TY - JOUR
AU1 - Flaherty, Gerard, T
AU2 - Geoghegan,, Rosemary
AU3 - Brown, Ibinabo, Gabriel
AU4 - Finucane, Francis, M
AB - Abstract Background It is unknown whether obesity is a barrier to international travel. The purpose of this qualitative study was to describe the travel experiences of a cohort of severely obese individuals attending a hospital-based bariatric service, to identify their perceived barriers to travel and to generate recommendations that address the needs of severely obese individuals. Methods Semi-structured interviews were conducted with severely obese patients attending a regional, structured, multidisciplinary lifestyle modification programme. Coding and thematic analysis of the transcripts were completed by three independent researchers. A thematic analysis was performed based on examination of the transcribed interviews. Demographic and clinical data such as gender, age and body mass index were also recorded. Results Twelve patients (six males), with a mean age of 54 ± 5.98 years and a mean body mass index of 46.2 ± 8.2 kg/m2, agreed to semi-structured interviews (14–52-minute duration). The principal themes emerging from the interviews included obese air traveller embarrassment, physical discomfort on commercial flights, perceived weight bias, challenges in accessing hotel rooms, heat intolerance in warm climates, restricted leisure travel activities and medical co-morbidities. Most of the interviewees perceived a health benefit to travel but regarded obesity as a significant barrier to international travel. Conclusion These findings highlight the limitations experienced by obese travellers when engaging in international travel. Our results may inform the pre-travel health advice given to obese travellers. They might also serve to raise awareness among operators within the travel industry of the difficulties travellers with severe obesity face. Severe obesity, bariatric, air travel, accommodation, barriers, disability, prejudice Introduction In spite of its increasing global prevalence,1 obesity has received limited coverage in the travel medicine literature2 and the proportion of all travellers who are severely obese has not been estimated. Obesity has not been considered in previous retrospective studies of the burden of chronic medical illness in travellers.3 The extent to which obese individuals are the object of discrimination in civilian life and in healthcare settings has been previously discussed,4 but whether obesity is a perceived barrier to international travel and the extent to which the severely obese traveller’s real-life travel experiences are limited by the body habitus are unknown. Likewise, whether the known health benefits of travel extend to those with severe obesity has not been determined.5 Cultural attitudes towards obesity vary around the world, and it is reasonable to assume that some obese travellers will encounter negative experiences as a result of their obese status. A previous cross-sectional analysis has established a hierarchy of health priorities for travellers in general,6 but those for severely obese travellers have not been studied and are likely to be different. We sought to describe the travel experiences of a cohort of severely obese adults attending a specialist bariatric lifestyle modification programme, to identify perceived barriers to travel and to generate recommendations for travellers, travel destinations and the travel industry that would serve to address the specific needs of severely obese individuals. Methods We employed a qualitative study design using semi-structured interviews centred on an underpinning phenomenological research design, in order to explore the travel experiences of severely obese adults.7 Each semi-structured interview was conducted by one male research team member (I.G.B.) who received prior training on semi-structured interview techniques. These were guided by an interview schedule developed by the research team and informed by the body of knowledge of the International Society of Travel Medicine.8 Prompts were used to elicit greater detail and to elaborate descriptions of participants’ travel experiences. Interview data were collected under the following headings: travel history, travel pattern, pre-travel preparation, transportation, travel accommodation, activities, prejudice, medications and co-existing illnesses and perceived barriers and solutions. Participants were recruited using homogeneous purposive sampling. The study population consisted of adults >18 years with severe obesity, defined as a body mass index (BMI) of ≥40 kg/m2 or ≥35 kg/m2 with co-morbidities such as type 2 diabetes mellitus or sleep apnoea, who were attending a hospital-based regional bariatric referral service and who had been enrolled in a single-centre structured lifestyle modification programme9 as part of their routine bariatric care. Patients were approached in person at the facility by study personnel, and the purpose of the research was outlined; a participant information leaflet was provided, and written informed consent was obtained from those willing to participate. Ethical approval was granted by the Clinical Research Ethics Committee of Galway University Hospitals (reference number C.A. 1781). Data were collected through digital audio recording of interviews in a private room during the months of June and July 2017. Interviews were transcribed verbatim by the interviewer. No repeat interviews were conducted, and no field notes were made during or after the interview. Individual transcripts were made available to the relevant participant for comment or correction. The interviews continued until the researchers perceived that no new themes were being derived from the content of the transcripts. Interview notes were subjected to thematic content analysis by three researchers to identify underlying themes. This iterative process was done individually in the first instance followed by collective discussions to reach consensus agreement, as previously described.10 The process of questioning the meanings inferred from the data served to clarify the definition of codes and to delineate the relationships between thematic categories. Study participants did not provide feedback on the findings of the coding process. Quotations were extracted from the transcripts to illustrate the themes and sub-themes emerging from the study. These were identified by participant number only (e.g. P1, P2 etc.). Results Twelve individuals (six males), with a mean age of 54 ± 5.98 years, agreed to participate and were interviewed. Data saturation was reached after 12 interviews. Their mean BMI was 46.2 ± 8.2 kg/m2 (range, 34.3–58.5 kg/m2). The interviews ranged in duration from 14 to 52 minutes, with a mean duration of 35 minutes. None of the participants requested any changes to be made upon viewing their transcript prior to analysis. Inductive thematic analysis revealed six major themes with multiple sub-themes (Table 1). Table 1 Sub-themes and descriptive examples of theme 1, necessity for strategic planning of itinerary Sub-theme Representative quotations Advanced planning of travel arrangements ‘They have not taken into consideration it might take me that half an hour to get half way to the plane. So you have to go a couple of hours early and plan it a good distance in advance.’ (P1) Travel health insurance ‘I always organise insurance when I am travelling and you have to declare any conditions you have obviously on that, and that tends to slightly increase the price. And that’s kind of understandable, if you are a higher risk.’ (P4) Concerns about medical evacuation ‘But now I would not travel without insurance. Just, [be]cause if anything did happen, the cost of repatriation…could be very expensive.’ (P4) Sub-theme Representative quotations Advanced planning of travel arrangements ‘They have not taken into consideration it might take me that half an hour to get half way to the plane. So you have to go a couple of hours early and plan it a good distance in advance.’ (P1) Travel health insurance ‘I always organise insurance when I am travelling and you have to declare any conditions you have obviously on that, and that tends to slightly increase the price. And that’s kind of understandable, if you are a higher risk.’ (P4) Concerns about medical evacuation ‘But now I would not travel without insurance. Just, [be]cause if anything did happen, the cost of repatriation…could be very expensive.’ (P4) View Large Table 1 Sub-themes and descriptive examples of theme 1, necessity for strategic planning of itinerary Sub-theme Representative quotations Advanced planning of travel arrangements ‘They have not taken into consideration it might take me that half an hour to get half way to the plane. So you have to go a couple of hours early and plan it a good distance in advance.’ (P1) Travel health insurance ‘I always organise insurance when I am travelling and you have to declare any conditions you have obviously on that, and that tends to slightly increase the price. And that’s kind of understandable, if you are a higher risk.’ (P4) Concerns about medical evacuation ‘But now I would not travel without insurance. Just, [be]cause if anything did happen, the cost of repatriation…could be very expensive.’ (P4) Sub-theme Representative quotations Advanced planning of travel arrangements ‘They have not taken into consideration it might take me that half an hour to get half way to the plane. So you have to go a couple of hours early and plan it a good distance in advance.’ (P1) Travel health insurance ‘I always organise insurance when I am travelling and you have to declare any conditions you have obviously on that, and that tends to slightly increase the price. And that’s kind of understandable, if you are a higher risk.’ (P4) Concerns about medical evacuation ‘But now I would not travel without insurance. Just, [be]cause if anything did happen, the cost of repatriation…could be very expensive.’ (P4) View Large Theme 1: necessity for strategic planning of itinerary Participants spoke of the pressures they faced in preparing for an international trip. They found it difficult to make spontaneous decisions about travel plans and they felt restricted in not being able to deviate from a planned itinerary during travel (Table 1). Advanced planning measures including contacting hotels to assess their suitability for severely obese guests, checking airline policies on the purchase of additional seats for a single severely obese passenger and allowing significantly more time ahead of their flight at the airport owing to the mobility challenges they faced in reaching their departure gate were commonly reported by participants. Most participants were adamant that travel insurance was essential for an obese traveller and a minority felt that purchasing medical evacuation insurance was important because of the logistical difficulties they could face if they became medically incapacitated in a remote destination. Theme 2: challenges of air transportation Reflections of participants in relation to commercial air travel are summarized in Table 2. Several expressed a preference for cruise ship travel as it avoided many of the practical inconveniences of air travel. Travellers found the airport experience very stressful. Despite using luggage with wheels, there was still a need to lift items of luggage onto scales and security conveyor belts. Even pulling luggage intended for the hold to the check-in desk or pulling hand luggage to the airplane involved significant perceived physical exertion. Some travellers reported routinely requesting airport wheelchair assistance, citing co-morbidities such as heart disease when making such requests. The perceived unsuitability of airport wheelchairs for severely obese passengers was criticized with some reporting that the chairs were uncomfortably narrow for their body size. Severely obese travellers who walked to their gate discussed the long transfer distances involved and the need for them to rest frequently on the way. This was a perceived source of embarrassment to them if they were travelling with young children or grandchildren and made it difficult for them to adequately supervise their children who often ran ahead in a busy airport. Table 2 Sub-themes and descriptive examples of theme 2, challenges of air transportation Sub-theme Representative quotations Preference for cruise ship travel ‘I found cruising is suiting my lifestyle better because it’s more accommodating for the obese lady.’ (P1) Difficulties carrying luggage ‘Like if you are taking hand luggage just for say a two-day city break, how far from once you check in…are you going to carry that bag? …So you have to look into the way your luggage moves. Whether it’s going to be two wheels or one of those push along with four wheels.’ (P1) Airport wheelchair assistance ‘Now the only problem with the wheelchairs is the wheelchairs are too small for obese people. Airport wheelchairs are too small for obese people.’ (P7) Long transfer distances at airport ‘…just even the transfers. From gate 12 to gate 36 you know. It’s just, you are too exhausted, you cannot do it. Or you can, but it’s a challenge.’ (P11) Airplane seat and aisle dimensions ‘There’s barely enough room to get down the aisle and, if somebody’s coming with a trolley of coffee, that means you are standing in the aisle until they have done the full length of the plane to let you out.’ (P1) Airplane seat belt extenders ‘Some of (the flight attendants) could be nice, and they could just hand (the seat belt extender) to you inconspicuously, and there’s others that would almost walk along, you know, the gangway going “oh look what I have got”, you know, waving it around as if to say “oh look, there’s a fat woman here!”’ (P11) Need to purchase additional seats ‘Most of the spaces are near where the exits are, but because of my hips and knees they will not let me near an exit. Because I’d be too slow to react if there was a problem on the plane. So, which means my husband cannot sit there either. So he has to try and sit in an outside seat, and put his legs out in the aisle.’ (P10) Inability to occupy emergency rows ‘Because if you are having a bad day and you bring a stick and you book the extra leg room, the airline will not let you sit at the emergency row because you have to be fit in the case of an emergency to get up and assist the passengers to open the door. If you have a walking aid with you, they’d say you are not fit to do that.’ (P1) Sub-theme Representative quotations Preference for cruise ship travel ‘I found cruising is suiting my lifestyle better because it’s more accommodating for the obese lady.’ (P1) Difficulties carrying luggage ‘Like if you are taking hand luggage just for say a two-day city break, how far from once you check in…are you going to carry that bag? …So you have to look into the way your luggage moves. Whether it’s going to be two wheels or one of those push along with four wheels.’ (P1) Airport wheelchair assistance ‘Now the only problem with the wheelchairs is the wheelchairs are too small for obese people. Airport wheelchairs are too small for obese people.’ (P7) Long transfer distances at airport ‘…just even the transfers. From gate 12 to gate 36 you know. It’s just, you are too exhausted, you cannot do it. Or you can, but it’s a challenge.’ (P11) Airplane seat and aisle dimensions ‘There’s barely enough room to get down the aisle and, if somebody’s coming with a trolley of coffee, that means you are standing in the aisle until they have done the full length of the plane to let you out.’ (P1) Airplane seat belt extenders ‘Some of (the flight attendants) could be nice, and they could just hand (the seat belt extender) to you inconspicuously, and there’s others that would almost walk along, you know, the gangway going “oh look what I have got”, you know, waving it around as if to say “oh look, there’s a fat woman here!”’ (P11) Need to purchase additional seats ‘Most of the spaces are near where the exits are, but because of my hips and knees they will not let me near an exit. Because I’d be too slow to react if there was a problem on the plane. So, which means my husband cannot sit there either. So he has to try and sit in an outside seat, and put his legs out in the aisle.’ (P10) Inability to occupy emergency rows ‘Because if you are having a bad day and you bring a stick and you book the extra leg room, the airline will not let you sit at the emergency row because you have to be fit in the case of an emergency to get up and assist the passengers to open the door. If you have a walking aid with you, they’d say you are not fit to do that.’ (P1) View Large Table 2 Sub-themes and descriptive examples of theme 2, challenges of air transportation Sub-theme Representative quotations Preference for cruise ship travel ‘I found cruising is suiting my lifestyle better because it’s more accommodating for the obese lady.’ (P1) Difficulties carrying luggage ‘Like if you are taking hand luggage just for say a two-day city break, how far from once you check in…are you going to carry that bag? …So you have to look into the way your luggage moves. Whether it’s going to be two wheels or one of those push along with four wheels.’ (P1) Airport wheelchair assistance ‘Now the only problem with the wheelchairs is the wheelchairs are too small for obese people. Airport wheelchairs are too small for obese people.’ (P7) Long transfer distances at airport ‘…just even the transfers. From gate 12 to gate 36 you know. It’s just, you are too exhausted, you cannot do it. Or you can, but it’s a challenge.’ (P11) Airplane seat and aisle dimensions ‘There’s barely enough room to get down the aisle and, if somebody’s coming with a trolley of coffee, that means you are standing in the aisle until they have done the full length of the plane to let you out.’ (P1) Airplane seat belt extenders ‘Some of (the flight attendants) could be nice, and they could just hand (the seat belt extender) to you inconspicuously, and there’s others that would almost walk along, you know, the gangway going “oh look what I have got”, you know, waving it around as if to say “oh look, there’s a fat woman here!”’ (P11) Need to purchase additional seats ‘Most of the spaces are near where the exits are, but because of my hips and knees they will not let me near an exit. Because I’d be too slow to react if there was a problem on the plane. So, which means my husband cannot sit there either. So he has to try and sit in an outside seat, and put his legs out in the aisle.’ (P10) Inability to occupy emergency rows ‘Because if you are having a bad day and you bring a stick and you book the extra leg room, the airline will not let you sit at the emergency row because you have to be fit in the case of an emergency to get up and assist the passengers to open the door. If you have a walking aid with you, they’d say you are not fit to do that.’ (P1) Sub-theme Representative quotations Preference for cruise ship travel ‘I found cruising is suiting my lifestyle better because it’s more accommodating for the obese lady.’ (P1) Difficulties carrying luggage ‘Like if you are taking hand luggage just for say a two-day city break, how far from once you check in…are you going to carry that bag? …So you have to look into the way your luggage moves. Whether it’s going to be two wheels or one of those push along with four wheels.’ (P1) Airport wheelchair assistance ‘Now the only problem with the wheelchairs is the wheelchairs are too small for obese people. Airport wheelchairs are too small for obese people.’ (P7) Long transfer distances at airport ‘…just even the transfers. From gate 12 to gate 36 you know. It’s just, you are too exhausted, you cannot do it. Or you can, but it’s a challenge.’ (P11) Airplane seat and aisle dimensions ‘There’s barely enough room to get down the aisle and, if somebody’s coming with a trolley of coffee, that means you are standing in the aisle until they have done the full length of the plane to let you out.’ (P1) Airplane seat belt extenders ‘Some of (the flight attendants) could be nice, and they could just hand (the seat belt extender) to you inconspicuously, and there’s others that would almost walk along, you know, the gangway going “oh look what I have got”, you know, waving it around as if to say “oh look, there’s a fat woman here!”’ (P11) Need to purchase additional seats ‘Most of the spaces are near where the exits are, but because of my hips and knees they will not let me near an exit. Because I’d be too slow to react if there was a problem on the plane. So, which means my husband cannot sit there either. So he has to try and sit in an outside seat, and put his legs out in the aisle.’ (P10) Inability to occupy emergency rows ‘Because if you are having a bad day and you bring a stick and you book the extra leg room, the airline will not let you sit at the emergency row because you have to be fit in the case of an emergency to get up and assist the passengers to open the door. If you have a walking aid with you, they’d say you are not fit to do that.’ (P1) View Large The necessity to purchase an additional seat was a source of considerable distress to some severely obese passengers, and this restricted their financial capacity to travel more frequently. The narrow dimensions of the airplane aisle presented practical challenges during boarding. Some travellers recalled flights where they were unable to lower the meal tray and were forced to draw in their abdomen throughout a flight in order to be able to secure their seat belt and were unable to use the airplane toilet for the duration of a long haul flight given its small size and the fact that the door opens inwards. Participants developed solutions for dealing with the latter inconvenience by using the airport toilet facilities immediately prior to boarding if possible and by avoiding drinking fluids during the flight. Theme 3: hotel accommodation accessibility Serious safety concerns were raised by several participants when discussing their experiences of hotel accommodation during overseas travel. They tended to request rooms that were in close proximity to elevators, in order to minimize the physical effort involved (Table 3). The group expressed an absolute dependence on hotel elevators, which, if under repair, presented significant difficulties. One participant believed that he would perish in the event of a hotel fire because he could not evacuate his room quickly enough. The difficulties stepping into and out of baths and showers were described by most of the interviewees and several individuals chose to compromise on personal hygiene by having a rudimentary bath at the hotel bathroom sink instead. One obese participant reported having damaged hotel beds in the past because of his excessive body weight but felt too embarrassed to report this to the hotel staff. Table 3 Sub-themes and descriptive examples of theme 3, hotel accommodation accessibility Sub-theme Representative quotations Hotel access and egress ‘You kind of have to ask for the disability room for the bit of an extra space for the shower and the bathroom and even just for the amenity of getting around.’ (P1) Concerns regarding fire safety ‘…if you are in a place that does not have a lift, that’s a nightmare. You are talking time wise. Now imagine if there was a fire like, I do not…you’ll probably stay and burn. It’ll be easier than running down the stairs.’ (P7) Difficulties negotiating stairs ‘…if we were on more than say the second flight up, I’d have to make sure there was a lift. I can do a flight or two of stairs without difficulty, but I would not like to be going up and down multiple flights of stairs with no lift.’ (P4) Dependence on rooms being near elevators ‘…if I am booking a hotel room, I try and say, can I have one near the lift? I was in a hotel not so long ago and I did not ask for that. And I was miles away from reception.’ (P8) Access to bath and shower facilities ‘So you have to wash at the sink. Because you could not open the shower door, especially the corner ones you know…you cannot get in. I mean even in my own bathroom at home, I could not go in my door straight on.’ (P11) Damage to hotel beds ‘But hotels then, the main problem I would have is breaking beds. I have broken more than a few beds. As a rule, that’s pretty embarrassing.’ (P7) Sub-theme Representative quotations Hotel access and egress ‘You kind of have to ask for the disability room for the bit of an extra space for the shower and the bathroom and even just for the amenity of getting around.’ (P1) Concerns regarding fire safety ‘…if you are in a place that does not have a lift, that’s a nightmare. You are talking time wise. Now imagine if there was a fire like, I do not…you’ll probably stay and burn. It’ll be easier than running down the stairs.’ (P7) Difficulties negotiating stairs ‘…if we were on more than say the second flight up, I’d have to make sure there was a lift. I can do a flight or two of stairs without difficulty, but I would not like to be going up and down multiple flights of stairs with no lift.’ (P4) Dependence on rooms being near elevators ‘…if I am booking a hotel room, I try and say, can I have one near the lift? I was in a hotel not so long ago and I did not ask for that. And I was miles away from reception.’ (P8) Access to bath and shower facilities ‘So you have to wash at the sink. Because you could not open the shower door, especially the corner ones you know…you cannot get in. I mean even in my own bathroom at home, I could not go in my door straight on.’ (P11) Damage to hotel beds ‘But hotels then, the main problem I would have is breaking beds. I have broken more than a few beds. As a rule, that’s pretty embarrassing.’ (P7) View Large Table 3 Sub-themes and descriptive examples of theme 3, hotel accommodation accessibility Sub-theme Representative quotations Hotel access and egress ‘You kind of have to ask for the disability room for the bit of an extra space for the shower and the bathroom and even just for the amenity of getting around.’ (P1) Concerns regarding fire safety ‘…if you are in a place that does not have a lift, that’s a nightmare. You are talking time wise. Now imagine if there was a fire like, I do not…you’ll probably stay and burn. It’ll be easier than running down the stairs.’ (P7) Difficulties negotiating stairs ‘…if we were on more than say the second flight up, I’d have to make sure there was a lift. I can do a flight or two of stairs without difficulty, but I would not like to be going up and down multiple flights of stairs with no lift.’ (P4) Dependence on rooms being near elevators ‘…if I am booking a hotel room, I try and say, can I have one near the lift? I was in a hotel not so long ago and I did not ask for that. And I was miles away from reception.’ (P8) Access to bath and shower facilities ‘So you have to wash at the sink. Because you could not open the shower door, especially the corner ones you know…you cannot get in. I mean even in my own bathroom at home, I could not go in my door straight on.’ (P11) Damage to hotel beds ‘But hotels then, the main problem I would have is breaking beds. I have broken more than a few beds. As a rule, that’s pretty embarrassing.’ (P7) Sub-theme Representative quotations Hotel access and egress ‘You kind of have to ask for the disability room for the bit of an extra space for the shower and the bathroom and even just for the amenity of getting around.’ (P1) Concerns regarding fire safety ‘…if you are in a place that does not have a lift, that’s a nightmare. You are talking time wise. Now imagine if there was a fire like, I do not…you’ll probably stay and burn. It’ll be easier than running down the stairs.’ (P7) Difficulties negotiating stairs ‘…if we were on more than say the second flight up, I’d have to make sure there was a lift. I can do a flight or two of stairs without difficulty, but I would not like to be going up and down multiple flights of stairs with no lift.’ (P4) Dependence on rooms being near elevators ‘…if I am booking a hotel room, I try and say, can I have one near the lift? I was in a hotel not so long ago and I did not ask for that. And I was miles away from reception.’ (P8) Access to bath and shower facilities ‘So you have to wash at the sink. Because you could not open the shower door, especially the corner ones you know…you cannot get in. I mean even in my own bathroom at home, I could not go in my door straight on.’ (P11) Damage to hotel beds ‘But hotels then, the main problem I would have is breaking beds. I have broken more than a few beds. As a rule, that’s pretty embarrassing.’ (P7) View Large Table 4 Sub-themes and descriptive examples of theme 4, restriction of recreational travel activities Sub-theme Representative quotations Limited holiday clothing options ‘So when you are buying clothes online, and waiting for them to come to see that they fit. And if not, you have to post them back. So you have to prepare in advance.’ (P5) Avoidance of water parks ‘A lot of stuff I just cannot, I would not even attempt to do. There’s a couple of times now a few years ago even in the summer at the water parks, I struggled on some of the slides there you know, and I was very self-conscious. It was embarrassing you know.’ (P2) Concerns about participation in walking tours ‘Because you could get caught on a walking tour that would have a lot of steps. That would not suit, and then you are holding everybody else back so.’ (P1) Barriers to playing with own children ‘Even going to the likes of say Disney World or things like that, you’ll have to think twice. What kind of ride would you be getting into? Some of them would have safety bars and things that would close. You do not want to embarrass your children either like, “oh Daddy cannot go” you know, that type of thing.’ (P2) Embarrassment in bathing areas ‘Like when I was younger, I was a lot more active. I was a keen swimmer and I swam a lot. But I would not go to a pool now. And I would not go to a beach now.’ (P3) Vulnerability to being mugged ‘And you are vulnerable too. When you are in (a city), people take advantage of you. Because it’ll be easier to rob a man like me than it would be for a chap like you.’ (P9) Dependence on taxis at destination ‘Because even, like there was a good place to walk and that, and I just wasn’t able to do it, you know, we were getting taxis anywhere.’ (P12) Poor heat tolerance ‘So if there was something that involved that kind of activity to get to it, if it was particularly warm, I would be waiting until the temperature would cool, or I’ll go earlier or late, when it’s much cooler. I would not be able to go in the heat.’ (P4) Sub-theme Representative quotations Limited holiday clothing options ‘So when you are buying clothes online, and waiting for them to come to see that they fit. And if not, you have to post them back. So you have to prepare in advance.’ (P5) Avoidance of water parks ‘A lot of stuff I just cannot, I would not even attempt to do. There’s a couple of times now a few years ago even in the summer at the water parks, I struggled on some of the slides there you know, and I was very self-conscious. It was embarrassing you know.’ (P2) Concerns about participation in walking tours ‘Because you could get caught on a walking tour that would have a lot of steps. That would not suit, and then you are holding everybody else back so.’ (P1) Barriers to playing with own children ‘Even going to the likes of say Disney World or things like that, you’ll have to think twice. What kind of ride would you be getting into? Some of them would have safety bars and things that would close. You do not want to embarrass your children either like, “oh Daddy cannot go” you know, that type of thing.’ (P2) Embarrassment in bathing areas ‘Like when I was younger, I was a lot more active. I was a keen swimmer and I swam a lot. But I would not go to a pool now. And I would not go to a beach now.’ (P3) Vulnerability to being mugged ‘And you are vulnerable too. When you are in (a city), people take advantage of you. Because it’ll be easier to rob a man like me than it would be for a chap like you.’ (P9) Dependence on taxis at destination ‘Because even, like there was a good place to walk and that, and I just wasn’t able to do it, you know, we were getting taxis anywhere.’ (P12) Poor heat tolerance ‘So if there was something that involved that kind of activity to get to it, if it was particularly warm, I would be waiting until the temperature would cool, or I’ll go earlier or late, when it’s much cooler. I would not be able to go in the heat.’ (P4) View Large Table 4 Sub-themes and descriptive examples of theme 4, restriction of recreational travel activities Sub-theme Representative quotations Limited holiday clothing options ‘So when you are buying clothes online, and waiting for them to come to see that they fit. And if not, you have to post them back. So you have to prepare in advance.’ (P5) Avoidance of water parks ‘A lot of stuff I just cannot, I would not even attempt to do. There’s a couple of times now a few years ago even in the summer at the water parks, I struggled on some of the slides there you know, and I was very self-conscious. It was embarrassing you know.’ (P2) Concerns about participation in walking tours ‘Because you could get caught on a walking tour that would have a lot of steps. That would not suit, and then you are holding everybody else back so.’ (P1) Barriers to playing with own children ‘Even going to the likes of say Disney World or things like that, you’ll have to think twice. What kind of ride would you be getting into? Some of them would have safety bars and things that would close. You do not want to embarrass your children either like, “oh Daddy cannot go” you know, that type of thing.’ (P2) Embarrassment in bathing areas ‘Like when I was younger, I was a lot more active. I was a keen swimmer and I swam a lot. But I would not go to a pool now. And I would not go to a beach now.’ (P3) Vulnerability to being mugged ‘And you are vulnerable too. When you are in (a city), people take advantage of you. Because it’ll be easier to rob a man like me than it would be for a chap like you.’ (P9) Dependence on taxis at destination ‘Because even, like there was a good place to walk and that, and I just wasn’t able to do it, you know, we were getting taxis anywhere.’ (P12) Poor heat tolerance ‘So if there was something that involved that kind of activity to get to it, if it was particularly warm, I would be waiting until the temperature would cool, or I’ll go earlier or late, when it’s much cooler. I would not be able to go in the heat.’ (P4) Sub-theme Representative quotations Limited holiday clothing options ‘So when you are buying clothes online, and waiting for them to come to see that they fit. And if not, you have to post them back. So you have to prepare in advance.’ (P5) Avoidance of water parks ‘A lot of stuff I just cannot, I would not even attempt to do. There’s a couple of times now a few years ago even in the summer at the water parks, I struggled on some of the slides there you know, and I was very self-conscious. It was embarrassing you know.’ (P2) Concerns about participation in walking tours ‘Because you could get caught on a walking tour that would have a lot of steps. That would not suit, and then you are holding everybody else back so.’ (P1) Barriers to playing with own children ‘Even going to the likes of say Disney World or things like that, you’ll have to think twice. What kind of ride would you be getting into? Some of them would have safety bars and things that would close. You do not want to embarrass your children either like, “oh Daddy cannot go” you know, that type of thing.’ (P2) Embarrassment in bathing areas ‘Like when I was younger, I was a lot more active. I was a keen swimmer and I swam a lot. But I would not go to a pool now. And I would not go to a beach now.’ (P3) Vulnerability to being mugged ‘And you are vulnerable too. When you are in (a city), people take advantage of you. Because it’ll be easier to rob a man like me than it would be for a chap like you.’ (P9) Dependence on taxis at destination ‘Because even, like there was a good place to walk and that, and I just wasn’t able to do it, you know, we were getting taxis anywhere.’ (P12) Poor heat tolerance ‘So if there was something that involved that kind of activity to get to it, if it was particularly warm, I would be waiting until the temperature would cool, or I’ll go earlier or late, when it’s much cooler. I would not be able to go in the heat.’ (P4) View Large Theme 4: restriction of recreational travel activities Participants in this study described perceived barriers to engaging in recreational pursuits abroad. Several reported having to purchase oversized clothing online well in advance of travel because local stores might not have an adequate range of swimwear clothing options for severely obese customers. Avoidance of water-based theme parks and general embarrassment at being exposed in bathing areas emerged frequently as a sub-theme in interviews (Table 4). These personal limitations restricted tourists’ ability to fully enjoy time spent with children at holiday resorts. There was also a reluctance to participate in tours that involved walking. This was a source of disappointment to some individuals with an interest in historical walking tours, for example. Many travellers felt unduly dependent on taxi transport, especially in warmer climates. Personal heat intolerance was a frequently reported issue. Many perceived that they would need to endure personal discomfort in order for their family to engage in enjoyable outdoor activities. Some participants expressed fear of becoming targets for assault and theft, given the difficulty they would have in pursuing or fleeing from an assailant. Theme 5: perceived weight bias and stigma The participants in this study reflected on the unique discomforts associated with international air travel. Most of this group perceived a prejudicial attitude from fellow airplane passengers, with some bemoaning the behaviour of flight attendants that caused embarrassment when distributing seat belt extenders (Table 5). The public nature of some flight attendants’ presentation of seat belt extenders was raised by most participants in this study. Some felt that the extenders should be more discreetly provided and ideally that they would not be a prominent orange colour. Severely obese passengers seemed conscious of the dissatisfaction of normal weight neighbouring passengers when seated next to them. Several participants voiced their acute awareness of the physical discomfort their fellow air travel passengers experienced because of their body size. Others were embarrassed at being informed that they could not occupy emergency exit seats, even though they may have booked them in advance, given their apparent physical limitations. One participant described a reluctance to take second helpings during a breakfast buffet when staying in hotels abroad as a result of the judgmental attitude they perceived from other guests in the dining room. Table 5 Sub-themes and descriptive examples of theme 5, perceived weight bias and stigma Sub-theme Representative quotations Perceived prejudice from fellow passengers ‘As you were coming down the gangway, everybody would just, you can see them going, “ugh, I hope this fat woman is not going to sit next to me”. And now, I can see it. I can see people looking at others, and you do, you just feel horrible.’ (P11) Awareness of passenger discomfort caused ‘…nobody likes to sit next to somebody who’s twice their size but I try to stay within the seat.’ (P8) Embarrassment caused by flight attendants ‘I would be really embarrassed if somebody had to come down and offer me an extension to my seat belt. That should be something that’s in a side pocket or it’s somewhere like in the front pocket or something that somebody can do themselves without drawing attention.’ (P4) Need for a stoic approach to challenges ‘You know, you just have to have a thick skin and get over yourself. Because if you took it to heart, you would not go anywhere.’ (P1) Greater cultural acceptance in Asia/USA ‘When you talk about the Asian countries, they have actually fantastic respect for you as a big person.’ (P7) Self-blame for obesity ‘It’s like this, I am overweight, it’s my own fault the weight came on you know.’ (P9) Feeling like a lower class citizen ‘I have not travelled much due to obesity, I travelled to Turkey 12 years ago. I think that was my last major holiday. That was hard going. It was just exhausting, and embarrassing. Having to ask for a seat belt extender and you looked like a lower class citizen, and I did not travel again after that.’ (P11) Reluctance to seek second helpings ‘You know, if you go up to the breakfast bar, for your second helping or just that you have missed something you know, your cereal, you have forgotten your spoon and you want to go and “oh look, she’s up for more”.’ (P11) Sub-theme Representative quotations Perceived prejudice from fellow passengers ‘As you were coming down the gangway, everybody would just, you can see them going, “ugh, I hope this fat woman is not going to sit next to me”. And now, I can see it. I can see people looking at others, and you do, you just feel horrible.’ (P11) Awareness of passenger discomfort caused ‘…nobody likes to sit next to somebody who’s twice their size but I try to stay within the seat.’ (P8) Embarrassment caused by flight attendants ‘I would be really embarrassed if somebody had to come down and offer me an extension to my seat belt. That should be something that’s in a side pocket or it’s somewhere like in the front pocket or something that somebody can do themselves without drawing attention.’ (P4) Need for a stoic approach to challenges ‘You know, you just have to have a thick skin and get over yourself. Because if you took it to heart, you would not go anywhere.’ (P1) Greater cultural acceptance in Asia/USA ‘When you talk about the Asian countries, they have actually fantastic respect for you as a big person.’ (P7) Self-blame for obesity ‘It’s like this, I am overweight, it’s my own fault the weight came on you know.’ (P9) Feeling like a lower class citizen ‘I have not travelled much due to obesity, I travelled to Turkey 12 years ago. I think that was my last major holiday. That was hard going. It was just exhausting, and embarrassing. Having to ask for a seat belt extender and you looked like a lower class citizen, and I did not travel again after that.’ (P11) Reluctance to seek second helpings ‘You know, if you go up to the breakfast bar, for your second helping or just that you have missed something you know, your cereal, you have forgotten your spoon and you want to go and “oh look, she’s up for more”.’ (P11) View Large Table 5 Sub-themes and descriptive examples of theme 5, perceived weight bias and stigma Sub-theme Representative quotations Perceived prejudice from fellow passengers ‘As you were coming down the gangway, everybody would just, you can see them going, “ugh, I hope this fat woman is not going to sit next to me”. And now, I can see it. I can see people looking at others, and you do, you just feel horrible.’ (P11) Awareness of passenger discomfort caused ‘…nobody likes to sit next to somebody who’s twice their size but I try to stay within the seat.’ (P8) Embarrassment caused by flight attendants ‘I would be really embarrassed if somebody had to come down and offer me an extension to my seat belt. That should be something that’s in a side pocket or it’s somewhere like in the front pocket or something that somebody can do themselves without drawing attention.’ (P4) Need for a stoic approach to challenges ‘You know, you just have to have a thick skin and get over yourself. Because if you took it to heart, you would not go anywhere.’ (P1) Greater cultural acceptance in Asia/USA ‘When you talk about the Asian countries, they have actually fantastic respect for you as a big person.’ (P7) Self-blame for obesity ‘It’s like this, I am overweight, it’s my own fault the weight came on you know.’ (P9) Feeling like a lower class citizen ‘I have not travelled much due to obesity, I travelled to Turkey 12 years ago. I think that was my last major holiday. That was hard going. It was just exhausting, and embarrassing. Having to ask for a seat belt extender and you looked like a lower class citizen, and I did not travel again after that.’ (P11) Reluctance to seek second helpings ‘You know, if you go up to the breakfast bar, for your second helping or just that you have missed something you know, your cereal, you have forgotten your spoon and you want to go and “oh look, she’s up for more”.’ (P11) Sub-theme Representative quotations Perceived prejudice from fellow passengers ‘As you were coming down the gangway, everybody would just, you can see them going, “ugh, I hope this fat woman is not going to sit next to me”. And now, I can see it. I can see people looking at others, and you do, you just feel horrible.’ (P11) Awareness of passenger discomfort caused ‘…nobody likes to sit next to somebody who’s twice their size but I try to stay within the seat.’ (P8) Embarrassment caused by flight attendants ‘I would be really embarrassed if somebody had to come down and offer me an extension to my seat belt. That should be something that’s in a side pocket or it’s somewhere like in the front pocket or something that somebody can do themselves without drawing attention.’ (P4) Need for a stoic approach to challenges ‘You know, you just have to have a thick skin and get over yourself. Because if you took it to heart, you would not go anywhere.’ (P1) Greater cultural acceptance in Asia/USA ‘When you talk about the Asian countries, they have actually fantastic respect for you as a big person.’ (P7) Self-blame for obesity ‘It’s like this, I am overweight, it’s my own fault the weight came on you know.’ (P9) Feeling like a lower class citizen ‘I have not travelled much due to obesity, I travelled to Turkey 12 years ago. I think that was my last major holiday. That was hard going. It was just exhausting, and embarrassing. Having to ask for a seat belt extender and you looked like a lower class citizen, and I did not travel again after that.’ (P11) Reluctance to seek second helpings ‘You know, if you go up to the breakfast bar, for your second helping or just that you have missed something you know, your cereal, you have forgotten your spoon and you want to go and “oh look, she’s up for more”.’ (P11) View Large Self-deprecation and self-blame were prominent features of these semi-structured interviews. The obese travellers in this study expressed personal responsibility for being overweight. Over half of the participants demonstrated this in the context of their previous leisure travel experiences. Participants reflected on their embarrassment at being obese and the psychological burden this imposed on them: ‘But I’m going to tell you one thing. No matter what you’re doing weight is an embarrassment.’ (P9) ‘so suddenly…your weight problem really magnifies…so it just hits you psychologically and physically.’ (P5) There appeared to be a greater cultural openness towards the needs of obese travellers in Asia and the USA, but the opposite situation prevailed in Northern and Western Europe where there was a much stronger perceived weight stigma. Participants reported engaging in considerable self-blame as a result of these negative experiences. Theme 6: health benefits of travel Each participant was asked to consider whether they appreciated any benefits to their health of international travel. Most individuals alluded to the opportunity afforded to them by travel to broaden their cultural horizons and to appreciate their domestic situation to a greater extent (Table 6). Mental health benefits and an escape from their routine existence were discussed by some of the participants. Travel provided a perceived chance to enjoy quality time with their family. There was also an acknowledgement of the perceived physical benefits of sun exposure for patients with arthritis, which was a common co-morbidity mentioned by participants in this study. Table 6 Sub-themes and descriptive examples of theme 6, health benefits of travel Sub-theme Representative quotations Capacity to broaden horizons ‘…it does not matter where you go or what you see, I think (travel is) very important and everybody should be able to do those things because it broadens your mind and it broadens your horizons you know. And there’s no point in being stuck at home.’ (P3) Mental health benefits ‘For my mental health it is good [yes]. Definitely.’ (P2) Exposure to other cultures ‘When you go and see different cultures, sometime you say when you come back, “thank God I have what I have at home”, and that our country is such a nice country. And then there’s other times you say…when you go to a country that has more than Ireland has here you say “gosh, we should have that here too” you know.’ (P10) Opportunity for quality time with family ‘Taking some time out to spend quality time with family is beneficial.’ (P4) Benefits of sun for arthritis ‘I think doctors should prescribe at least a 7-day holiday in the sun to every patient with arthritis.’ (P1) Sub-theme Representative quotations Capacity to broaden horizons ‘…it does not matter where you go or what you see, I think (travel is) very important and everybody should be able to do those things because it broadens your mind and it broadens your horizons you know. And there’s no point in being stuck at home.’ (P3) Mental health benefits ‘For my mental health it is good [yes]. Definitely.’ (P2) Exposure to other cultures ‘When you go and see different cultures, sometime you say when you come back, “thank God I have what I have at home”, and that our country is such a nice country. And then there’s other times you say…when you go to a country that has more than Ireland has here you say “gosh, we should have that here too” you know.’ (P10) Opportunity for quality time with family ‘Taking some time out to spend quality time with family is beneficial.’ (P4) Benefits of sun for arthritis ‘I think doctors should prescribe at least a 7-day holiday in the sun to every patient with arthritis.’ (P1) View Large Table 6 Sub-themes and descriptive examples of theme 6, health benefits of travel Sub-theme Representative quotations Capacity to broaden horizons ‘…it does not matter where you go or what you see, I think (travel is) very important and everybody should be able to do those things because it broadens your mind and it broadens your horizons you know. And there’s no point in being stuck at home.’ (P3) Mental health benefits ‘For my mental health it is good [yes]. Definitely.’ (P2) Exposure to other cultures ‘When you go and see different cultures, sometime you say when you come back, “thank God I have what I have at home”, and that our country is such a nice country. And then there’s other times you say…when you go to a country that has more than Ireland has here you say “gosh, we should have that here too” you know.’ (P10) Opportunity for quality time with family ‘Taking some time out to spend quality time with family is beneficial.’ (P4) Benefits of sun for arthritis ‘I think doctors should prescribe at least a 7-day holiday in the sun to every patient with arthritis.’ (P1) Sub-theme Representative quotations Capacity to broaden horizons ‘…it does not matter where you go or what you see, I think (travel is) very important and everybody should be able to do those things because it broadens your mind and it broadens your horizons you know. And there’s no point in being stuck at home.’ (P3) Mental health benefits ‘For my mental health it is good [yes]. Definitely.’ (P2) Exposure to other cultures ‘When you go and see different cultures, sometime you say when you come back, “thank God I have what I have at home”, and that our country is such a nice country. And then there’s other times you say…when you go to a country that has more than Ireland has here you say “gosh, we should have that here too” you know.’ (P10) Opportunity for quality time with family ‘Taking some time out to spend quality time with family is beneficial.’ (P4) Benefits of sun for arthritis ‘I think doctors should prescribe at least a 7-day holiday in the sun to every patient with arthritis.’ (P1) View Large Discussion In addition to the burden of premature morbidity and mortality associated with obesity,11 those with the highest accumulation of excess body fat perceive a significant negative impact on their ability to travel in safety and with dignity. This is the first study to describe the experiences and attitudes of severely obese individuals who have travelled to other countries. With the increasing prevalence of severe obesity12 and the relative ease of modern international travel, our findings will be of interest to the travelling public, the travel industry and the clinicians caring for and advising obese travellers. The pressure felt by severely obese travellers to organize their travel itineraries well in advance of arrival at their destination was apparent. Early planning of international travel is generally encouraged by travel medicine specialists13 and may be particularly valuable for this patient group. We have previously highlighted the high levels of traveller uncertainty about their itinerary and the difficulties this pose for the provision of comprehensive pre-travel health advice,13 but this may be an even greater problem in severe obesity. Timely preparation for travel should be the norm among international travellers. Tour operators and travel agents have significant influence in ensuring that all travellers plan their trips well in advance of travel and attend for specialist pre-travel health advice as appropriate. A study of travel agents determined that two-thirds of travel agents had been approached by their clients for travel health advice.14 Airports emerged as a significant source of travel-related stress. Large modern airports often involve large transfer distances between the check-in desks and departure gates. Only the busiest international airports employ automated travellators (moving walkways) on sections of the journey. Passengers at multi-storey airports typically have a choice of using stairs, escalators or elevators. While long walks may impose physical stresses on severely obese airport users, little is known about how this affects their lifestyle choices in airport settings or what proportion of them request wheelchair assistance just because of their obesity, as suggested in our study. A recent study demonstrated that signs were effective in prompting stair use at San Diego International Airport in an effort to promote higher rates of incidental physical activity.15 Further research is needed to ascertain the public health impact of such measures in the severely obese travelling population. Airport architects and managers should consider whether the physical environment of their airport is suitably adapted to an increasingly obese passenger base. Our study participants recounted distressing experiences aboard commercial flights. There was repeated reference to the narrow dimensions of aircraft aisles and the limiting width and leg room of airplane seats in the economy class cabin. None of our subjects reported any experiences of business class or first class air travel. While we are not aware of any universal regulation regarding the need for obese passengers to purchase an additional seat, there is considerable variation between individual airlines’ policies in this regard and obese travellers should be made aware of these restrictions.16 Embarrassment around the use of seat belt extenders could be minimized if they were readily available to severely obese passengers or if their deployment was handled with more tact and sensitivity by airline personnel. Some subjects found the belts uncomfortable even when extended and this might adversely affect seat belt use compliance and ultimately the safety of these passengers, as unpredictable clear air turbulence may pose a risk of physical injury if seat belts are not fastened.17 Indeed, a study of traffic injury susceptibility in obese drivers and passengers recommended that seat belt extenders could be examined to improve wearing rates.18 Several individuals noted the discomfort of avoiding micturition during flights because of the practical difficulty of entering and leaving cramped airplane toilets or of disturbing passengers seated outside them. We recommend that airline staff receive sensitivity training to increase their awareness of the perspectives of obese passengers. Medical co-morbidities including type 2 diabetes, chronic heart failure and obstructive sleep apnoea are over-represented in the obese population. Another study of travel-related difficulties in a cohort of patients with chronic heart failure found that one-third reported health problems aggravated by travelling, specifically when passing through security, on the aircraft and at their final destination, with one-quarter expressing reluctance to travel again by air as a result, but over a third would do so with more leg room on the airplane.19 A notable concern of severely obese travellers related to fire safety in their hotel and the difficulties they anticipated in evacuating safely in a fire. We have previously tabulated fire safety advice for hotel guests.20 These and other safety risks such as vulnerability to mugging imposed by mobility restrictions on obese travellers warrant further research. Most travel medicine research to date has outlined the health risks of international travel and migration2 rather than the potential health benefits of travel, with few exceptions.21 Our sample of severely obese travellers highlights the potential mental health benefits of travel, and participants seemed to value the cultural enrichment afforded by foreign travel. However, this was tempered by not feeling enabled to engage fully in physical recreational activities such as water sports and walking tours. Travel industry operators could address these concerns and adapt their products to better suit holidaymakers of all body sizes. People with severe obesity are a recognized risk group for travel health-related illness because of physiological impairments in the regulation of core body temperature in hot conditions.22 Pre-travel health advice to obese patients should routinely address this issue, and the obese traveller should be advised to take protective steps to mitigate the effects of heat illness during travel to hot climates. One of the strongest themes to emerge from this work was the weight bias and stigma perceived by severely obese travellers, although this was not recounted by all participants. This was particularly apparent from their accounts of walking to their seat as they boarded aircraft and in dining situations abroad. A study using semi-structured interviews of self-identified obese people found that the self-perception of people’s bodies as stigmatized was an important factor in determining the quality of their experience aboard international flights.23 A qualitative study of obese men revealed that all felt personally responsible for their excessive weight and that weight-based stigma was a significant barrier to weight loss.24 Weight stigma has been found to be an important mediator of the association observed between BMI and self-reported health.25 The cross-sectional REasons for Geographic and Racial Differences in Stroke (REGARDS) study determined that the presence of depressive symptoms and perceived stress was associated with increased weight circumference.26 The lower perceived discrimination felt towards severely obese travellers to the USA and Asia warrants further studies. The importance of purchasing travel medical insurance with evacuation coverage was reinforced by the obese subjects in our study. This recognition of the importance of travel insurance is not always appreciated by the travelling public, up to 40% of whom may travel abroad without medical insurance cover.27 In a Swiss study of insurance claims among the travelling general public, most were due to medical illness (69.4%) and the remainder (30.6%) were due to accidental trauma.28 In a similar Australian study, most claims were for respiratory (20.4%), musculoskeletal (16.7%) and gastrointestinal (13.9%) complaints.29 Most diagnoses requiring aeromedical evacuation are for femoral neck fracture (15%), stroke (14%) and myocardial infarction (8%), all of which occur more frequently in obese individuals.30 Some participants noted potential practical difficulties that rescue services might encounter with emergency aeromedical repatriation from overseas. The semi-structured interviews captured in this study, though a rich source of patient-generated data, are limited by volunteer bias, recall bias and possible researcher bias. Patients with severe obesity do not self-enrol but instead are referred by their physician to the CLANN lifestyle intervention programme, thus minimizing the likelihood that these participants had more or less perceived weight bias. The reliability of qualitative data and the generalizability of their findings are not without inherent limitations. Whether the severely obese patients in our cohort, who were attending a bariatric lifestyle modification programme, are representative of all obese travellers also cannot be determined. We acknowledge that this is a single-centre study and recommend that it be extended to multiple international centres if possible. While efforts were made to minimize the effects of these factors, their influence cannot be excluded. Two researchers independently agreed that data saturation was reached after conducting 12 patient interviews and there was excellent agreement between three researchers on the emergent themes and sub-themes. Our findings were consistent with the sparse available qualitative research in this field. Conclusion This study highlights the unique limitations confronting severely obese travellers. Travel industry educational courses should include sensitivity training in relation to severely obese travellers, and public awareness campaigns should be designed to promote greater tolerance in non-obese travellers. Potential issues facing severely obese travellers should be openly addressed in the pre-travel consultation. Future research should focus on investigating the attitudes and practices of members of the travel industry towards their severely obese clients and evaluation of an educational intervention to maximize the benefit of the pre-travel consultation for severely obese travellers. Funding I.G.B. received an unrestricted research bursary from the Travel Medicine Society of Ireland. Conflict of interest. None declared. Acknowledgements We wish to acknowledge the kind assistance of members of the Croí Heart and Stroke Centre healthcare team, in particular the nurse coordinator, Therese Manton, and programme administrator, Annie Costello, for facilitating access to patients attending the CLANN lifestyle intervention programme. References 1. GBD 2015 Obesity Collaborators . Health effects of overweight and obesity in 195 countries over 25 years . N Engl J Med 2017 ; 377 : 13 – 27 . doi: https://doi.org/10.1056/NEJMoa1614362 . Crossref Search ADS PubMed 2. Flaherty GT , Yap KL . Bibliometric analysis and curriculum mapping of travel medicine research . J Travel Med 2017 ; 24 : 1 – 5 . Google Scholar Crossref Search ADS 3. Han CTJ , Flaherty G . Profile of travelers with preexisting medical conditions attending a specialist travel medicine clinic in Ireland . J Travel Med 2015 ; 22 : 312 – 317 . Google Scholar Crossref Search ADS PubMed 4. Puhl RM , Heuer CA . The stigma of obesity: a review and update . Obesity 2009 ; 17 : 941 – 964 . Google Scholar Crossref Search ADS PubMed 5. Mozo MV , Finucane FM , Flaherty GT . Health challenges of international travel for obese patients . J Travel Med 2017 , 24 : 1 – 4 . doi: https://doi.org/10.1093/jtm/tax065 . Google Scholar Crossref Search ADS 6. Flaherty GT , Chen B , Avalos G. Individual traveller health priorities and the pre-travel health consultation . J Travel Med 2017 ; 24 : 1 – 4 . doi: https://doi.org/10.1093/jtm/tax059 . Google Scholar Crossref Search ADS 7. Rodriguez A , Smith J . Phenomenology as a healthcare research method . Evid Based Nurs 2018 ; 21 : 96 – 98 . Google Scholar Crossref Search ADS PubMed 8. Kozarsky P . The body of knowledge for the practice of travel medicine - 2006 . J Travel Med 2006 ; 13 : 251 – 254 . Google Scholar Crossref Search ADS PubMed 9. Crowe A , Gibson I , Cunningham K , et al. Effects of an eight-week supervised, structured lifestyle modification programme on anthropometric, metabolic and cardiovascular risk factors in severely obese adults . BMC Endocr Disord 2015 ; 15 : 37 . doi: https://doi.org/10.1186/s12902-015-0038-x . Google Scholar Crossref Search ADS PubMed 10. Tong A , Sainsbury P , Craig J . Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for itnerviews and focus groups . International J Qual Health Care 2007 ; 19 : 349 – 357 . Google Scholar Crossref Search ADS 11. Lung T , Jan S , Tan EJ , et al. Impact of overweight, obesity and severe obesity on life expectancy of Australian adults . Int J Obes (Lond) 2018 . doi: https://doi.org/10.1038/s41366-018-0210-2 . 12. Sturm R , Hattori A . Morbid obesity rates continue to rise rapidly in the United States . Int J Obes (Lond) 2013 ; 37 : 889 – 891 . Google Scholar Crossref Search ADS PubMed 13. Flaherty G , Md Nor MN . Travel itinerary uncertainty and the pre-travel consultation – a pilot study . J Travel Med 2016 ; 23 : 1 – 3 . doi: https://doi.org/10.1093/jtm/tav010 . Google Scholar Crossref Search ADS 14. Travel S . Airline Obesity Policies . https://www.smartertravel.com/airline-obesity-policies/ (4 March 2019, date last accessed) . 15. Bellettiere J , Liles S , BenPorat Y , et al. And she’s buying a stairway to health: signs and participant factors influencing stair ascent at a public airport . J Prim Prev 2017 ; 38 : 597 – 611 . Google Scholar Crossref Search ADS PubMed 16. Flaherty G , Lim D , Fry G . Travel agency awareness of the health risks of international travel: a pilot study . Int J Trav Med Glob health 2015 ; 3 : 121 – 124 . Google Scholar Crossref Search ADS 17. Flaherty GT , Lehane SM . Fasten your seatbelts: preventing injury from air turbulence in travellers . J Travel Med 2016 ; 1 : 1 – 1 . doi: https://doi.org/10.1093/jtm/taw096 . 18. Viano DC , Parenteau CS , Edwards ML . Crash injury risks for obese occupants using a matched-pair analysis . Traffic Inj Prev 2008 ; 9 : 59 – 64 . Google Scholar Crossref Search ADS PubMed 19. Ingle L , Hobkirk J , Damy T et al. Experiences of air travel in patients with chronic heart failure . Int J Cardiol 2012 ; 158 : 66 – 70 . Google Scholar Crossref Search ADS PubMed 20. Flaherty G , Hession M , Cuggy C . Hotel fire safety for international travellers . Travel Med Infect Dis 2016 ; 14 : 529 – 530 . Google Scholar Crossref Search ADS PubMed 21. Saunders LE , Green JM , Petticrew MP , et al. What are the health benefits of active travel? A systematic review of trials and cohort studies . PLoS One 2013 ; 8 :e69912. 22. Kenny GP , Yardley J , Brown C , et al. Heat stress in older individuals and patients with common chronic diseases . CMAJ 2010 ; 182 : 1053 – 1060 . Google Scholar Crossref Search ADS PubMed 23. Poria Y , Beal J . An exploratory study about obese people’s flight experience . J Travel Res 2017 ; 56 : 370 – 380 . Google Scholar Crossref Search ADS 24. Lewis S , Thomas SL , Hyde J , et al. A qualitative investigation of obese men’s experiences with their weight . Am J Health Behav 2011 ; 35 : 458 – 469 . Google Scholar Crossref Search ADS PubMed 25. Hunger JM , Major B . Weight stigma mediates the association between BMI and self-reported health . Health Psychol 2015 ; 34 : 172 – 175 . Google Scholar Crossref Search ADS PubMed 26. Gowey MA , Khodneva Y , Tison SE , et al. Depressive symptoms, perceived stress, and metabolic health: the REGARDS study . Int J Obes (Lond) 2018 ; 43 : 615 – 632 . doi: https://doi.org/10.1038/s41366-018-0270-3 . Google Scholar Crossref Search ADS PubMed 27. Flaherty G , Maarof MA , Fry G . An analysis of the preventive behavior and attitudes of international travelers from South East Asia: the Kuala Lumpur airport survey . Int J Trav Med Glob Health 2015 ; 3 : 5 – 9 . Google Scholar Crossref Search ADS 28. Somer Kniestedt RA , Steffen R . Travel health insurance: indicator of serious travel health risks . J Travel Med 2003 ; 10 : 185 – 188 . Google Scholar Crossref Search ADS PubMed 29. Leggat PA , Leggat FW . Travel insurance claims made by travelers from Australia . J Travel Med 2002 ; 9 : 59 – 65 . Google Scholar Crossref Search ADS PubMed 30. Sand M , Bollenbach M , Sand D, et al. Epidemiology of aeomedical evacuation: an analysis of 504 cases . J Travel Med 2010 ; 17 : 405 – 409 . Google Scholar Crossref Search ADS PubMed © International Society of Travel Medicine 2019. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Severe obesity as a barrier to international travel: a qualitative analysis
JF - Journal of Travel Medicine
DO - 10.1093/jtm/taz018
DA - 2019-05-10
UR - https://www.deepdyve.com/lp/oxford-university-press/severe-obesity-as-a-barrier-to-international-travel-a-qualitative-1Z0qCLI0x5
VL - 26
IS - 3
DP - DeepDyve
ER -