Addressing equality, diversity and inclusion (EDI) and real-world learning was at the heart of this study, given the explicit objective to examine the equity impact of the NHS LCD programme and assess the transferability of learning to inform the applicability and development of the national roll-out (WP5).
Understanding our target population demographics and study representation
Type 2 diabetes prevalence remains slightly higher in men, older adults (although more younger people are now being diagnosed), and those of Asian, Chinese, Black African and Black Caribbean ethnicities. It can also be more prevalent in people living in social and economic deprivation.2,4 This prevalence pattern is reflected in overweight and obesity, and as both conditions are key inclusion criteria it was critical our study population mirrored the broad and diverse populations who are eligible for the LCD programme, and captured data on those most at risk. We, therefore, took a multifaceted approach to maximise inclusion (described below) and undertook a maximum variation sampling framework in order to ensure representation across gender and age groups, and oversample for those under-represented in the underpinning trial data7,10 who are living in socioeconomic deprivation and/or from diverse ethnic groups. Any shortfalls in achieving this framework for the longitudinal interviews were made up with the addition of further cross-sectional interviews to ensure lived experiences from across the breadth of eligible populations were captured (see RA20, RA11 and Appendix 4).
Overall, the sociodemographic data from the interviews (see Appendix 4) and service user survey (see Appendix 5) aligned closely to the sociodemographic characteristics of those who were referred to, and started, the NHS LCD programme (see Appendix 6). However, additional cross-sectional interviews had to be undertaken to capture experiences across diverse ethnic communities, and recruitment of service users to the participation survey remained lower for diverse ethnic groups. This is therefore an important consideration for future survey research and requires more research coproduction with target communities to co-develop new methods to increase survey uptake.
Our research team and wider involvement
It was critically important that our team represented the diversity of voices to be represented in the study. Therefore, our PPI group included representation from a range of ages, ethnicities (including black and South Asian heritage), genders, socioeconomic status, geographies and comorbidities; this ensured that all our co-development activity represented voices from across our broad and diverse communities that the study would be working with. Our research team also included researchers who represented a range of genders, sexual orientations, ethnicities (including black and South Asian heritage), sociodemographic backgrounds, career stages, ages, experience, skills and expertise. This was important in both the research development and conduct, where researchers and PPI members were matched with the sociodemographics of participants for data collection. We also had a dedicated inequalities lead: Professor Maria Maynard who leads our migrant health research group and extensive EDI activity across the university. Maria ensured an inequalities lens was applied throughout the study.
Our research team included two PhD students (Evans and Dhir) who were supported throughout the study to share their learning at regional, national and international conferences, and professional meetings. These included presentations at the European and UK congresses on obesity, The British Psychological Society and the UK Society of Behavioural Medicine. They also led the authorship of several study publications (RA2, RA3, RA5, RA8, RA11, RA18, RA21) as well as co-authored several other papers. The team also included two early career researchers (Marwood and Drew) who led the authorship of RA6, RA7, RA12, RA16, RA17, and co-authored many of the other study papers. Marwood also took the lead for the associated SWAP study (see Appendix 1).
Opportunities to attend conferences, meetings and develop networks were shared across all team members, with an emphasis placed on career development. As such, both doctoral students are continuing post-doctoral work with the team as a direct result of their involvement in the study. Involvement in the study also supported the career progression of Matu, Brown and Homer to reader/associate professor, and Homer taking lead PI for a new NIHR HSDR award to evaluate the NHS complications in excess weight clinics, which directly builds upon the learning and team skills developed in this study.
Inclusive language, terminology and methodology
All our methods and patient-facing materials were co-designed with our diverse PPI group to ensure all materials were understandable, accessible and appropriate to the breadth of our target audience. Where work was undertaken with specific groups where English was not their first language, study materials and data collection were undertaken in the required language through either a formal translator or using the language skills available within the research team. This was particularly important when undertaking research within diverse ethnic communities (with several interviews conducted in Urdu, and a survey completed over the phone in Polish), thus enabling the use of first language and importantly the application of cultural understanding and context. A freephone number was provided to enable participants to receive information about the study and take part verbally to ensure that language and digital literacy/availability were not a barrier to participation, and tablets were provided to all participants taking part in the photovoice and MyFood24 dietary assessment.