnicity, sexual identity, and gender expression as potential characteristics that differed within and across communities and that may influence participation in healthy weight interventions. Participants were divided on the need for a specific group for lesbian and bisexual women age 40 and older, with some desiring a targeted group that matched their demographics or shared identities and others reporting more interest in a group that focused on a common goal such as improved health. In more than half of the groups, women discussed gender expression differences (such as butch/femme)49 within lesbian communities and the associated body and appearance expectations. ‘‘I think it’s easier to be overweight and butch than it is to be overweight and femme. In some cases I do know some overweight femmes and they carry it off very, very well. And it’s all great. But.it is rarer to see overweight femmes than it is to see overweight butches. I have no idea why that is, exactly.’’ (Group 8) ‘‘I think within the lesbian community.there’s much more attention around folks who.use roles that (are) more appearance driven. It might be a lot of how you carry yourself and how you present—and how you dress—and whatever else. But, there is more attention given to how you look in whatever way that might be.’’ (Group 5)
In several of the groups, subgroup differences in perceived athletic ability were cited as a barrier to participating in physical activities. Frequently, these subgroup differences intersected with generational differences. ‘‘I just don’t feel welcome or capable of really participating in something that is going to be populated by people who have a long history of being really athletic. That’s a big part of our community.there’s this definite big subset of women who have always been involved in athletics.. There (are) a couple (of) groups that I thought about going to, but.I feel like I would get there and just not be capable of participating.’’ (Group 2) ‘‘I’ve been to those exercises classes.and it’s like, for every person like me, there’s 20 beautiful, 20-year-olds. It’s like I just can’t relate and they can’t relate to me.’’ (Group 10)
Family and partner support
Families past and present arose as both a barrier to and a facilitator for health and healthy weight. In several groups, women reported feeling pressure from family members about
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
changing their body size. Several participants reported being shamed by family members for being overweight. ‘‘I always thought that I was too heavy because (my mother) is really thin and she is sort of petite and she always felt that I was a fat kid basically and never hesitated to point it out.. As much as I try to (be) healthier and that I know that I’m okay and my partner loves me and my daughter loves me and my dogs love me, that nagging mom still calling me fat saying I need to lose some weight.. I feel good, but when she says that, I don’t feel good.’’ (Group 6) ‘‘Every time, my family used to greet me, ’Oh, you looked like you gained a lot of (weight).’ There’s no, ’Hi, how you doing?’ ’’ (Group 8)
On the other hand, sometimes families—particularly partners—were cited as a source of social support providing motivation and accountability to engage in physical activity. ‘‘We rarely work out together, but we may go to the gym together but she does her thing and I do my thing.. It just works out, because there’s somebody out there who’s encouraging you.’’ (Group 11) ‘‘I never thought I would get into yoga. My partner always did yoga. She tried to drag me out to do it a couple times and I wouldn’t go. But, I started doing this and it’s wonderful.’’ (Group 5) ‘‘When my girlfriend’s in town, because she eats very well and in a certain way—never has dessert and stuff like that—I always lose like ten pounds when she’s around.’’ (Group 7) ‘‘My partner is.younger than me and she loves to hike. And she loves to do a lot of stuff. And I’m saying, ‘Hey, I’ll see you when you get back.’ But, I’d like to join her in a lot of the stuff that she does and I can’t physically right now.’’ (Group 8)
Participants in many groups voiced concerns about social isolation as a result of living alone, and expressed an interest in interventions that directly acknowledged and addressed this fact. ‘‘I could drop dead right now and, if I live alone, no one would know until it smelled so bad.or I missed a meeting or something. So (an intervention should) ask us about those things. Who is in our life? Do you have some connections? Making sure that we are connected in a way, given that our families might look different.’’ (Group 1) ‘‘But there are a lot of people that are alone. And this is true whether you’re lesbian or not—they don’t feel like cooking for themselves.. The items that they buy, or go out to eat or whatever, are not nutritionally the greatest.. I don’t know how to get around that problem, but maybe somebody does.’’ (Group 4)
Awareness and tracking of diet and physical activity
In Groups 6 and 10, moderators initiated discussions about mindfulness interventions. The broader theme of awareness or paying attention emerged in four other groups. Despite some reservations about terminology, participants conveyed experience with such approaches, using terms such as ‘‘paying attention to what you’re eating’’ (Groups 3 and 4), ‘‘taking time’’ (Group 7), or ‘‘consciousness’’ (Group 2). Participants
181
described an interest in using specific approaches or tools to support mindfulness, such as ‘‘keeping a journal’’ (Group 4) and ‘‘keeping track’’ (Group 6) of behavior such as eating or physical activity. ‘‘When I was writing everything down, it helped me think about that conscious eating piece in terms of how I’ve been eating throughout the day. I don’t use it as a way of shaming myself, but just as a way of keeping a record. Because when you’re unconsciously eating, then you eat McDonald’s on the fly and Taco Bell for dinner, you don’t even realize (it). You put those together and it’s like 2,000 calories and most of it’s empty. So me putting it down just helps me keep a record.’’ (Group 11) ‘‘I think the keeping track and kind of being (aware) without any specific goal, but just writing it down, keeping track, being mindful, being more aware, and all of that—finding an easy way of doing that—and for me, it’s finding time to walk—would be really helpful.’’ (Group 3)
Discussion
This metasynthesis was specifically designed to confirm, clarify, and explore in greater detail previously identified themes regarding weight, health, and health behaviors among lesbian and bisexual women to guide development and refinement of healthy weight interventions in this community. This analysis forged new ground by elucidating the interrelationships among existing themes and identifying new themes. Emerging from this inquiry was a new and central theme, the effects of aging and the changing health needs that come with older age, a key factor identified in a large-scale survey of lesbian and bisexual older adults50 but explored in only a handful of qualitative inquiries that did not examine weight.50–52 In this analysis, multiple factors relating to weight among lesbian and bisexual women intersected with age to affect women’s ability to engage in behaviors to achieve healthy weight and support better health.53 These factors, previously identified in the literature, included physical and mental health status,29,54,55 mobility,4 body image,38,56 minority stress (stress caused by experiences with antigay stigma),53 competing demands in terms of time and cost,32 social support, or lack thereof,30 as well as family37 and partners.57 Despite the methodological steps taken to maximize validity, some limitations merit consideration.43,45 This qualitative meta-analysis used primary data from 11 different groups in three geographic locations (San Francisco Bay area; Washington, D.C. area; and Columbia, Missouri). Some locations contributed a greater volume of data than others. The semistructured discussion guides for the groups (ranging from two to eight participants) were not originally designed to be consistent across sites, as each site had a different proposed intervention. Two sites, for example, were developing health care provider education components. In addition, recruitment of focus group participants varied considerably by site: methods included recruitment through institutions’ social media sites, from prior health interventions, among community members using snowball techniques, from clinical settings, and from community members known by the study staff. Furthermore, the analysis was conducted on de-identified transcripts without individual participant characteristics. We
182
GARBERS ET AL.
Table 3. Summary of Key Themes and Implications of Healthy Weight Intervention Content and Format Development and Recruitment Approaches, with Illustrative Quotes Key Theme Aging{
Implications for Interventions Information on aging, menopause, and effects on health is important. Emphasize importance of community connections to address concerns about aging.
Physical and Mental Health Status
Recognize and address mobility, resources, and health status as barriers to physical activity and healthy eating. Stress-reduction techniques and other approaches to improving mental health may be relevant.
Community Norms About Body Size
Focus on health and healthy behaviors, not weight loss.
Illustrative Quotes on Specific Ways to Address Theme in Intervention Content, Format and Recruitment Approaches ‘‘I think it’s really helpful to help people understand and put into the conversation that there are certain changes that come about (with aging), and these are some of the tools for coping.’’ (Group 2) ‘‘Actually what’s true with this—and with many things that I don’t feel are addressed around nutrition and weight—is that things change with age.’’ (Group 6) ‘‘I think one of the specific health things I would want to discuss and it’s not particularly for lesbians, but just the older part, the (question of) do you take hormone (replacement therapy), do you not, why do you need them, what’s going to happen if you do or you don’t. The whole libido thing.’’ (Group 4) ‘‘It’s about time somebody listens to us (lesbian and bisexual women over age 40), you know, because we seem to be the forgotten bunch. With all of the health issues that we have that are different from them like the heart issues and things like that, you know, finding out that we need to be treated in a different way.’’ (Group 6) ‘‘Part of my desire to grow healthier is that I’m aging.and I don’t want to be sedentary as an older person and I know that I have to do something now.’’ (Group 11) ‘‘As we get older—not even just lesbians—and without a partner or with a partner, is a topic (to address).’’ (Group 4) ‘‘Everyone is going through this. Everyone is getting older. (I would like information on) ‘in this particular situation, this is what (worked).’ But it seems that no one keeps a record of success. They just keep a record of everything that makes you get sick.’’ (Group 1) ‘‘So telling me ‘you should change your eating habits or exercise’... Sometimes you have injuries or stuff like that, so it doesn’t help me to tell me to work out and exercise if you don’t guide me.’’ (Group 1) ‘‘I would love to see specific exercises and use of specific equipment, like at (a) fitness center, that would be beneficial for specific things. (For example,) ‘this is how you use a machine, and this is what you should do and if you’re having knee issues, you should use the bike for so many times to build it up before you get the knee replaced.’’’ (Group 4) ‘‘With my age (and) what have you.even having someone come in and say, ‘Hey, here’s a class on how to put your socks on when you’re overweight,’ that’s an exercise believe it or not and it would add value. There are.techniques.that I think are necessary and very helpful and that I would totally.be interested in. (Group 9) ‘‘I’m interested in some tools on how to (be more healthy in terms of) nutrition and exercise, both categories of what would work for a real person in the real world, and also stress management, because.I know for me, it ties into the way I eat.’’ (Group 2) An intervention should ‘‘at least to try to get to the root cause, and not necessarily (just weight loss). Exercise and food help.you feel better. When you do exercise—it doesn’t (just) contribute to the weight loss.’’ (Group 1) ‘‘It’s about bringing positive energy into your life, getting healthier. So, yeah, there’s got to be better choices of words (in the recruitment materials).’’ (Group 2) (continued)
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
183
Table 3. (Continued) Key Theme
Subgroup Differences
Implications for Interventions
Address identity differences within lesbian and bisexual women’s communities.
Promote activities as ‘‘all abilities welcome.’’
Family
Awareness and Tracking{
Ensure interventions are inclusive of the diversity within lesbian and bisexual women’s communities (e.g., disabilities movement, fat activism, recovery communities). Address impact that family of origin has on body image. Acknowledge the role of family members (partners and children) and household structure in health-promoting behaviors. Promote social support within interventions to address concerns about isolation. Incorporate mindfulness in many forms using familiar terminology. Provide support for tools for tracking.
{
Illustrative Quotes on Specific Ways to Address Theme in Intervention Content, Format and Recruitment Approaches ‘‘I don’t think the idea is.doing exercises to get like 16-yearold beautiful again. Just to be healthy.so that aging processes slow down.’’ (Group 9) ‘‘(Using the term ‘health at any size’) is a marker for people like me to see that you’re not coming at it solely from a weight loss perspective, so I think that is.a potentially helpful language thing to do.’’ (Group 3) ‘‘We’re talking about weight and we’re talking about health. Is there some kind of way that (the intervention is) really going to be looking at the real impacts (of being overweight)?.Is it possible for a person to be ‘overweight’ and to be healthy?’’ (Group 7) ‘‘There’s not a big lesbian thing that glues us all together.’’ (Group 11) ‘‘I’m interested in learning more about health, and having a contrast to the constant television commercials about skinny, young straight women.’’ (Group 2) ‘‘(There could be) an intersection between different groups, and that would be a beautiful thing happening. How can you find those intersections, because after all, we lesbians are part of all those groups.’’ (Group 3) ‘‘We’ve got the real sports-minded people.and folks that are real couch potatoes. So it’s a whole different set of problems and attitudes. So that’s one other way of divvying people up.’’ (Group 4) ‘‘(Using the terms) every size (and) every ability would attract people with disabilities.’’ (Group 3) ‘‘I’m not so much interested in uncovering the deep roots of my childhood that are attached to my weight and sharing that on a public level and all that kind of stuff, but I really would love some tools.’’ (Group 2) ‘‘Include content on how to maintain an interest in eating. That it seems to have some pleasure involved, particularly if you’re alone, you know, there’s so many decisions you have to make.’’ (Group 4) ‘‘Someone to exercise with certainly helps. Having a group, maybe just to meet whoever shows up on particular days to walk.’’ (Group 4) ‘‘Mindfulness.. I see that word and I find that word attractive.. I don’t think you want to necessarily take those words out, and yet, I think you want to find a translation that’s friendly.’’ (Group 3) ‘‘I had seen mindfulness around for a long time, and it was just like, ‘Oh, that’s for white people over there.’ But then something happened in my life where I needed to be able to reduce my stress.. I took the jump into mindfulness.. So now, I’m an advocate for it and I really believe in it.. But that whole concept of, ‘Who’s that for?’ At first, I was like, ‘Oh that’s over there.’ ’’ (Group 5) ‘‘I make time for work, I make time for other things. I don’t make time to exercise. I just don’t, and I need to. Just making the time for it, making that commitment, whatever that takes, I don’t know—logging it? Something.’’ (Group 4) ‘‘You talk about mindfulness—just paying attention to what you’re eating, keeping a journal of what you eat and logging it (helps). Maybe not even a plan, but.really seeing what you’re eating, is a great start.’’ (Group 2)
Newly identified theme. Themes not marked with a dagger were previously identified in the literature.
184
were, therefore, unable to report findings by subgroups such as age, which has been found to be an important moderating factor in other qualitative studies32 or other potentially important factors such as race, ethnicity, disability status, or gender identity. Still, the approach used in conducting this analysis has a number of strengths. By including primary data from the voices of ethnically diverse older women (ages 38–80) from three geographic regions of the United States, we addressed limitations of the narrow demographic focus and small sample size that have been challenges to conducting research with lesbian and bisexual women.33,34 This analysis yielded specific guidance on ways healthy weight interventions for adult lesbian and bisexual women can be developed and refined (Table 3). Rather than offer standard information, program implementers should provide direction and guidance that is embedded in community norms and tailored to the goals and functional status of the recipient. Incorporating techniques to support ‘‘paying attention’’ or ‘‘awareness of’’ eating and physical activity emerged as a useful approach to help women engage in healthy behaviors no matter their subgroup differences. Conclusion
This synthesis of qualitative data highlights the varied and unique barriers that lesbian and bisexual adult women face in engaging in physical activity and healthy eating, and points the way for interventions to surmount these barriers.3,17,58,59 Any intervention that seeks to improve health for adult lesbian and bisexual women should recognize the heterogeneity of subgroups within communities, and the individuals within them, when addressing change. This synthesis supports Fogel, Calman, and Magrini’s31 conclusion that listening to and determining what women want and need from interventions is necessary to promote healthier lives. Further examination of intervention approaches to incorporate and address these concerns, and the impact of such interventions on health status among lesbian and bisexual adult women, is merited. Acknowledgments
The study was funded via contracts from the Office on Women’s Health, Healthy Weight Initiative, to five individual projects across the United States, and this paper was developed via a cross-site editorial committee. These contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government. Contract Numbers: George Washington University: HHSP23320095635WC; Lewin Group: HH SP223320095639WC; Impaq International (formerly Berkeley Policy Associates): HHSP233420095615; NORC: HHSP233 20095647; Research Triangle Institute: HHSP22332009563 9WC; The CDM Group HHSP23320095629WC and HHSP2 3337005T-01 Author Disclosure Statement
The primary data for this metasynthesis were collected by the institutions of the authors (excluding Garbers, McDonnell, Radix and Haynes). IRB approval was obtained at each institution for primary data collection protocols and procedures. No competing financial interests exist.
GARBERS ET AL. References
1. Kulie T, Slattengren A, Redmer J, et al.: Obesity and women’s health: An evidence-based review. J Am Board Fam Med 2011;24:75–85. 2. Lash MM, Armstrong A: Impact of obesity on women’s health. Fertil Steril 2009;91:1712–1716. 3. Bowen DJ, Balsam KF, Ender SR: A review of obesity issues in sexual minority women. Obesity 2008;16:221–228. 4. Conron KJ, Mimiaga MJ, Landers SJ: A population-based study of sexual orientation identity and gender differences in adult health. Am J Public Health 2010;100:1953–1960. 5. Eliason MJ, Ingraham N, Fogel SC, et al.: A systematic review of the literature on weight in sexual minority women. Women’s Health Issues 2015;25:162–175. 6. Ward BW, Dahlhamer JM, Galinsky AM, Joestl SS: Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013. Natl Health Stat Report 2014;77:1–12. 7. Visscher TL, Seidell JC: The public health impact of obesity. Annu Rev Public Health 2001;22:355–375. 8. Aronne LJ, Wadden T, Isoldi KK, Woodworth KA: When prevention fails: Obesity treatment strategies. Am J Med 2009;122:S24–S32. 9. Neter JE, Stam BE, Kok FJ, et al.: Influence of weight reduction on blood pressure: A meta-analysis of randomized controlled trials. Hypertension 2003;42:878–884. 10. Grave RD, Centis E, Marzocchi R, et al.: Major factors for facilitating change in behavioral strategies to reduce obesity. Psychol Res Behav Manag 2013;6:101–110. 11. Thorogood A, Mottillo S, Shimony A, et al.: Isolated aerobic exercise and weight loss: A systematic review and metaanalysis of randomized controlled trials. Am J Med 2011; 124:747–755. 12. Umpierre D, Ribeiro PA, Kramer CK, et al.: Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: A systematic review and meta-analysis. JAMA 2011;305:1790–1799. 13. Anderson JW, Kendall CW, Jenkins DJ: Importance of weight management in type 2 diabetes: Review with meta-analysis of clinical studies. J Am Coll Nutr 2003;22:331–339. 14. Shaw K, Gennat H, O’Rourke P, Del Mar C: Exercise for overweight or obesity. Cochrane Database Syst Rev 2006;(4):CD003817. 15. Sarwer DB, Moore RH, Diewald LK, et al.: The impact of a primary care-based weight loss intervention on the quality of life. Int J Obes 2013;37:S25–S30. 16. Jeffery RW, Epstein LH, Wilson GT, et al.: Long-term maintenance of weight loss: Current status. Health Psychol 2000;19:5–16. 17. Douketis JD, Macie C, Thabane L, Williamson DF: Systematic review of long-term weight loss studies in obese adults: Clinical significance and applicability to clinical practice. Int J Obes 2005;29:1153–1167. 18. Moroshko I, Brennan L, O’Brien P: Predictors of dropout in weight loss interventions: A systematic review of the literature. Obes Rev 2011;12:912–934. 19. Mann T, Tomiyama AJ, Westling E, et al.: Medicare’s search for effective obesity treatments: Diets are not the answer. Am Psychol 2007;62:220–233. 20. Dansinger ML, Tatsioni A, Wong JB, et al.: Meta-analysis: The effect of dietary counseling for weight loss. Ann Intern Med 2007;147:41–50. 21. Akers JD, Estabrooks PA, Davy BM: Translational research: Bridging the gap between long-term weight loss
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
22.
23. 24. 25. 26. 27.
28.
29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.
43.
maintenance research and practice. J Am Diet Assoc 2010; 110:1511–1522. Brittain DR, Dinger MK. BE-PALS: An innovative theorybased intervention to promote moderate physical activity among adult lesbians. Women in Sport and Physical Activity Journal 2014;22:71–75. Van Dorsten B, Lindley EM: Cognitive and behavioral approaches in the treatment of obesity. Med Clin North Am 2011;95:971–988. Dubnov-Raz G, Berry EM: The dietary treatment of obesity. Med Clin North Am 2011;95:939–952. Elfhag K, Ro¨ssner S: Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obes Rev 2005;6:67–85. Teixeira PJ, Silva MN, Coutinho SR, et al.: Mediators of weight loss and weight loss maintenance in middle-aged women. Obesity 2010;18:725–735. Napolitano MA, Papandonatos GD, Borradaile KE, et al.: Effects of weight status and barriers on physical activity adoption among previously inactive women. Obesity 2011; 19:2183–2189. Neve M, Morgan PJ, Jones P, Collins C: Effectiveness of webbased interventions in achieving weight loss and weight loss maintenance in overweight and obese adults: A systematic review with meta-analysis. Obes Rev 2010;11:306–321. Roberts SJ, Stuart-Shor EM, Oppenheimer RA: Lesbians’ attitudes and beliefs regarding overweight and weight reduction. J Clin Nurs 2010;19:1986–1994. Fogel S, Young L, McPherson JB: The experience of group weight loss efforts among lesbians. Women Health 2009;49: 540–554. Fogel SC, Calman L, Magrini D: Lesbians’ and bisexual women’s definition of health. J Homosex 2012;59:851–863. Brittain DR, Baillargeon T, McElroy M, et al.: Barriers to moderate physical activity in adult lesbians. Women Health 2006;43:75–92. Crisp C: Selected characteristics of research on lesbian women: 1995–1997. J Homosex 2003;44:139–155. de Vries B, Croghan CF: LGBT aging: The contributions of community-based research. J Homosex 2014;61:1–20. Sandelowski M: Sample size in qualitative research. Res Nurs Health 1995;18:179–183. Thomas J, Harden A: Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45. Bowen DJ, Balsam KF, Diergaarde B, et al.: Healthy eating, exercise, and weight: Impressions of sexual minority women. Women Health 2006;44:79–93. Kelly L: Lesbian body image perceptions: The context of body silence. Qual Health Res 2007;17:873–883. Chmielewski JF, Yost MR: Psychosocial Influences on Bisexual Women’s Body Image Negotiating Gender and Sexuality. Psychol Women Q 2013;37:224–241. Sandelowski M, Barroso J: Finding the findings in qualitative studies. J Nurs Scholarsh 2002;34:213–219. Hruschka DJ, Schwartz D, John DC, et al.: Reliability in coding open-ended data: Lessons learned from HIV behavioral research. Field Methods 2004;16:307–331. Popay J, Roberts H, Sowden A, et al.: Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme (Version 1). Lancaster, England: Institute of Health Research, 2006. Finfgeld DL: Metasynthesis: The state of the art—so far. Qual Health Res 2003;13:893–904.
185
44. Booth A: ‘‘Brimful of STARLITE’’: Toward standards for reporting literature searches. J Med Libr Assoc 2006;94: 421–429. 45. Whittemore R, Chase SK, Mandle CL: Validity in qualitative research. Qual Health Res 2001;11:522–537. 46. Rodgers BL, Cowles KV: The qualitative research audit trail: A complex collection of documentation. Res Nurs Health 1993,16:219–226. 47. Bodnar LM, Siega-Riz AM, Simhan HN, et al.: Severe obesity, gestational weight gain, and adverse birth outcomes. Am J Clin Nutr 2010;91:1642–1648. 48. Huxley CJ, Clarke V, Halliwell E: A qualitative exploration of whether lesbian and bisexual women are ‘protected’from sociocultural pressure to be thin. J Health Psychol 2014;19:273–284. 49. Levitt HM, Puckett JA, Ippolito M, Horne SG: Sexual minority women’s gender identity and expression: Challenges and supports. J Lesbian Stud 2012;16:153–176. 50. Fredriksen-Goldsen KI, Emlet CA, Kim HJ, et al.: The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: The role of key health indicators and risk and protective factors. Gerontologist 2013;53:664–675. 51. King S, Dabelko-Schoeny H: ‘‘Quite frankly, I have doubts about remaining’’: Aging-in-place and health care access for rural midlife and older lesbian, gay, and bisexual individuals. J LGBT Health Res 2009;5:10–21. 52. Orel NA: Investigating the needs and concerns of lesbian, gay, bisexual, and transgender older adults: The use of qualitative and quantitative methodology. J Homosex 2014;61:53–78. 53. Lick DJ, Durso LE, Johnson KL: Minority stress and physical health among sexual minorities. Perspect Psychol Sci 2013;8:521–548. 54. Diamant AL, Wold C: Sexual orientation and variation in physical and mental health status among women. J Women’s Health 2003;12:41–49. 55. Brittain DR, Dinger MK, Hutchinson SR: Sociodemographic and lesbian-specific factors associated with physical activity among adult lesbians. Women’s Health Issues 2013; 23:e103-e108. 56. Morrison MA, Morrison TG, Sager CL: Does body image satisfaction differ between gay men and lesbian women and heterosexual men and women? A meta-analytic review. Body Image: An International Journal of Research 2004; 1:127–138. 57. Markey CN, Markey PM: Weight disparities between female same-sex romantic partners and weight concerns examining partner comparison. Psychol Women Q 2013;37:469–477. 58. Stephens S, Cobiac L, Veerman L: Improving diet and physical activity to reduce population prevalence of overweight and obesity: An overview of current evidence. Prev Med 2014;62:167–178. 59. Boehmer U, Bowen DJ, Bauer GR: Overweight and obesity in sexual-minority women: Evidence from population-based data. Am J Public Health 2007;97:1134–1140.
Address correspondence to: Samantha Garbers, PhD Research & Evaluation Unit Public Health Solutions 40 Worth Street, 5th Floor New York, NY 10013 E-mail: [email protected]
(Appendix follows/)
186
GARBERS ET AL.
Appendix 1. Themes Identified in Published and Unpublished Reports Author Bowen 2006 (6 themes)
Brittain 2006 (6 themes)
Roberts 2010 (3 themes) Fogel 2009 (7 themes)
Fogel 2012 (5 themes)
Kelly 2007 (5 themes)
Chmielewski 2013 (4 themes)
Site A (Unpublished Report) (6 themes)
Site B (Unpublished Report) (17 themes)
Theme in Original Source (verbatim) Body image Health Weight loss Diet/healthy eating Physical activity/exercise Subgroup differences Intrapersonal Interpersonal Institutional Community/Society Public Policy Lesbian-Specific Generational differences Acceptance of weight and body images Effect of minority stress and depression on risk behaviors Desire to improve health History of weight loss attempts Shame Unaccepted due to sexual identity Safety and acceptance Physical environment Social support Feelings about health Benefits of a healthy body Descriptions of a healthy body Strategies to get a healthy body Exercise Lesbian invisibility Fear of misinterpretation of intent Discomfort during intimacy Questionable feedback Body image and sexual identity Tension between judging and experiencing body Unique struggles of being a bisexual woman Finding body affirmation in LGBT communities and from feminist identity Body image and romantic relationships with men and women Assumptions of heteronormativity Personalization Prevention Provider specialty Communication: provider engagement and non-engagement Insurance Lesbian community norms Weight and health in the San Francisco LB community American food culture and media Health care and cultural competency Family and community Gyms Groups Physical activity Healthy eating Terminology Location Group structures Social influence on body image Importance of patient-provider interaction Barriers to implementing change Stress & stress reduction Non-provider sources of health information (continued)
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
187
Appendix 1. (Continued) Author Site D (Unpublished Report) (11 themes)
Theme in Original Source (verbatim) Finding accessible activities that can accommodate pain mobility and skill level Making eating well tasty and fun Understanding what healthy means/looks like Other people can hold us accountable, encourage us, and make activities more fun Individual exercise = reaching goals/meditation/relaxation/self-care Group exercise = social, communal, fun Making time for healthy living is a difficult thing to do We blame ourselves for our unhealthiness We set rigid standards for what makes exercise worthwhile Confusion about what ‘‘healthy’’ is ‘‘Exercise’’ = a dirty word, but playing basketball sounds fun
LGBT, lesbian, gay, bisexual, and transgender; LB, lesbian and bisexual.
Aging, Weight, and Health Among Adult Lesbian and Bisexual Women: A Metasynthesis of the Multisite ‘‘Healthy Weight Initiative’’ Focus Groups Samantha Garbers, PhD,1,2 Cheryl McDonnell, PhD,3 Sarah C. Fogel, PhD,4 Michele Eliason, PhD,5 Natalie Ingraham, MPH,6 Jane A. McElroy, PhD,7 Anita Radix, MD, MPH,8,9 Suzanne G. Haynes, PhD10
Abstract
Purpose: Adult lesbian and bisexual (LB) women are more likely to be obese than adult heterosexual women. Achieving a healthy weight reduces health risks and improves quality of life, but the evidence based on successful weight interventions is limited. To inform a national initiative, a metasynthesis (a form of qualitative metaanalysis) of focus group data was conducted to gather lesbian and bisexual womens’ perspectives. Methods: Analysis used de-identified transcripts and narrative reports from 11 focus groups guided by different semi-structured discussion guides with 65 participants from five locations. A literature search was conducted to identify existing themes in published literature and unpublished reports. Results: Six key themes were identified: aging; physical and mental health status; community norms; subgroup differences; family and partner support; and awareness and tracking of diet and physical activity. Participants expressed feeling unprepared for age-related changes to their health and voiced interest in interventions addressing these issues. Their perspectives on community acceptance of body size shifted as they aged. Participants cited age, class, race, ethnicity, sexual identity, and gender expression as potential characteristics that may influence participation in interventions. Families were both a barrier to and a facilitator of health behaviors. Awareness and tracking of dietary habits, stressors, and physical activity levels emerged as a theme in more than half of the groups. Conclusion: An unsolicited, overarching theme was aging and its influence on the participants’ perspectives on health and weight. Interventions should be tailored to the needs, goals, and community norms of LB women. Key words: aging,
bisexual, health promotion, lesbian, obesity, weight.
Introduction
O
besity and being overweight are associated with adverse health conditions in women, including diabetes, coronary artery disease, joint pain, some cancers, and reduced quality of life.1,2 Additional evidence shows that weight varies by sexual orientation, with several reports indicating that adult lesbian and bisexual women are more likely
to be obese than adult women who identify as heterosexual.3–6 In the 2013 National Health Interview Survey (the first to include a question on sexual orientation), 37 percent of adult women who identified as gay or lesbian and 41 percent who identified as bisexual were obese, compared with 28 percent who identified as straight or heterosexual.6 In light of the public health costs of obesity in general7 and identified disparities in obesity prevalence by sexual orientation, the
1
Research & Evaluation Unit, Public Health Solutions, New York, New York. Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, New York. 3 The CDM Group, Bethesda, Maryland. 4 School of Nursing, Vanderbilt University, Nashville, Tennessee. 5 Department of Health Education, San Francisco State University, San Francisco, California. 6 Lyon-Martin Health Services, San Francisco, California. 7 Department of Community & Family Medicine, University of Missouri, Columbia, Missouri. 8 Department of Medicine, New York University, New York, New York. 9 Callen-Lorde Community Health Center, New York, New York. 10 Office on Women’s Health, U.S. Department of Health & Human Services, Washington, D.C. 2
176
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
U.S. Department of Health and Human Services Office on Women’s Health funded five projects to develop and test community-based Healthy Weight Initiatives for Lesbian and Bisexual Women. Achieving a healthy weight8,9 has been shown to reduce health risks10–14 and improve quality of life,15 but the evidence base on what makes weight interventions successful in the general population is limited by participant attrition and a lack of generalizability of findings,16–21 and the fact that only one intervention has been conducted specifically with lesbian and bisexual women.22 Recent reviews suggest that weight interventions must be tailored to the individual, ideally with community input.10,23,24 Individual and structural barriers to achieving and maintaining optimal health, including health behaviors, self-efficacy, body image, and limited mobility, have been reported among adult women, but only a few studies have addressed lesbian and bisexual women.25–28 However, previous qualitative studies of lesbian and bisexual women have identified issues specific to this community, including a focus on health rather than on weight loss; the importance of social support; minority stress and isolation; generational differences; lesbian community norms regarding the acceptability of larger bodies; and the impact of stress on wellness.29–32 Focus groups were convened at five geographic locations across the country to gather lesbian and bisexual women’s specific perspectives on topics relevant to the national initiative such as health behaviors, barriers and factors that promote exercise and healthy eating, participant recruitment strategies, and the preferred content and delivery of the interventions. A thematic synthesis was conducted to add to the literature
177
reflecting lesbian and bisexual women’s perspectives. This metasynthesis, a form of qualitative meta-analysis, counteracts documented challenges in recruiting sufficient numbers of lesbian and bisexual women for participation in research, by bringing together data from multiple focus groups.33–35 Methods Recruitment
Four out of five funded institutions contributed de-identified transcripts from separate focus groups for joint analyses. Eleven focus groups were conducted from January to April 2013 at five geographic locations: Washington, D.C.; San Francisco, Oakland, and Santa Rosa, California; and Columbia, Missouri. The Institutional Review Board (IRB) at each institution approved the protocols and materials. Eligibility criteria included being age 40 and over, currently female identified (regardless of sex assigned at birth), and identifying as lesbian or bisexual. Two sites had additional inclusion criteria: body mass index ‡ 27.5 according to self-reported height and weight (Site C) or ‘‘at risk for weight-related health problems’’ (Site B). Primary data collection
Each focus group was guided by one to two moderators using different semistructured discussion guides: The planned discussion topics, summarized in Table 1, (full list in Supplementary Data: Focus Group Discussion Guides), expanded on themes identified in previously published studies of health, weight loss, physical activity, and diet among lesbian and
Table 1. Topic Areas Included in Focus Group Discussion Guides Group General Topics About Health and Healthy Weight
1
2
Definitions and feelings about health and being healthy Interactions with providers regarding weight, nutrition, exercise, and health Current health habits (nutrition, exercise, stress relief) Support and motivation for health and health habits Barriers and challenges to staying healthy (nutrition, exercise, other) Sources of information on health, nutrition, and exercise Relationship between health and weight
x x
x x
x x
x
Lesbian and Bisexual-Specific Topics
1
2
Provider understanding of health needs of lesbian and bisexual women Specific health needs and concerns of lesbian and bisexual women Cultural differences in lesbian and bisexual women communities Attitudes and messages about weight in lesbian and bisexual women communities Raising awareness of health issues in lesbian and bisexual communities
x
Intervention-Specific Topics
1
Interest in and feedback about intervention components, topics, and structure Recruitment and messaging to promote intervention
x
3
4
5
6
7
8
9
10
x
x
x
x
x
x
x
x
x
x
x
x
x
x x
x x
x x
x x
x x
x x
4
5
6
7
8
9
10
x
x
x
x
x
x
x
x
x
x
x
x
x
11 x
x
3
x
x x x
11
x x x 2
3
4
5
6
7
8
9
10
11
x
x
x
x
x
x
x
x
x
x
x
178
GARBERS ET AL.
bisexual women (Appendix 1).29–32 (Supplementary data is available online at www.liebertpub.com/lgbt.) Each focus group was audiotaped; de-identified verbatim transcripts and narrative reports were used for analysis. This qualitative analysis of de-identified secondary data was deemed exempt from review by the IRB at the Healthy Weight Initiative Coordinating Center. Literature search and identification of initial themes
Consistent with methodology for metasyntheses, a literature search was conducted to identify existing themes.36 Articles were considered that: explored health, healthy weight, weight loss, exercise, and diet and/or physical activity; were published in English between January 2003 and December 2013; included adult lesbian and/or bisexual women; and used qualitative data. The lead author conducted the search. To ensure conceptual saturation,36 and for consistency with search terms used by Bowen and Balsam,36,37 a search of two electronic databases—PubMed and SCOPUS (health science/social science/humanities)—was conducted using the search terms: lesbian OR bisexual OR (sexual minority AND women); health OR healthy; weight OR weight loss OR exercise OR diet OR physical activity OR fitness; and qualitative OR focus group OR interview. From the 27 articles identified, we excluded studies that did not: include adult lesbian or bisexual women (n = 14); present findings separately by gender and sexual orientation (n = 1); address definitions of health, healthy weight, diet, or physical fitness or activity (n = 3); or include qualitative data (n = 5). This process yielded four eligible peer-reviewed manuscripts. We reviewed the bibliographies for each reference cited in the four published papers and found three additional unique papers, which yielded seven published articles.31,38,39 Finally, the four unpublished reports summarizing the focus group findings written by the facilitators were included, for a total of 11 original sources of data for thematic synthesis. The first author conducted the theme identification using existing literature, with confirmation and refinement by the second author. Any subheading within a section labeled ‘‘Results’’ or ‘‘Findings’’ was incorporated as a theme, as was any text within a conceptual map or table.36,40 The themes identified in the 11 underlying studies (listed in Appendix 1) became the initial codes for analysis of the transcripts. Coding
Two independent coders conducted line-by-line coding. Coding agreement was determined after completion of each transcript. Discrepancies in coding were resolved through consensus. Newly identified themes were proposed at the conclusion of each transcript review. If the new themes were agreed upon by the two coders, a new code was added in NVivo qualitative data analysis software (QSR International Pty Ltd., Version 10, 2012). Iterative coding was conducted: when any new theme was identified, previously reviewed transcripts were recoded. Conceptual saturation was achieved by the fourth transcript, and no new themes were identified in the remaining transcripts.36 After final review, agreement was 99 percent and kappa was 0.76, representing substantial to excellent agreement.41 Concept mapping
After completion of transcript coding, linkages between themes were identified by running NVivo-based matrix code
FIG. 1.
Conceptual map of the six identified key themes.
queries. Concept mapping (Figure 1) was used to represent the linkages among the identified themes.42 This approach enabled us to identify relationships across the focus groups as the evidence was synthesized.36,42 Methods to improve validity and reliability
Methods to maximize trustworthiness of the analysis (validity) included the following: credibility, the extent to which findings reflect the experience of participants, was enhanced by drawing themes from multiple underlying studies, using broad literature search terms, and providing verbatim transcription;43,44 authenticity, an awareness of the subtle differences between the voices of all participants,45 was improved by using matrix codes to identify rare or atypical themes;43 and matrix coding for both negative and positive attitudes facilitated identification of contradictory findings.45 A lengthy audit trail outlining the methods for identifying themes was used to enhance reliability (consistency).46 Results Focus group participants
A total of 65 women (aged 38 through 80) participated in the 11 focus groups (Table 2). In total, 14% of participants were Black or African American, 8% Hispanic or Latina, and 9% Asian, Native American, or an unspecified race other than White. Findings
Six key themes were identified in this analysis: aging, physical and mental health status, community norms, subgroup differences, family and partner support, and awareness and tracking of eating and physical activity. Key themes were identified based on frequency of coding, their applicability
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
179
Table 2. Summary of Focus Groups and Sample Characteristics (n = 65) Site
Focus Group Recruitment/ Setting(s)
Group Number
A
Clinical & Community
1
B
Community
C
Clinical & Community
D
Community
Month and Year
Moderator (n)
n
Age Range
March 2013
2
9
38*–61
2 3
January 2013 January 2013
1 1
8 6
51–61 46–72
4 5 6
February 2013 March 2013 March 2013
1 1 2
7 2 5
62–80 40–45 40–65
7
March 2013
1
4
40–55
8
April 2013
2
7
40–65
9
April 2013
1
5
40–65
10
April 2013
1
4
40–65
11
March 2013
1
8
41–59
Racial/Ethnic White (n = 6) Non-White (n = 3) White (n = 8) White (n = 3) Latina (n = 1) Native American (n = 1) Black (n = 1) White (n = 7) White (n = 2) Latina (n = 2) White (n = 2) Asian (n = 1) White (n = 3) Black (n = 1) White (n = 3) Black (n = 2) Latina (n = 2) Black (n = 3) White (n = 2) White (n = 3) Black (n = 1) White (n = 7) Black (n = 1)
*One participant, age 38, was included as a key stakeholder.
to informing the interventions, and the extent to which our findings uncovered new insight beyond the existing literature. Each of these key themes had a coding frequency of more than 50 times and was discussed in at least half of the groups. Three of the six key themes were identified in all 11 groups: physical and/or mental health status, community norms, and subgroup differences. The themes of aging and family influences were mentioned in 10 groups and awareness and tracking in six groups. Two key themes—aging, and awareness and tracking— were not previously identified in the literature. Several themes previously identified in the literature were confirmed: preference for interventions that focus on promoting health and on the ability to participate fully in life rather than on weight loss only;29,31,37 cultural norms within lesbian communities that are accepting of larger body types;29,32,38,47,48 and, importance of social support and group structures in initiating and maintaining healthy behaviors.29–32,37,38,47,48 Aging
Aging was not a planned discussion topic in any of the groups, and was not identified as a theme in the published or unpublished reports, yet the theme emerged in 10 of the 11 groups. Many participants cited aging as a key determinant of health and wellbeing and, in many cases, as a source of stress.
‘‘When I hit 40, my health started going downhill in a big way.’’ (Group 2) ‘‘You get old and people don’t want to hire you even though you got degrees and experience.. I did find myself sometimes wondering, ‘Is it because I’m older? Is it because I’m a lesbian?’ It’s hard not to internalize that. That’s one of my stressors.’’ (Group 9)
Health changes related to increased age and menopause (including apparent changes in metabolism and inability to control weight gain) were a specific concern cited in most of the groups. Many expressed feeling unprepared for age-related changes to their health and voiced an interest in an intervention to directly address these issues. ‘‘I am pretty healthy.but I have a lot of complaints, and that includes weight issues. I just need others to talk about health. I don’t really talk about the aches and pains and changes and things that make me hate the way I look, and all that stuff about aging.’’ (Group 3) ‘‘Once your body goes through changes some of the stuff you do doesn’t apply anymore. So telling me you should change your eating habits or exercise.doesn’t help me. (It doesn’t) tell me.why you suddenly gain all this weight when you’re 50.’’ (Group 1)
Physical and mental health status ‘‘I think once you get to our age, there’s just no way of avoiding the fact that you’re falling apart.. It’s one thing after another. It’s like keeping up an old car.’’ (Group 4)* *Group discussion topics are reviewed in Table 1 and the Supplementary Data: Focus Group Discussion Guides. Composition of groups is summarized in Table 2.
Most participants defined health as the absence of physical and mental health conditions that impair quality of life. For many, health conditions (including stroke; diabetes; limited mobility due to pain, arthritis, or disability; or depression) limited their ability to engage in physical activity. At the same time, excess weight was perceived as one of many
180
GARBERS ET AL.
factors that impacted health, sometimes creating a ‘‘snowball effect’’ (Group 10) when considered in the context of medical conditions.
gret the amount of time I spent under that belief that I could be healthy at any size, because I’m not sure that’s sustainable as you age.’’ (Group 1)
‘‘We’re all at the particular age where we just want to be able to get around and feel good.. I think that when you carry more weight.with the joints and everything else, it does limit your activity. It limits my activity. I’m looking.to (not) be incapacitated and having to be in a wheelchair— all that kind of stuff.’’ (Group 8)
‘‘Like, the stuff on TV doesn’t really affect me a whole lot these days. And when I was younger, it really would. But I would like to feel healthy, I would like to not have pain. When it gets right down to it, I would like to be able to move with more grace and stuff like that. I’d like to feel better in my body.. I think in our community, there is a wider range of acceptance, and that’s nice. There’s extremists, too, because really, when you have a huge amount of weight, and you have diabetes, and you have knee surgeries, it’s kind of like, come on, that’s not good either.’’ (Group 3)
‘‘I want to feel good inside and out.. There are certain measurements that I’m really looking for—my fasting blood sugar right now is too high.. I’d like to reduce pain, physical pain.. And then there’s mood stuff.the anxiety and stress. So there’s.mind and body. I’d like to.feel better inside. And then the body part, I’d like to feel better, you know, more alacrity getting out of bed. Not going, ‘Ouch!’ ’’ (Group 3)
Community norms
Several groups initiated discussions about lesbian community norms around body size and size acceptance. There was agreement that such social influences had an impact on health behaviors in both positive and negative ways. Community acceptance of body size differences was mentioned in many groups as a source of support, particularly in younger years and during the coming out process. These norms were viewed as being in opposition to the images of thinness that, ‘‘the mainstream media pushes (in terms of) what health should look like’’ (Group 11). Yet, in almost all groups, participants cited a need for ‘‘balance,’’ recognizing health problems that can result from heavier weight. ‘‘It kind of is the double-edged sword.. There is this Madison Avenue image of what you’re supposed to look like.and I think that the fat activist community within women’s/lesbian community is really important for redefining that and saying there’s not just one way to be beautiful, and you don’t have to feel like crap about yourself because you don’t fit into this size 10 or 12. And then, at the same time, it kind of can start to go too far, where you do kind of put blinders on and don’t pay attention to the signals in your body and, you know, don’t make changes that are better for your health, like movement, eating healthy foods, things like that. So it’s sort of an interesting balance that I think needs to be struck there.’’ (Group 2) ‘‘If you can be overweight and you can be still healthy, and your body’s OK with that, then cool. But, if it’s not, then it’s not really your bowing down to what popular culture will tell you about your weight is. It’s really that you’d like to walk without a cane (or) you don’t want to be diabetic.. There’s a certain point where yes, (it’s) good to accept yourself and validate yourself, and know that you’re a good person, (that) you’re worthy of people loving you and caring about you. But, then sometimes it gets taken a little too far.’’ (Group 8) ‘‘It’s tricky, it’s that whole fat-phobic thing we live in, the whole balance of.(being) a feminist and person who cares about everybody’s rights, and then at the same time, not let that tilt me into someone with really bad health.’’ (Group 11)
Participants often noted a shift as they aged in their perception of the effect of such community norms about body size, weight, and health. ‘‘I felt like when I saw women getting older, I saw more and more problems—not just problems of aging, but problems of aging compounded by weight for me—this was my truth. I re-
Subgroup differences
Participants cited age, class, race, ethnicity, sexual identity, and gender expression as potential characteristics that differed within and across communities and that may influence participation in healthy weight interventions. Participants were divided on the need for a specific group for lesbian and bisexual women age 40 and older, with some desiring a targeted group that matched their demographics or shared identities and others reporting more interest in a group that focused on a common goal such as improved health. In more than half of the groups, women discussed gender expression differences (such as butch/femme)49 within lesbian communities and the associated body and appearance expectations. ‘‘I think it’s easier to be overweight and butch than it is to be overweight and femme. In some cases I do know some overweight femmes and they carry it off very, very well. And it’s all great. But.it is rarer to see overweight femmes than it is to see overweight butches. I have no idea why that is, exactly.’’ (Group 8) ‘‘I think within the lesbian community.there’s much more attention around folks who.use roles that (are) more appearance driven. It might be a lot of how you carry yourself and how you present—and how you dress—and whatever else. But, there is more attention given to how you look in whatever way that might be.’’ (Group 5)
In several of the groups, subgroup differences in perceived athletic ability were cited as a barrier to participating in physical activities. Frequently, these subgroup differences intersected with generational differences. ‘‘I just don’t feel welcome or capable of really participating in something that is going to be populated by people who have a long history of being really athletic. That’s a big part of our community.there’s this definite big subset of women who have always been involved in athletics.. There (are) a couple (of) groups that I thought about going to, but.I feel like I would get there and just not be capable of participating.’’ (Group 2) ‘‘I’ve been to those exercises classes.and it’s like, for every person like me, there’s 20 beautiful, 20-year-olds. It’s like I just can’t relate and they can’t relate to me.’’ (Group 10)
Family and partner support
Families past and present arose as both a barrier to and a facilitator for health and healthy weight. In several groups, women reported feeling pressure from family members about
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
changing their body size. Several participants reported being shamed by family members for being overweight. ‘‘I always thought that I was too heavy because (my mother) is really thin and she is sort of petite and she always felt that I was a fat kid basically and never hesitated to point it out.. As much as I try to (be) healthier and that I know that I’m okay and my partner loves me and my daughter loves me and my dogs love me, that nagging mom still calling me fat saying I need to lose some weight.. I feel good, but when she says that, I don’t feel good.’’ (Group 6) ‘‘Every time, my family used to greet me, ’Oh, you looked like you gained a lot of (weight).’ There’s no, ’Hi, how you doing?’ ’’ (Group 8)
On the other hand, sometimes families—particularly partners—were cited as a source of social support providing motivation and accountability to engage in physical activity. ‘‘We rarely work out together, but we may go to the gym together but she does her thing and I do my thing.. It just works out, because there’s somebody out there who’s encouraging you.’’ (Group 11) ‘‘I never thought I would get into yoga. My partner always did yoga. She tried to drag me out to do it a couple times and I wouldn’t go. But, I started doing this and it’s wonderful.’’ (Group 5) ‘‘When my girlfriend’s in town, because she eats very well and in a certain way—never has dessert and stuff like that—I always lose like ten pounds when she’s around.’’ (Group 7) ‘‘My partner is.younger than me and she loves to hike. And she loves to do a lot of stuff. And I’m saying, ‘Hey, I’ll see you when you get back.’ But, I’d like to join her in a lot of the stuff that she does and I can’t physically right now.’’ (Group 8)
Participants in many groups voiced concerns about social isolation as a result of living alone, and expressed an interest in interventions that directly acknowledged and addressed this fact. ‘‘I could drop dead right now and, if I live alone, no one would know until it smelled so bad.or I missed a meeting or something. So (an intervention should) ask us about those things. Who is in our life? Do you have some connections? Making sure that we are connected in a way, given that our families might look different.’’ (Group 1) ‘‘But there are a lot of people that are alone. And this is true whether you’re lesbian or not—they don’t feel like cooking for themselves.. The items that they buy, or go out to eat or whatever, are not nutritionally the greatest.. I don’t know how to get around that problem, but maybe somebody does.’’ (Group 4)
Awareness and tracking of diet and physical activity
In Groups 6 and 10, moderators initiated discussions about mindfulness interventions. The broader theme of awareness or paying attention emerged in four other groups. Despite some reservations about terminology, participants conveyed experience with such approaches, using terms such as ‘‘paying attention to what you’re eating’’ (Groups 3 and 4), ‘‘taking time’’ (Group 7), or ‘‘consciousness’’ (Group 2). Participants
181
described an interest in using specific approaches or tools to support mindfulness, such as ‘‘keeping a journal’’ (Group 4) and ‘‘keeping track’’ (Group 6) of behavior such as eating or physical activity. ‘‘When I was writing everything down, it helped me think about that conscious eating piece in terms of how I’ve been eating throughout the day. I don’t use it as a way of shaming myself, but just as a way of keeping a record. Because when you’re unconsciously eating, then you eat McDonald’s on the fly and Taco Bell for dinner, you don’t even realize (it). You put those together and it’s like 2,000 calories and most of it’s empty. So me putting it down just helps me keep a record.’’ (Group 11) ‘‘I think the keeping track and kind of being (aware) without any specific goal, but just writing it down, keeping track, being mindful, being more aware, and all of that—finding an easy way of doing that—and for me, it’s finding time to walk—would be really helpful.’’ (Group 3)
Discussion
This metasynthesis was specifically designed to confirm, clarify, and explore in greater detail previously identified themes regarding weight, health, and health behaviors among lesbian and bisexual women to guide development and refinement of healthy weight interventions in this community. This analysis forged new ground by elucidating the interrelationships among existing themes and identifying new themes. Emerging from this inquiry was a new and central theme, the effects of aging and the changing health needs that come with older age, a key factor identified in a large-scale survey of lesbian and bisexual older adults50 but explored in only a handful of qualitative inquiries that did not examine weight.50–52 In this analysis, multiple factors relating to weight among lesbian and bisexual women intersected with age to affect women’s ability to engage in behaviors to achieve healthy weight and support better health.53 These factors, previously identified in the literature, included physical and mental health status,29,54,55 mobility,4 body image,38,56 minority stress (stress caused by experiences with antigay stigma),53 competing demands in terms of time and cost,32 social support, or lack thereof,30 as well as family37 and partners.57 Despite the methodological steps taken to maximize validity, some limitations merit consideration.43,45 This qualitative meta-analysis used primary data from 11 different groups in three geographic locations (San Francisco Bay area; Washington, D.C. area; and Columbia, Missouri). Some locations contributed a greater volume of data than others. The semistructured discussion guides for the groups (ranging from two to eight participants) were not originally designed to be consistent across sites, as each site had a different proposed intervention. Two sites, for example, were developing health care provider education components. In addition, recruitment of focus group participants varied considerably by site: methods included recruitment through institutions’ social media sites, from prior health interventions, among community members using snowball techniques, from clinical settings, and from community members known by the study staff. Furthermore, the analysis was conducted on de-identified transcripts without individual participant characteristics. We
182
GARBERS ET AL.
Table 3. Summary of Key Themes and Implications of Healthy Weight Intervention Content and Format Development and Recruitment Approaches, with Illustrative Quotes Key Theme Aging{
Implications for Interventions Information on aging, menopause, and effects on health is important. Emphasize importance of community connections to address concerns about aging.
Physical and Mental Health Status
Recognize and address mobility, resources, and health status as barriers to physical activity and healthy eating. Stress-reduction techniques and other approaches to improving mental health may be relevant.
Community Norms About Body Size
Focus on health and healthy behaviors, not weight loss.
Illustrative Quotes on Specific Ways to Address Theme in Intervention Content, Format and Recruitment Approaches ‘‘I think it’s really helpful to help people understand and put into the conversation that there are certain changes that come about (with aging), and these are some of the tools for coping.’’ (Group 2) ‘‘Actually what’s true with this—and with many things that I don’t feel are addressed around nutrition and weight—is that things change with age.’’ (Group 6) ‘‘I think one of the specific health things I would want to discuss and it’s not particularly for lesbians, but just the older part, the (question of) do you take hormone (replacement therapy), do you not, why do you need them, what’s going to happen if you do or you don’t. The whole libido thing.’’ (Group 4) ‘‘It’s about time somebody listens to us (lesbian and bisexual women over age 40), you know, because we seem to be the forgotten bunch. With all of the health issues that we have that are different from them like the heart issues and things like that, you know, finding out that we need to be treated in a different way.’’ (Group 6) ‘‘Part of my desire to grow healthier is that I’m aging.and I don’t want to be sedentary as an older person and I know that I have to do something now.’’ (Group 11) ‘‘As we get older—not even just lesbians—and without a partner or with a partner, is a topic (to address).’’ (Group 4) ‘‘Everyone is going through this. Everyone is getting older. (I would like information on) ‘in this particular situation, this is what (worked).’ But it seems that no one keeps a record of success. They just keep a record of everything that makes you get sick.’’ (Group 1) ‘‘So telling me ‘you should change your eating habits or exercise’... Sometimes you have injuries or stuff like that, so it doesn’t help me to tell me to work out and exercise if you don’t guide me.’’ (Group 1) ‘‘I would love to see specific exercises and use of specific equipment, like at (a) fitness center, that would be beneficial for specific things. (For example,) ‘this is how you use a machine, and this is what you should do and if you’re having knee issues, you should use the bike for so many times to build it up before you get the knee replaced.’’’ (Group 4) ‘‘With my age (and) what have you.even having someone come in and say, ‘Hey, here’s a class on how to put your socks on when you’re overweight,’ that’s an exercise believe it or not and it would add value. There are.techniques.that I think are necessary and very helpful and that I would totally.be interested in. (Group 9) ‘‘I’m interested in some tools on how to (be more healthy in terms of) nutrition and exercise, both categories of what would work for a real person in the real world, and also stress management, because.I know for me, it ties into the way I eat.’’ (Group 2) An intervention should ‘‘at least to try to get to the root cause, and not necessarily (just weight loss). Exercise and food help.you feel better. When you do exercise—it doesn’t (just) contribute to the weight loss.’’ (Group 1) ‘‘It’s about bringing positive energy into your life, getting healthier. So, yeah, there’s got to be better choices of words (in the recruitment materials).’’ (Group 2) (continued)
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
183
Table 3. (Continued) Key Theme
Subgroup Differences
Implications for Interventions
Address identity differences within lesbian and bisexual women’s communities.
Promote activities as ‘‘all abilities welcome.’’
Family
Awareness and Tracking{
Ensure interventions are inclusive of the diversity within lesbian and bisexual women’s communities (e.g., disabilities movement, fat activism, recovery communities). Address impact that family of origin has on body image. Acknowledge the role of family members (partners and children) and household structure in health-promoting behaviors. Promote social support within interventions to address concerns about isolation. Incorporate mindfulness in many forms using familiar terminology. Provide support for tools for tracking.
{
Illustrative Quotes on Specific Ways to Address Theme in Intervention Content, Format and Recruitment Approaches ‘‘I don’t think the idea is.doing exercises to get like 16-yearold beautiful again. Just to be healthy.so that aging processes slow down.’’ (Group 9) ‘‘(Using the term ‘health at any size’) is a marker for people like me to see that you’re not coming at it solely from a weight loss perspective, so I think that is.a potentially helpful language thing to do.’’ (Group 3) ‘‘We’re talking about weight and we’re talking about health. Is there some kind of way that (the intervention is) really going to be looking at the real impacts (of being overweight)?.Is it possible for a person to be ‘overweight’ and to be healthy?’’ (Group 7) ‘‘There’s not a big lesbian thing that glues us all together.’’ (Group 11) ‘‘I’m interested in learning more about health, and having a contrast to the constant television commercials about skinny, young straight women.’’ (Group 2) ‘‘(There could be) an intersection between different groups, and that would be a beautiful thing happening. How can you find those intersections, because after all, we lesbians are part of all those groups.’’ (Group 3) ‘‘We’ve got the real sports-minded people.and folks that are real couch potatoes. So it’s a whole different set of problems and attitudes. So that’s one other way of divvying people up.’’ (Group 4) ‘‘(Using the terms) every size (and) every ability would attract people with disabilities.’’ (Group 3) ‘‘I’m not so much interested in uncovering the deep roots of my childhood that are attached to my weight and sharing that on a public level and all that kind of stuff, but I really would love some tools.’’ (Group 2) ‘‘Include content on how to maintain an interest in eating. That it seems to have some pleasure involved, particularly if you’re alone, you know, there’s so many decisions you have to make.’’ (Group 4) ‘‘Someone to exercise with certainly helps. Having a group, maybe just to meet whoever shows up on particular days to walk.’’ (Group 4) ‘‘Mindfulness.. I see that word and I find that word attractive.. I don’t think you want to necessarily take those words out, and yet, I think you want to find a translation that’s friendly.’’ (Group 3) ‘‘I had seen mindfulness around for a long time, and it was just like, ‘Oh, that’s for white people over there.’ But then something happened in my life where I needed to be able to reduce my stress.. I took the jump into mindfulness.. So now, I’m an advocate for it and I really believe in it.. But that whole concept of, ‘Who’s that for?’ At first, I was like, ‘Oh that’s over there.’ ’’ (Group 5) ‘‘I make time for work, I make time for other things. I don’t make time to exercise. I just don’t, and I need to. Just making the time for it, making that commitment, whatever that takes, I don’t know—logging it? Something.’’ (Group 4) ‘‘You talk about mindfulness—just paying attention to what you’re eating, keeping a journal of what you eat and logging it (helps). Maybe not even a plan, but.really seeing what you’re eating, is a great start.’’ (Group 2)
Newly identified theme. Themes not marked with a dagger were previously identified in the literature.
184
were, therefore, unable to report findings by subgroups such as age, which has been found to be an important moderating factor in other qualitative studies32 or other potentially important factors such as race, ethnicity, disability status, or gender identity. Still, the approach used in conducting this analysis has a number of strengths. By including primary data from the voices of ethnically diverse older women (ages 38–80) from three geographic regions of the United States, we addressed limitations of the narrow demographic focus and small sample size that have been challenges to conducting research with lesbian and bisexual women.33,34 This analysis yielded specific guidance on ways healthy weight interventions for adult lesbian and bisexual women can be developed and refined (Table 3). Rather than offer standard information, program implementers should provide direction and guidance that is embedded in community norms and tailored to the goals and functional status of the recipient. Incorporating techniques to support ‘‘paying attention’’ or ‘‘awareness of’’ eating and physical activity emerged as a useful approach to help women engage in healthy behaviors no matter their subgroup differences. Conclusion
This synthesis of qualitative data highlights the varied and unique barriers that lesbian and bisexual adult women face in engaging in physical activity and healthy eating, and points the way for interventions to surmount these barriers.3,17,58,59 Any intervention that seeks to improve health for adult lesbian and bisexual women should recognize the heterogeneity of subgroups within communities, and the individuals within them, when addressing change. This synthesis supports Fogel, Calman, and Magrini’s31 conclusion that listening to and determining what women want and need from interventions is necessary to promote healthier lives. Further examination of intervention approaches to incorporate and address these concerns, and the impact of such interventions on health status among lesbian and bisexual adult women, is merited. Acknowledgments
The study was funded via contracts from the Office on Women’s Health, Healthy Weight Initiative, to five individual projects across the United States, and this paper was developed via a cross-site editorial committee. These contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government. Contract Numbers: George Washington University: HHSP23320095635WC; Lewin Group: HH SP223320095639WC; Impaq International (formerly Berkeley Policy Associates): HHSP233420095615; NORC: HHSP233 20095647; Research Triangle Institute: HHSP22332009563 9WC; The CDM Group HHSP23320095629WC and HHSP2 3337005T-01 Author Disclosure Statement
The primary data for this metasynthesis were collected by the institutions of the authors (excluding Garbers, McDonnell, Radix and Haynes). IRB approval was obtained at each institution for primary data collection protocols and procedures. No competing financial interests exist.
GARBERS ET AL. References
1. Kulie T, Slattengren A, Redmer J, et al.: Obesity and women’s health: An evidence-based review. J Am Board Fam Med 2011;24:75–85. 2. Lash MM, Armstrong A: Impact of obesity on women’s health. Fertil Steril 2009;91:1712–1716. 3. Bowen DJ, Balsam KF, Ender SR: A review of obesity issues in sexual minority women. Obesity 2008;16:221–228. 4. Conron KJ, Mimiaga MJ, Landers SJ: A population-based study of sexual orientation identity and gender differences in adult health. Am J Public Health 2010;100:1953–1960. 5. Eliason MJ, Ingraham N, Fogel SC, et al.: A systematic review of the literature on weight in sexual minority women. Women’s Health Issues 2015;25:162–175. 6. Ward BW, Dahlhamer JM, Galinsky AM, Joestl SS: Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013. Natl Health Stat Report 2014;77:1–12. 7. Visscher TL, Seidell JC: The public health impact of obesity. Annu Rev Public Health 2001;22:355–375. 8. Aronne LJ, Wadden T, Isoldi KK, Woodworth KA: When prevention fails: Obesity treatment strategies. Am J Med 2009;122:S24–S32. 9. Neter JE, Stam BE, Kok FJ, et al.: Influence of weight reduction on blood pressure: A meta-analysis of randomized controlled trials. Hypertension 2003;42:878–884. 10. Grave RD, Centis E, Marzocchi R, et al.: Major factors for facilitating change in behavioral strategies to reduce obesity. Psychol Res Behav Manag 2013;6:101–110. 11. Thorogood A, Mottillo S, Shimony A, et al.: Isolated aerobic exercise and weight loss: A systematic review and metaanalysis of randomized controlled trials. Am J Med 2011; 124:747–755. 12. Umpierre D, Ribeiro PA, Kramer CK, et al.: Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: A systematic review and meta-analysis. JAMA 2011;305:1790–1799. 13. Anderson JW, Kendall CW, Jenkins DJ: Importance of weight management in type 2 diabetes: Review with meta-analysis of clinical studies. J Am Coll Nutr 2003;22:331–339. 14. Shaw K, Gennat H, O’Rourke P, Del Mar C: Exercise for overweight or obesity. Cochrane Database Syst Rev 2006;(4):CD003817. 15. Sarwer DB, Moore RH, Diewald LK, et al.: The impact of a primary care-based weight loss intervention on the quality of life. Int J Obes 2013;37:S25–S30. 16. Jeffery RW, Epstein LH, Wilson GT, et al.: Long-term maintenance of weight loss: Current status. Health Psychol 2000;19:5–16. 17. Douketis JD, Macie C, Thabane L, Williamson DF: Systematic review of long-term weight loss studies in obese adults: Clinical significance and applicability to clinical practice. Int J Obes 2005;29:1153–1167. 18. Moroshko I, Brennan L, O’Brien P: Predictors of dropout in weight loss interventions: A systematic review of the literature. Obes Rev 2011;12:912–934. 19. Mann T, Tomiyama AJ, Westling E, et al.: Medicare’s search for effective obesity treatments: Diets are not the answer. Am Psychol 2007;62:220–233. 20. Dansinger ML, Tatsioni A, Wong JB, et al.: Meta-analysis: The effect of dietary counseling for weight loss. Ann Intern Med 2007;147:41–50. 21. Akers JD, Estabrooks PA, Davy BM: Translational research: Bridging the gap between long-term weight loss
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
22.
23. 24. 25. 26. 27.
28.
29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.
43.
maintenance research and practice. J Am Diet Assoc 2010; 110:1511–1522. Brittain DR, Dinger MK. BE-PALS: An innovative theorybased intervention to promote moderate physical activity among adult lesbians. Women in Sport and Physical Activity Journal 2014;22:71–75. Van Dorsten B, Lindley EM: Cognitive and behavioral approaches in the treatment of obesity. Med Clin North Am 2011;95:971–988. Dubnov-Raz G, Berry EM: The dietary treatment of obesity. Med Clin North Am 2011;95:939–952. Elfhag K, Ro¨ssner S: Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obes Rev 2005;6:67–85. Teixeira PJ, Silva MN, Coutinho SR, et al.: Mediators of weight loss and weight loss maintenance in middle-aged women. Obesity 2010;18:725–735. Napolitano MA, Papandonatos GD, Borradaile KE, et al.: Effects of weight status and barriers on physical activity adoption among previously inactive women. Obesity 2011; 19:2183–2189. Neve M, Morgan PJ, Jones P, Collins C: Effectiveness of webbased interventions in achieving weight loss and weight loss maintenance in overweight and obese adults: A systematic review with meta-analysis. Obes Rev 2010;11:306–321. Roberts SJ, Stuart-Shor EM, Oppenheimer RA: Lesbians’ attitudes and beliefs regarding overweight and weight reduction. J Clin Nurs 2010;19:1986–1994. Fogel S, Young L, McPherson JB: The experience of group weight loss efforts among lesbians. Women Health 2009;49: 540–554. Fogel SC, Calman L, Magrini D: Lesbians’ and bisexual women’s definition of health. J Homosex 2012;59:851–863. Brittain DR, Baillargeon T, McElroy M, et al.: Barriers to moderate physical activity in adult lesbians. Women Health 2006;43:75–92. Crisp C: Selected characteristics of research on lesbian women: 1995–1997. J Homosex 2003;44:139–155. de Vries B, Croghan CF: LGBT aging: The contributions of community-based research. J Homosex 2014;61:1–20. Sandelowski M: Sample size in qualitative research. Res Nurs Health 1995;18:179–183. Thomas J, Harden A: Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45. Bowen DJ, Balsam KF, Diergaarde B, et al.: Healthy eating, exercise, and weight: Impressions of sexual minority women. Women Health 2006;44:79–93. Kelly L: Lesbian body image perceptions: The context of body silence. Qual Health Res 2007;17:873–883. Chmielewski JF, Yost MR: Psychosocial Influences on Bisexual Women’s Body Image Negotiating Gender and Sexuality. Psychol Women Q 2013;37:224–241. Sandelowski M, Barroso J: Finding the findings in qualitative studies. J Nurs Scholarsh 2002;34:213–219. Hruschka DJ, Schwartz D, John DC, et al.: Reliability in coding open-ended data: Lessons learned from HIV behavioral research. Field Methods 2004;16:307–331. Popay J, Roberts H, Sowden A, et al.: Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme (Version 1). Lancaster, England: Institute of Health Research, 2006. Finfgeld DL: Metasynthesis: The state of the art—so far. Qual Health Res 2003;13:893–904.
185
44. Booth A: ‘‘Brimful of STARLITE’’: Toward standards for reporting literature searches. J Med Libr Assoc 2006;94: 421–429. 45. Whittemore R, Chase SK, Mandle CL: Validity in qualitative research. Qual Health Res 2001;11:522–537. 46. Rodgers BL, Cowles KV: The qualitative research audit trail: A complex collection of documentation. Res Nurs Health 1993,16:219–226. 47. Bodnar LM, Siega-Riz AM, Simhan HN, et al.: Severe obesity, gestational weight gain, and adverse birth outcomes. Am J Clin Nutr 2010;91:1642–1648. 48. Huxley CJ, Clarke V, Halliwell E: A qualitative exploration of whether lesbian and bisexual women are ‘protected’from sociocultural pressure to be thin. J Health Psychol 2014;19:273–284. 49. Levitt HM, Puckett JA, Ippolito M, Horne SG: Sexual minority women’s gender identity and expression: Challenges and supports. J Lesbian Stud 2012;16:153–176. 50. Fredriksen-Goldsen KI, Emlet CA, Kim HJ, et al.: The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: The role of key health indicators and risk and protective factors. Gerontologist 2013;53:664–675. 51. King S, Dabelko-Schoeny H: ‘‘Quite frankly, I have doubts about remaining’’: Aging-in-place and health care access for rural midlife and older lesbian, gay, and bisexual individuals. J LGBT Health Res 2009;5:10–21. 52. Orel NA: Investigating the needs and concerns of lesbian, gay, bisexual, and transgender older adults: The use of qualitative and quantitative methodology. J Homosex 2014;61:53–78. 53. Lick DJ, Durso LE, Johnson KL: Minority stress and physical health among sexual minorities. Perspect Psychol Sci 2013;8:521–548. 54. Diamant AL, Wold C: Sexual orientation and variation in physical and mental health status among women. J Women’s Health 2003;12:41–49. 55. Brittain DR, Dinger MK, Hutchinson SR: Sociodemographic and lesbian-specific factors associated with physical activity among adult lesbians. Women’s Health Issues 2013; 23:e103-e108. 56. Morrison MA, Morrison TG, Sager CL: Does body image satisfaction differ between gay men and lesbian women and heterosexual men and women? A meta-analytic review. Body Image: An International Journal of Research 2004; 1:127–138. 57. Markey CN, Markey PM: Weight disparities between female same-sex romantic partners and weight concerns examining partner comparison. Psychol Women Q 2013;37:469–477. 58. Stephens S, Cobiac L, Veerman L: Improving diet and physical activity to reduce population prevalence of overweight and obesity: An overview of current evidence. Prev Med 2014;62:167–178. 59. Boehmer U, Bowen DJ, Bauer GR: Overweight and obesity in sexual-minority women: Evidence from population-based data. Am J Public Health 2007;97:1134–1140.
Address correspondence to: Samantha Garbers, PhD Research & Evaluation Unit Public Health Solutions 40 Worth Street, 5th Floor New York, NY 10013 E-mail: [email protected]
(Appendix follows/)
186
GARBERS ET AL.
Appendix 1. Themes Identified in Published and Unpublished Reports Author Bowen 2006 (6 themes)
Brittain 2006 (6 themes)
Roberts 2010 (3 themes) Fogel 2009 (7 themes)
Fogel 2012 (5 themes)
Kelly 2007 (5 themes)
Chmielewski 2013 (4 themes)
Site A (Unpublished Report) (6 themes)
Site B (Unpublished Report) (17 themes)
Theme in Original Source (verbatim) Body image Health Weight loss Diet/healthy eating Physical activity/exercise Subgroup differences Intrapersonal Interpersonal Institutional Community/Society Public Policy Lesbian-Specific Generational differences Acceptance of weight and body images Effect of minority stress and depression on risk behaviors Desire to improve health History of weight loss attempts Shame Unaccepted due to sexual identity Safety and acceptance Physical environment Social support Feelings about health Benefits of a healthy body Descriptions of a healthy body Strategies to get a healthy body Exercise Lesbian invisibility Fear of misinterpretation of intent Discomfort during intimacy Questionable feedback Body image and sexual identity Tension between judging and experiencing body Unique struggles of being a bisexual woman Finding body affirmation in LGBT communities and from feminist identity Body image and romantic relationships with men and women Assumptions of heteronormativity Personalization Prevention Provider specialty Communication: provider engagement and non-engagement Insurance Lesbian community norms Weight and health in the San Francisco LB community American food culture and media Health care and cultural competency Family and community Gyms Groups Physical activity Healthy eating Terminology Location Group structures Social influence on body image Importance of patient-provider interaction Barriers to implementing change Stress & stress reduction Non-provider sources of health information (continued)
METASYNTHESIS: AGING, WEIGHT, & HEALTH IN LESBIANS
187
Appendix 1. (Continued) Author Site D (Unpublished Report) (11 themes)
Theme in Original Source (verbatim) Finding accessible activities that can accommodate pain mobility and skill level Making eating well tasty and fun Understanding what healthy means/looks like Other people can hold us accountable, encourage us, and make activities more fun Individual exercise = reaching goals/meditation/relaxation/self-care Group exercise = social, communal, fun Making time for healthy living is a difficult thing to do We blame ourselves for our unhealthiness We set rigid standards for what makes exercise worthwhile Confusion about what ‘‘healthy’’ is ‘‘Exercise’’ = a dirty word, but playing basketball sounds fun
LGBT, lesbian, gay, bisexual, and transgender; LB, lesbian and bisexual.
