“Moved by Love” Project Suggests Adaptations to Improve MOVE! for Black Veterans

MOVE! is a free, evidence-based weight management program offered by VA, in individual or group formats, with in-person and virtual options. MOVE! is run by the National Center for Health Promotion and Disease Prevention (NCP). The MOVE! program usually entails 8-16 weeks of group treatment focused on teaching people about healthful eating, physical activity, and the ways that mood can affect eating habits and weight management. Research has demonstrated that attending MOVE! is associated with weight loss¹, but racial disparities in outcomes exist. While African American or Black Veterans (hereafter referred to as Black Veterans) are more likely than White Veterans to attend MOVE! and weight-related nutrition visits², they are less likely to have clinically meaningful weight loss 6 and 12 months after attending MOVE! than White Veterans³.

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The goal of the Moved by Love project was to develop a partnership among researchers, operational partners at VA's National Center for Health Promotion and Disease Prevention (NCP), and Black Veterans to understand causes and solutions to the weight loss disparities experienced by Black Veterans. As part of this goal, HSR investigators Jessica Breland, PhD, with the Center for Innovation to Implementation (Ci2i) and Katherine Hoerster, PhD, with the Center of Innovation for Veteran-Centered and Value Driven Care (Seattle-Denver COIN) used the Photovoice method (highlighted in the August 2019 Veterans' Perspectives) in the Moved by Love project. Photovoice is a participatory method in which group members bring photos - and in this case other forms of media (e.g., art, poetry, quotes) - relevant to their community. In the Moved by Love project, Black Veterans who had recently started or scheduled MOVE! sessions (two women, seven men) participated in six Photovoice sessions between October 2022 and February 2023. Each session focused on a different topic chosen by participants, such as body image or experiences with "kryptonite foods." Before each session participants sent photos or other forms of expression related to the topic. During the sessions the participants discussed the artwork and related themes, and revisited topics and themes from prior sessions.

Poem written and submitted by Moved by Love participant Jo Anne Hall, to stimulate discussion during the Photovoice sessions.

The session facilitators and investigators completed a rapid qualitative analysis of session notes and transcripts. They found several themes across the following three main categories related to Black Veterans' experiences with weight management and general care in VA:

1) Food in our lives and healthcare

2) Body image, self-image, and health

3) Healthcare bias and discrimination

For example, participants shared that many foods are enjoyable to eat and linked to positive memories of family, which can make them difficult to stop eating. A picture of a bowl of grits sparked especially positive comments, with one Veteran noting it took him immediately back to days with his grandmother. Some Veterans also felt that traditional foods were vilified, but that clinicians did not offer possible substitutions. As one participant said: "Instead of maybe vilifying it, show some alternatives to alfredo, something that's maybe alfredo-like, but with less calories."

A picture of grits provoked positive comments and nostalgia by Black Veterans.

A Black Veteran participant at the doctor's office (name withheld).

An important theme related to Category #2 was the use of body mass index (BMI) by providers to label patients as having obesity and/or needing weight management support. Participants felt that these labels did not always match their self-image. One participant noted:

"I've never looked at myself as being someone overweight. I just say I'm a thick sister, I'm thick… It stinged a little bit but… ok, you're seeing me as you're seeing me... so maybe I can make some adjustments to the way I see me to better me."

This quote highlights that many Black patients do the work to understand their clinician's point of view, but the clinicians often do not take the time to understand their patients' understanding of themselves.

Several Veterans also talked about healthcare discrimination and bias, although not all said they experienced discrimination in VA care. Some participants felt Black patients received less attentive care than White patients. They felt unheard and rushed during appointments, which damaged trust. The participant pictured above stated:

"A visit to the provider should be a good and thorough work up. We are missing that."

It is notable that while many participants said they would appreciate more Black providers, they also noted that having a provider who listened and understood them was more important than the provider's race or ethnicity.

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Solutions specific to weight management identified by the group included:

• Better patient education that is less generic.
  • For example, having MOVE! material provide information on how to make traditional foods healthier, while taking into consideration culturally meaningful meals.
• Better clinician education that helps clinicians understand the eating habits and culture of Black patients.
  • As one participant said, they want clinicians who "understand the culture, how we eat, where it came from. Why I love grandma's cooking, although there's a lot of stuff that's not good for me."

Other suggested solutions focused on VA care in general such as:

• Providing consistent quality care across VA sites.
• Hiring more Black doctors, nurses, and staff.
• Spending money and resources on patient experience, including longer appointments.
• Allow Black Veterans to give input to leaders locally and nationally.
  • One participant said "I think some type of local forum would be really beneficial. Where the African American Veterans meet with the local VA representation, and they actually address some of the concerns. I think that would be a really good first step."

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One Veteran noted "What's important to me is that we're not just another study that's going to end up on a scholarly review page of papers of information, you know? That [doesn't] invoke change." In the spirit of that request, the project's investigators have presented this work to local and national audiences within VA, through the MOVE! coordinators call, this publication, and other internal dissemination venues, and will continue to share the results whenever possible. They are working closely with the NCP MOVE! Program leadership to adapt MOVE! to address the suggestions made by their Veteran partners. (NCP partially funded this work, along with a local VA Puget Sound seed grant). Externally, this project was featured in the peer reviewed Journal of General Internal Medicine, and VA's Office of Health Equity hosted a virtual art show of Veterans' submissions.

References

1. Maciejewski ML, Shepherd-Banigan M, Raffa SD, et al., Systematic Review of Behavioral Weight Management Program MOVE! for Veterans. American Journal of Preventive Medicine. May 2018;54(5): 704-714.
2. Breland JY, Phibbs CS, Frayne SM, et al., Behavioral weight management use in the Veterans Health Administration: Sociodemographic and health correlates. Eating Behaviors. April 2024;53(101864).
3. Hoerster KD, Lai Z, Goodrich DE, et al., Weight Loss After Participation in a National VA Weight Management Program Among Veterans With or Without PTSD. Psychiatric Services. November 2014;65(11):1385-8.

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