Irene Ficaro 1 The prevalence of obesity has risen dramatically, affecting more than 250 million people around

the world. In 2009, African Americans (AA) were 1.5 times more likely to be obese as non-Hispanic whites, and AA women have the highest rate of obesity compared to other groups in the United States (CDC, 2010). Bariatric surgery for weight loss is an increasingly popular option for obese AA women. Bariatric patients with morbid obesity (defined as a body mass index > 40) can achieve weight loss with improvement of weight-related comorbidities such as hypertension, diabetes, heart disease and obstructive sleep apnea. For the AA woman undergoing the life-altering experience of bariatric surgery, culturally relevant health care must be provided. Exploratory research is needed to identify the role that gender, cultural beliefs, trust and behavioral norms play in the obesity epidemic. Culturally competent nursing care begins by understanding the lived experience of the AA woman who has struggled with obesity and has had bariatric surgery. Background and Literature Review Although AA women have the highest rates of obesity compared to other groups in the United States (CDC, 2010), they are disproportionately represented by the bariatric surgery patient population, which is predominately white, privately insured females (Santry, 2007). Bariatric Longitudinal Data Base (BOLD) data analyzing bariatric patients indicate that AAs comprise only 10% of the population (DeMaria, Pate, Warthen & Winegar, 2010). Further study is needed, therefore, to explore the lived experience of this under-represented population. The Experiencing Transitions (ET) theory of Meleis (McEwen & Wills, 2007) will be the conceptual framework used to guide this study in

Irene Ficaro 2 the various transitions such as health, lifestyle, and body image these participants experience. A comprehensive literature search was conducted through CINAHL and PubMed. Buffington and Marema (2006) found that AA women weigh more than Caucasian (C) women presurgically, and they lose significantly less weight with bariatric surgery. Since there is a predominance of C females undergoing bariatric surgery, there is little known about the long-term postsurgical experience of the AA woman. This study intends to focus on the lived experience of AA women who have had bariatric surgery. Thomas, Moseley, Stallings, Nicholas-English and Thomas (2008) compared body image assessments between AA and C women in a study of obese women. Satisfaction with a larger body size and disagreement with ideal body weight were significant findings in the AA women, confirming past studies that found the AA population to perceive heavier body size as being more attractive. This perception can impact family and friend support systems, and has important implications in designing culturally specific bariatric programs. The proposed study will explore how the post bariatric AA females alteration in body image influences self-esteem. There is no mention in Thomas et al.s study regarding physician recommendation for surgery as a weight loss option, however, both AA and C obese females agreed their physicians did not provide them adequate weight loss referrals, support or resources. African American women value the need for a group approach to weight loss, which may have arisen from tribal survival found in the African culture (Aladesanmi & Blixen, 2004). The need for culturally competent support systems, including physician, family, and psychosocial, will be addressed in the proposed study.

Irene Ficaro 3 The emotional risks of bariatric surgery, including altered coping mechanisms grounded in the concept of rapid change from life-changing surgery, need further research. Themes of multiple losses (weight, social support systems, former identity and food coping mechanisms) and paradoxical feelings of sorrow and regret even as successful weight loss has been achieved (Sutton, Murphy & Raines, 2009) are psychosocial aspects of weight loss surgery that bear further research. Sutton et al.s (2009) study was conducted with predominately white females, reinforcing the need for more research in the lived experience of the female AA population. In a focused group study by Lynch, Chang and Ford (2007) examining barriers obese AA women have towards weight loss and weight reduction surgery, themes of lack of time and access to exercise and buying healthy food emerged. Issues regarding control, the ability to maintain a restrictive dietary intake, and loss of identity and companionship with their fat friends and family members, who could no longer eat the same foods or shop for the same types of clothing, also emerged. The Lynch et al. (2007) study identifies the value of collaboration with an organization for minority women committed to health promotion and empowerment as a resource and support system. A gap identified is the need for healthcare providers to assess their patients behavior- related attributes as part of their whole being. Nursing as a holistic practice must seek to treat the bariatric patient as a whole person, seeking to understand and improve psychosocial outcomes. The proposed study would benefit the total mind-body experience while defining culturally specific issues of the post bariatric AA female. Buffington and Maremas (2006) quantitative study examined ethnic differences in obesity and surgical weight loss between AA and C females using anthropometric

Irene Ficaro 4 measurements. They found that AA women lose significantly less weight than C women related to ethnic differences in fat metabolism and increased capacity for fat uptake and storage in adipose tissue in AA women. This is a significant fact that needs to be factored into the pre bariatric surgical counseling of AA women, to present a more realistic sense of surgical outcomes and barriers to successful weight loss. This fact exemplifies the importance of designing culturally specific bariatric health care, thus avoiding unrealistic expectations. Significance of This Study This research seeks to focus on the problem of obesity in the AA female population in the United States. The U.S. Department of Healths Office of Minority Health data base provides statistical data on the prevalence of obesity in AA females. A 2006-2008 Behavioral Risk Factor Surveillance System survey indicates that in the United States AA women have a 39% obesity rate compared to C women at 22% (CDC, 2010). Bariatric programs are designed to medically and psychologically assess potential candidates for weight loss surgery. After surgery, however, long term psychosocial support and follow up seem to be lacking (Stewart, 2010). This study will help to culturally define the specific experiences of AA women who have undergone the life-altering experience of surgical weight loss. Purpose of This Study The purpose of this study is to investigate how AA women experience life after weight loss surgery. Since obesity disproportionally affects this population, factors relating to gender, cultural beliefs, trust and behavioral norms need to be identified.

Irene Ficaro 5 Specific Aims This study will aim to understand the difficulties and barriers, as well as successes, which AA women encounter as they experience weight loss surgery. It will seek to enroll approximately12 AA post bariatric females, specifically those who have had surgery 18 months to two years prior to their interview. Data will be collected from personal interviews with the aim of defining culturally specific variations and beliefs affecting AA womens perception of obesity and weight loss surgery.

Research Question What is the lived experience after weight loss surgery for AA women?

Method A phenomenological study will be conducted to answer the research question. Procedure Approval will be obtained first from the Institutional Review Board of Molloy College. Participants will be recruited with approval and permission from a mid-Atlantic bariatric surgery center via advertisement in their monthly support newsletter. The advertisement will include: a designated phone number to contact the researcher, the purpose of the study, the $25 cash stipend for participation, the inclusion/exclusion criteria, the location and duration of the interview. The need for written informed consent (see Appendix A) and audio taping of interviews will be mentioned as well. The principal investigator (PI) will contact the participant via telephone to schedule the interview. Upon enrollment, details of the study will be explained .Written

Irene Ficaro 6 informed consent and brief demographic data will be obtained. Semi-structured interviews with a flexible emergent design will be conducted in a private room at the bariatric surgery center. Interviews will last about 2-2 hours and will be audio taped. Interview questions are based on the conceptual framework of Meleis ET theory. Change is a recurrent theme in bariatric surgery. Bariatric patients experience transition through the multiplicity of changes including dramatic weight loss, changes in eating habits, body image and even relationships (Reedy & Blum, 2010). All interviews will be transcribed by the PI and analyzed and coded for themes until data saturation is achieved. Confidentiality will be maintained by de-identifying data and using code numbers for participants. An ongoing member check will be conducted and all data will be stored on a secured flash drive. Sampling Design A typical case purposive sample will be recruited. All subjects must have experienced weight loss surgery and be able to articulate what it is like to have lived that experience. Pertinent demographic data (such as marital, employment and economic status) will be incorporated into the interview. The sample size will be approximately 10, and recruitment will end when the data are saturated (redundancy and no new information is received). A homogeneous sample will be chosen. Inclusion factors for eligibility screening are: all English speaking AA women age 18 or older who have had bariatric surgery with uncomplicated healing 18 months to 2 years prior to the interview. An exclusion factor would be inability to speak English and history of major post operative complications.

Irene Ficaro 7 Plan for Protection of Human Subjects Approval will be obtained from an Institutional Review Board. Due to the sensitive issue of weight and race/cultural aspects and in-depth exploration into highly personal areas, the researcher will guide the interview respectfully. To protect exploitation of the researcher-participant relationship, the researcher will inform the participant of the possibility of a possible future follow up study. Participants will be invited to volunteer with the understanding that they have a right to refuse giving information and are free to withdraw from the study at any time. The previously mentioned consent will be obtained with full disclosure of the nature of the study, rights to confidentiality and a risk/benefit assessment. Benefits include potential for selfgrowth. Potential risks include emotional/psychological distress due to recollection of an experience that might have been unpleasant. Data Collection and Handling The principal investigator, a registered nurse, will be the instrument for data collection. She has the ability to communicate clearly and help participants feel comfortable expressing their experiences, enabling her to gather commentaries and stories to add to the richness of the data. Gender similarity should ease the ability to communicate comfortably about this sensitive topic. The semi-structured interviews will consist of open-ended questions to facilitate ease and comfort of speaking about their perceptions, feelings and needs. Using Melais ET theory, a topic guide will be formulated. The Psychometric Characteristics of General Well-Being (GWB) with African American Women (Taylor, Haddock, Blackburn, Heber, Heymsfield & Foreyt, 2003) will be the instrument used to guide the questions. Development of this tool

Irene Ficaro 8 included AA women from various geographical regions of the U.S. and demonstrated strong internal consistency (Cronbachs alpha= 0.92). An exploratory factor analysis using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.94, which places it in the superior range for validity. After a question, sensitive follow-up probes will be used to elicit data-rich information. The interviewer will make field notes after the interview, enhancing the reproducibility of the data and establishing an audit trail for trustworthiness (Sutton et al., 2009). Transcribed interviews will be read along with the audio file to ensure no transcription errors and be analyzed for common themes. Recruiting and enrollment of volunteers will continue until data saturation is reached. Data Management Data will be transcribed as a word processing document on a computer. The data will be entered and backed up with a code assigned, enabling the researcher to know when the data was entered. This information also will be kept in a secured handwritten notebook for the audit trail. A manual method of organizing the data using file cards for each significant statement will be used. File cards will be sorted by piles representing themes and identified with the initials of the participant in the upper right corner. Data Analysis Editing analysis style will be used to search for meanings and patterns in data using Colaizzis methodological interpretation (Polit & Beck, 2008). Significant statements and their meanings will be organized into clusters of themes, taking note of any discrepancies. Relationships and connections with adjacent phenomena will be explored carefully so as not to overlook any significant data. As category schemes develop, data will be coded and related concepts grouped together. Time must be allotted

Irene Ficaro 9 to read transcriptions multiple times to decide appropriate coding with anticipation that a category may yet emerge that was not initially identified. If this happens careful review of all previous coded material must occur. An exhaustive description of the phenomenon will be written, and the investigator will return to the participants for validation. Any new data emerging from this will be incorporated into the exhaustive description. Plan to Address Potential Problems A carefully planned timeline (see Appendix B) will allow for adequate data collection and analysis with full data saturation achieved. The PI will strive to maintain the boundaries of a proper researcher-participant relationship, carefully balancing the principles of conducting sound research with concern for the health and welfare of the participant. Protection of the participants welfare will take precedence over research. Any issues of concern arising from the interview will be reviewed at the closure of the interview and appropriate follow-up initiated (Speziale & Carpenter, 2003). Adequate funding for the cash stipend must be ensured. High quality recording instruments, with extra batteries available, will ensure optimal transcription. Lapel microphones will aid in vocal recording quality. Copies of all data sheets will be kept in the event that data get lost, stolen or destroyed. To account for potential recruitment problems, a second bariatric surgery center may be considered, for example, North Shore University Hospital. Plan to Address Study Integrity and Study Fidelity To ensure that interpretation of the data is valid and bias free, ongoing selfreflection and self-scrutiny will be conducted throughout the flow of the study. A reflexive posture will allow the researcher to examine her previous experiences, values,

Irene Ficaro 10 background and prejudices in light of the analysis and interpretation of the data. This allows for preservation of objectivity and can be done by bracketing or reflective journaling. Transparency will be demonstrated by maintaining records needed to document a decision trail. Methodological coherence can be shown through careful checking for errors and accuracy of data analysis and interpretation. Replication will be achieved through meticulous, richly saturated data. The report will include information about the researcher, her credentials, and any personal connection she may have had to the people and topic under study. The researcher will strive to have a participant-driven inquiry, reflecting their voice in the analysis and interpretation of the study. The researcher will be prepared with considerable knowledge, ensuring commitment to insightful interpretation. Trustworthiness and credibility will be achieved as the researcher revisits each participant with her exhaustive description to ensure it adequately reflects her life experience; appropriate revisions will follow. Dependability will be achieved as the findings of the study are determined to be replicated with similar participants in similar contexts. If the data findings can be transferred or have applicability in other groups or settings, transferability will be achieved. As the reader senses the feelings of the participants lived experience in a vivid, tangible way, the studys authenticity is confirmed. Finally, inquiry audit can be done by an external reviewer to enhance the trustworthiness of the data.

Irene Ficaro 11 References Aladesanmi,O., & Blixen, C. (2004). African Americans. In R. Lang & D. Hensrud (Eds.), Clinical preventative medicine (2nd ed. pp. 432-432). Chicago: AMA Press. Blixen, C. E., Singh, A., & Thacker, H. (2006). Values and beliefs about obesity and weight reduction among African-American and Caucasian women. Journal of Transcultural Nursing, 17 (3), 290-297. doi: 10.1177/1043659606288375. Buffington, C. K., & Marema, R. T. (2006). Ethnic differences in obesity and surgical weight loss between African-American and Caucasian females. Obesity Surgery, 16, 159-165. Center for Disease Control and Prevention. (2010). Obesity and african americans. Retrieved February 9, 2011 from http://www.cdc.gov/nchs/data/hus09.pdf DeMaria,E. J., Pate, V., Warthen, M., & Winegar, D. (2010). Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Center of Excellence using bariatric outcome longitudinal data base. Surgery for Obesity and Related Diseases, 6(4), 346-355. doi:10:1016/j.soard. 2009.11.015 Lynch,C. S., Chang,J. C., & Ford, A. (2007). Obese African American womens perspective on weight loss and bariatric surgery. Journal of General Internal Medicine, 22(7), 908-914. doi: 10.1007/s11606-007-0218-0 McEwen, M., & Wills, E. (2007). Theoretical basis for nursing (2nded.). Philadelphia: Lippincott Williams & Wilkins.

Irene Ficaro 12 Polit, D. & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Reedy S., & Blum, K. (2010). Applying middle range nursing theory to bariatric surgery: Experiencing transitions. Bariatric Nursing and Surgical Patient Care, 5(1), 35-43. doi: 10.1089/bar.2009.9940 Santry, H. P., Lauderdale, D. S., Cagney, K.A., Rathouz, P. J., Alverdy, J. C., & Chin, M. H. (2007). Predictors of patient selection in bariatric surgery. Annals of Surgery, 245(1), 59-67. doi: 10.1097/01.sla0000232551.55712.b3 Speziale, H .J. S. & Carpenter, D. R. (2003). Qualitative research in nursing: Advancing the humanistic imperative. Philadelphia: Lippincott Williams & Wilkins. Stewart, K. E., Olbrisch, M. E., & Bean, M. K. (2010). Back on track: Confronting post-surgical weight loss. Bariatric Nursing and Surgical Patient Care, 5(2), 179-185. doi: 10.1089/bar2010.9920 Sutton, D. H., Murphy, N., & Raines, D. A. (2009). Transformation: The lifechanging experience of women who undergo a surgical weight-loss intervention. Bariatric Nursing and Surgical Patient Care, 4(4), 299-306. doi: 10.1089/bar.2009.9948 Taylor, J. E., Poston, W. S. C., Haddock, C. K., Blackburn, G. L., Heber, D., Heymsfield, S. B., & Foreyt, J. P. (2003). Psychometric characteristics of the general wellbeing schedule (GWB) with African-American women. Quality of Life Research, 12, 31-39.

Irene Ficaro 13 Thomas, A., Moseley, G., Stallings, R., Nicholas-English, G., & Wagner, P. (2008). Perceptions of obesity: Black and white differences. Journal of Cultural Diversity, 15(4), 174-180.

Irene Ficaro 14 Appendix A: Informed Consent MOLLOY COLLEGE GRADUATE SCHOOL OF NURSING Principal Investigator: Irene Ficaro R.N, B.S. Study Title: Weight Loss Surgery: The African-American Womans Lived Experience You are invited to participate in this study about the lived experience of AfricanAmerican women who had had weight-loss surgery. The purpose of this study is to understand what African American women have experienced in their lives 18 months to two years since they have had bariatric surgery. This will enable nurses to improve the quality of care they provide for patients who have bariatric surgery. The interview will focus on your experience after weight loss surgery. The interview will be tape recorded and you will be asked to wear a small lapel microphone to improve the audio quality of the tape recording. After the interview, you may be contacted by your nurse researcher with some follow up questions just to check what you have said or to ask you to expand on a point you have made. When the data from your interview are analyzed the nurse-researcher will send you a copy of the findings to verify whether you agree with them or not. After you have completed the interview and have reviewed the transcripts you will be given a cash gift of $25 for being in this study. Due to the sensitive issue of weight and race/cultural aspects and questions that may be highly personal, the nurse researcher will guide the study respectfully. Although there is no direct benefit for your participation in this study, the information you share and the knowledge gained may help you or others who will have weight loss surgery. The confidentiality of your taped interview will be protected in a number of ways. The written informed consent that you signed will be kept separate from your interview. If any identifying names are included in your taped interview, the researcher will delete them and replace names with generic descriptive words. The hard copy of your interview will be kept in a locked file cabinet in the researchers office at Molloy College. The researchers computer is password protected. When the findings are reported, the data will have a fake name attached. This information may be used in nursing publications or presentations. You should also know that the Molloy College Institutional Review Board (IRB) and the Office of Research Compliance may inspect the study records as part of its auditing program, but these reviews will only focus on the researcher and not on your responses or involvement. The IRB is a group of people who review proposed research studies to make sure they are safe for participants. Your participation in this study is entirely voluntary. If you agree to be in this study, but later change your mind, you may withdraw at any time. There are no penalties or negative consequences of any kind if you decide you do not want to participate. If you have any further questions about this study contact Irene Ficaro, R.N. by telephone (516) 587-1449 (ficaro09@lions.molloy.edu). If you have any questions or

Irene Ficaro 15 concerns about the conduct of this study you may contact the Molloy College Institutional Review Board (IRB) at 516-678-5000. I, ________________________ have read this form and agree to participate in the study described above. Its general purposes, the particulars of involvement, and possible hazards and inconveniences have been explained to my satisfaction. My signature also indicates that I have received a copy of this consent form. Signature: _____________________ Print Name: ________________________ Relationship: ___________________ Date: _________________________

__________________________________ Signature of Principal Investigator

_______________________________ Phone

Irene Ficaro 16 Appendix B: Study Timeline of Activities A year before submission for publication: Develop study design 9-11 months before submission for publication: Query population of interest, place ads, set up voice mail and toll-free telephone number Data collection (Interviews) Transcribe/analyze interviews 5-8 months before submission for publication: Finalize data analysis 2-3 months before submission for publication: Prepare exhaustive description Perform member check and make appropriate revisions Write/submit report to IRB Write manuscript for publication Submit abstracts

Irene Ficaro 17