Weight bias and health care utilization: a scoping review...Review and Meta-Analyses extension for...
Transcript of Weight bias and health care utilization: a scoping review...Review and Meta-Analyses extension for...
Primary Health CareResearch & Development
cambridge.org/phc
Review
Cite this article: Alberga AS, Edache IY,ForhanM, Russell-MayhewS. (2019) Weight biasand health care utilization: a scoping review.Primary Health Care Research & Development20(e116): 1–14. doi: 10.1017/S1463423619000227
Received: 15 March 2018Revised: 19 November 2018Accepted: 19 November 2018
Key words:obesity; primary health care; weight stigma
Author for correspondence:Angela S. Alberga, Assistant Professor,Department of Health, Kinesiology & AppliedPhysiology, Concordia University, 7141Sherbrooke Street West, SP-165.31, Montreal,QC H4B1R6, Canada.E-mail: [email protected]
© The Author(s) 2019. This is an Open Accessarticle, distributed under the terms of theCreative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), whichpermits unrestricted re-use, distribution, andreproduction in any medium, provided theoriginal work is properly cited.
Weight bias and health care utilization: ascoping review
Angela S. Alberga1 , Iyoma Y. Edache1, Mary Forhan2 and Shelly Russell-Mayhew3
1Department of Health, Kinesiology & Applied Physiology, Concordia University, Montreal, QC, Canada; 2Departmentof Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada and3Werklund School of Education, University of Calgary, Calgary, AB, Canada
Abstract
Aim: The purpose of this scoping review was to explore the evidence on how perceptions and/orexperiences of weight bias in primary health care influence engagement with and utilization ofhealth care services by individuals with obesity. Background: Prior studies have found discrep-ancies in the use of health care services by individuals living with obesity; a greater body massindex has been associated with decreased health care utilization, and weight bias has been iden-tified as a major barrier to engagement with health services. Methods: PubMed was searchedfrom January 2000 to July 2017. Four reviewers independently selected 21 studies examiningperceptions of weight bias and its impact on engagement with primary health care services.Findings:A thematic analysis was conducted on the 21 studies that were included in this scopingreview. The following 10 themes were identified: contemptuous, patronizing, and disrespectfultreatment, lack of training, ambivalence, attribution of all health issues to excess weight,assumptions about weight gain, barriers to health care utilization, expectation of differentialhealth care treatment, low trust and poor communication, avoidance or delay of health services,and ‘doctor shopping’. Overall, our scoping review reveals how perceptions and/or experiencesof weight bias from primary care health professionals negatively influence patient engagementwith primary health care services.
Introduction
Obesity management has been identified as a complex issue in primary health care (Brownell,1982; Lyznicki et al., 2001). Discrepancies in the usage of health care services by individualsliving with obesity have been reported in prior research (Drury and Louis, 2002; Coughlinet al., 2004; Ferrante et al., 2007; Aldrich andHackley, 2010). In fact, it has been shown that havingobesity impedes access to health care (Drury and Louis, 2002; Amy et al., 2006). Studies havedocumented a decrease in the use of health care services associated with an increasing body massindex (BMI) (Olson et al., 1994; Fontaine et al., 1998; Amy et al., 2006; Aldrich andHackley, 2010).This includes reduced rates of routine breast and gynecological cancer screening tests amongindividuals with obesity compared to individuals with a BMI classified as normal (Adamset al., 1993; Fontaine et al., 1998; Aldrich andHackley, 2010).When individuals with obesity avoidor delay health care services, the development of obesity-related comorbidities may go unnoticed,progress in severity, and become more difficult to treat. In this way, the avoidance of health careservices could have detrimental implications for the prevention and management of obesity, itspossible comorbidities, and other diseases (Phelan et al., 2015).
Weight bias and stigma, known as negative, prejudicial, or stereotypical beliefs and attitudestoward individuals based on their size, has been identified as a barrier to seeking health careservices (Drury and Louis, 2002; Puhl and Heuer, 2009; Washington, 2011). Weight biaswas cited as the fourth most common form of discrimination among US adults (Puhl et al.,2008). Over the past decade, the prevalence of weight bias has increased in the United Statesby 66% and has been documented in employment, education, and health care settings(Andreyeva et al., 2008; Puhl and Heuer, 2009). It has been reported that health professionals,specifically health care specialists in obesity treatment, hold strong implicit negative attitudesabout individuals living with obesity (Teachman and Brownell, 2001). These stigmatizing atti-tudes are perceived and received by individuals with obesity and may contribute to the creationof multiple barriers to health care utilization (Drury and Louis, 2002).
Not only does weight bias pose adverse mental and physical health consequences such asexercise avoidance (Vartanian and Shaprow, 2008), anxiety (Hilbert et al., 2014), low self-esteem(Hilbert et al., 2014), and depression (Hilbert et al., 2014), but it also negatively impacts healthcare treatment outcomes (Carels et al., 2009). For example, a study compared people with severeobesity who experienced weight bias and those with severe obesity who did not experienceweight bias. Those who experienced weight bias had a 1.5 kg/m2 greater BMI compared to thosewho did not report weight bias (Hansson and Rasmussen, 2014). In another study, participants
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000227Downloaded from https://www.cambridge.org/core. IP address: 54.39.106.173, on 05 Oct 2020 at 02:32:03, subject to the Cambridge Core terms of use, available at
who associated their obesity with more negative traits (higherweight bias) were more likely to drop out of an 18-week behavioralweight loss program compared to participants who evidencedlower levels of weight bias (Carels et al., 2009). These studies sug-gest that the stigma experienced by individuals with obesity mayimpede the adoptions and maintenance of healthy behaviors.
The purpose of this scoping review was to examine how percep-tions and experiences of weight bias in individuals with obesityinfluence engagement in primary health care. As this is an emerg-ing area of research, we used a scoping review methodology to pro-vide a broad overview of the state of the evidence and to determinethe value of undertaking a full systematic review. Note that for thepurpose of this paper, ‘engagement in primary health care’ isdefined as health care utilization, willingness to participate andbe involved in health care visits (i.e., screening, prevention, regularcheckups). Unless otherwise specified, the term ‘health profes-sional’ is used in this paper to refer to nurses, physicians, and otherallied health professionals (i.e., dietitians, health promotion spe-cialists) working in a primary care setting.
Methods
A scoping review of the literature was conducted using a predeter-mined specific research protocol based on the methodologydescribed by Arksey and O’Malley (2005). Using this method, rel-evant literature is systematically identified, located, and summa-rized. This methodological approach is not intended to assessthe quality of a study or provide quantitative synthesis of data.The purpose is to explore and chart the features of an emergingbody of evidence and therefore is an effective approach to providea broad overview of the literature and to identify research gaps. Themethods we used to identify, select, and evaluate the evidence aredescribed below. The Preferred Reporting Items for SystematicReview and Meta-Analyses extension for Scoping Reviews(PRISMA- ScR) was used to guide the reporting for this scopingreview (Tricco et al., 2018).
Literature search
A literature search was designed and conducted in consultationwith an information specialist. In July 2017, we searched PubMedwith a publications date limit between January 2000 to July 2017and limited to English and French languages. Subject headings andkey words were combined for concepts: weight bias and health careutilization. The keyword search strategy for each concept is pre-sented in the Appendix. Additional articles not identified in theonline database were either found as part of the researchers’ per-sonal library or located from the reference lists of related articles.
Study selection
Four independent reviewers screened titles and abstracts using thefollowing keywords and their synonyms: weight bias, primaryhealth care, and use of health care services. After screening by titleand then by abstract, we assessed the remaining articles by readingthe full text. Discrepancies were resolved by consensus betweenreviewers. Articles were included if they were original studies thatexamined the influence of perceived weight bias on engagement inprimary health care, and described the stigma experienced by indi-viduals with obesity in primary healthcare. We excluded articlesthat did not directly measure weight bias and/or engagement inprimary health care and review papers on the topic. We made sureto include all original studies cited in review papers and omittedreview papers to avoid duplication. We also included aPRISMA-SCR figure to detail the process and reasons for whichstudies were included and excluded (refer to Figure 1.)
Data charting
Reviewers charted data for study characteristics (country, year ofpublication, study design, number of participants enrolled), patientpopulation, and outcomes measured. All reviewers verified thedata for accuracy and completeness. The data are presented inTable 1.
Figure 1. PRISMA-ScR flowchart illustrating the process of article selection.
2 Angela S. Alberga et al.
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Table
1.Stud
ycharacteristics
No.
Author
Year
Title
Geo
grap
hical
location
Stud
ypu
rpose
Primaryhe
alth
sector
Samplede
scription
SampleBMI
classification
Stud
yde
sign
Measuresused
Mainfin
ding
s
1Am
y,N.K.,
Aalborg,
A.,
Lyon
s,P.,
Keran
en,L
.
2006
Barriersto
routine
gyne
cological
cancer
screen
ing
forWhite
and
African-Am
erican
obesewom
en
California,
USA
Toinvestigatethe
factorsthat
contribu
teto
lower
ratesof
gyne
cological
cancer
screen
ing
asrelatedto
wom
en’sbo
dysize
Preventive
cancer
screen
ing
Focusgrou
ps:n
=60
White
andAfrican
American
wom
en40–60yearsold,
n=29
gyne
cological
care
providers
(physician
assistan
ts,a
ndnu
rsepractition
ers
who
provide
gyne
cologicalc
are).
Survey:n
=498White
andAfrican
American
wom
en21–80years,
n=129he
alth
care
providers
Wom
enBMI:
25–35kg/m
2
(n=131);
>35–45kg/m
2
(n=169);
>45–55kg/m
2
(n=121);
>55
kg/m
2
(n=60)
Mixed
metho
dsFo
cusgrou
pqu
estion
sprom
pted
discussion
sab
outpe
rcep
tion
san
dattitude
sab
out
gyne
cologicalc
ancer
screen
ing.
Survey
question
swereba
sed
onfocusgrou
pdiscussion
s.Wom
enwithob
esityan
dhe
alth
care
providers
wereprovided
with
differen
tsurveys.
Wom
enrepo
rted
weigh
t-relatedba
rriers
tohe
alth
care
access.
Theseinclud
eddisrespe
ctful
treatm
ent,
emba
rrassm
entat
beingweigh
ed,
nega
tive
attitude
s,un
solicited
advice
abou
tweigh
tloss,a
ndinap
prop
riatemed
ical
equipm
ent.With
increasesin
BMI,a
greaterpe
rcen
tage
ofwom
enrepo
rted
delaying
cancer
screen
ingtests.
2Bottone
,F.G.,
Musich,
S.,
Wan
g,S.S.,
Hom
mer,
C.E.,Y
eh,
C.S.,
Haw
kins,K
.
2014
Obe
seolde
rad
ults
repo
rthigh
satisfaction
and
positive
expe
rien
ceswith
care
USA
Toassess
the
impa
ctof
obesity
onsatisfactionan
dexpe
riences
with
care
inolde
rad
ults
Did
not
exclusively
exam
ineon
ehe
alth
sector
(persona
ldo
ctorsan
dspecialists)
N=18,192
>65
years
oldwithan
AARP
Med
icare
Supp
lemen
tInsurancePlan
insuredby
UnitedH
ealthcare
Insurance
Compa
nyin
10states
Und
erweigh
t(n
=516),
norm
al(n
=7018),
overweigh
t(n
=6765)an
dob
ese
(n=3893)
Qua
ntitative
survey
Mod
ified
versionof
theCo
nsum
erAssessmen
tof
HealthcareProvide
rsan
dSystem
s(CAH
PS)
survey
mailedto
the
participan
ts
Obe
sity
was
associated
withhigh
erpa
tien
tsatisfaction
andbe
tter
health
care
expe
rien
ces.Patients
withob
esityha
dmore
doctor
officevisits
abou
tnu
tritionan
dexercise.
3Brown,
I.,Th
ompson
,J.,T
od,A
.,Jo
nes,G.
2006
Prim
arycare
supp
ort
fortacklingob
esity:
aqu
alitativestud
yof
theperceptio
nsof
obesepa
tients
Sheffie
ld,
Englan
dTo
exploreob
ese
person
’sexpe
rien
cesan
dpe
rcep
tion
sof
supp
ortin
prim
ary
care
Gen
eral
practice.
Nurse
practition
ers
orph
ysicians
N=28
(M=10,
F=18)pa
tien
ts,
>18
yearsfrom
five
gene
ralp
ractice
offices
Obe
seQua
litative
semi-structured
interviews
Face-to-face
1-h
interviews
Patientswithob
esity
weream
bivalent
abou
taccessing
health
services
dueto
thelack
ofsensitive
resourcesan
dam
bigu
ous
commun
ication.
Patientsalso
perceivedhe
alth
profession
alam
bivalence.
4Buxton,
B.K.,
Snethe
n,J.
2013
Obe
sewom
en’s
percep
tion
san
dexpe
rien
cesof
healthcare
and
prim
arycare
providers:a
phen
omen
olog
ical
stud
y
Pen
nsylvania,
USA
Tode
scribe
the
expe
rien
cesan
dpe
rcep
tion
sof
obesewom
enwithrega
rdto
stigmain
health
care
Gen
eral
practice.
Nurse
practition
ers
orph
ysicians
N=26
English-
speaking
wom
en27–66yearsold
Obe
sePhe
nomen
olog
ical
qualitativede
sign
usingtheCo
laizzi
metho
d
Semi-structured,
face-
to-face60–90min
interviews
Allp
articipa
ntsrepo
rted
receivingsomeform
ofne
gative
treatm
ent
from
health
care
providers.Most
participan
tsdidno
trepo
rtde
laying
oravoiding
health
care.
(Con
tinued)
Primary Health Care Research & Development 3
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Table
1.(Con
tinued)
No.
Author
Year
Title
Geo
grap
hical
location
Stud
ypu
rpose
Primaryhe
alth
sector
Samplede
scription
SampleBMI
classification
Stud
yde
sign
Measuresused
Mainfin
ding
s
5DeJoy,S
.B.,
Bittner,K
.,Man
del,D.
2016
Aqu
alita
tivestud
yof
thematernity
care
expe
riences
ofwom
enwith
obesity:‘morethan
just
anu
mberon
thescale’
USA
(13
differen
tstates)
Toexplorethe
expe
rien
cesof
wom
enwith
obesityin
the
maternity
care
system
inthe
UnitedStates
Maternity
N=16
pregna
ntor
recently
postpa
rtum
wom
enrecruitedfrom
onlin
ecommun
ities
forplus-size
pregna
ntwom
en
Obe
seQua
litative
interview
In-dep
thteleph
one
interview
rang
ingfor
15min–1
h
Mostpa
rticipan
tsrepo
rted
atleaston
estigmatizingmaternity
care
expe
rien
ce.
How
ever,som
epa
rticipan
tsdidrepo
rtbe
ingsatisfiedwith
thematernity
services
they
received
.
6Drury,C
.A.A.,
Louis,M.
2002
Exploringthe
association
betw
eenbo
dyweigh
t,stigmaof
obesity,
and
health
care
avoida
nce
LasVega
s,Nevad
a,USA
Toexplorethe
stigmaof
obesity
anditseffect
onhe
alth
care
utilization
Did
not
exclusively
exam
ineon
ehe
alth
sector
(fam
ilypractice,
nurse
practition
er,
and
gyne
cology)
N=216wom
enfrom
church
sites
30–59yearsold
Normal
<27.5kg/m
2
(n=137),m
ildob
esity
27.5–30.0kg/m
2
(n=19),
mod
erate
obesity
>30–40
kg/m
2(n=43),
morbidob
esity
>40
kg/m
2
(n=11)
Qua
ntitative
survey
Questionn
aire
develope
dby
Packer
(1990)
which
includ
edtwoqu
estio
nsfrom
theWeigh
tLocus
ofCo
ntrolS
cale
mod
ified
byPa
cker,the
Satisfactionwith
Medical
Care
Scale
mod
ified
byPa
cker
and
theRo
senb
ergSelf-
Esteem
Scale
Obe
sity
stigmaacts
asa
barrierto
accessing
health
care.W
ith
increasesin
BMI,a
greaternu
mbe
rof
participan
tsde
layed
and/or
avoide
dhe
alth
care
services.
7Ferran
te,J
.M.,
Seam
an,K
.,Bator,A
.,Ohm
an-
Strickland
,P.,
Gun
dersen
,D.,Clem
ow,
L.,P
uhl,R.
2016
Impa
ctof
perceived
weigh
tstigma
amon
gun
derserved
wom
enon
doctor-
patien
trelation
ships
New
Jersey,
USA
Toevalua
teho
wpe
rcep
tion
sof
weigh
tstigma
amon
gun
derserved
wom
enwith
obesityim
pacts
doctor-patient
relation
ships
General
practice
N=149wom
en21–70yearsold
visiting
physicians
atfour
fede
rally
qualified
health
centers
Obe
seQua
ntitativecross-
sectiona
lsurvey
TheStigmaSituations
inHealth
Care
instrument
andCo
nsultatio
nan
dRe
latio
nalE
mpa
thy
(CAR
E)measure
Increasesin
participan
tBMIclassificationwas
associated
with
increasedlikelihoo
dof
greaterpe
rcep
tion
sof
weigh
tstigma.
With
increasesin
stigma
situations,the
rewas
ade
crease
inpe
rcep
tion
sof
physicianem
pathy.
8Fo
rhan
,M.,
Risdo
n,C.,
Solomon
,P.
2013
Contribu
tors
topa
tien
ten
gagemen
tin
prim
aryhe
alth
care:p
erceptions
ofpa
tien
tswith
obesity
Ham
ilton
,Ontario,
Cana
da
Toiden
tify
issues
associated
with
enga
gemen
tin
prim
aryhe
alth
care
forpa
tien
tswithob
esity
Family
health
team
(fam
ilyph
ysicians,
family
med
icine
reside
nts,
andnu
rse
practition
ers)
N=11(M
=2,
F=8)
19–64yearsold
registered
witha
prim
arycare
practice
Obe
seQua
litativesemi-
structured
interviews
Face-to-face
and
teleph
oneinterviews
averag
ing33
min
Feelingjudg
ed,lackof
privacy,
poor
commun
ication,
and
limited
health
provider
know
ledg
eab
out
obesitywererepo
rted
asba
rriers
toprim
ary
health
care
enga
gemen
t.Facilitatorsto
enga
ging
inprim
ary
health
care
includ
edavailabilityof
resources,im
portan
ceof
relation
ship,a
ndmeaning
ful
commun
ication.
4 Angela S. Alberga et al.
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9Gud
zune
,K.A.,
Ben
nett,
W.L.,
Coop
er,
L.A.,B
leich,
S.N.
2014
Patientswho
feel
judg
edab
outtheir
weigh
tha
velower
trustin
their
prim
arycare
providers
USA
Toexplorewhe
ther
overweigh
tan
dob
esepa
tien
tsha
veless
trustin
theirprim
arycare
providers(PCP
s)
Gen
eral
practice
N=600(M
=312,
F=288)
adults
enga
gedin
prim
ary
care
in2012
Overw
eigh
tan
dob
ese
Qua
ntitativecross-
sectiona
lsurvey
Survey
question
sassessed
weigh
tloss
outcom
es,d
octor
shop
ping
beha
vior,
andpa
tien
t-provider
relation
ship
variab
les
includ
ingdu
ration
,trustin
PCP
,and
perceivedweigh
tjudg
men
t
21%
ofpa
rticipan
tspe
rceivedweigh
trelatedjudg
men
tfrom
theirPCP
s.Participa
ntswho
perceivedjudg
men
twereless
likelyto
trusttheircare
provider.
10Gud
zune
,K.A.,
Ben
nett,
W.L.,
Coop
er,
L.A.,B
leich,
S.N.
2014
Perceived
judg
men
tab
outweigh
tcan
nega
tively
influ
ence
weigh
tloss:a
cross-
sectiona
lstudy
ofoverweigh
tan
dob
esepa
tien
ts
USA
Toexam
inethe
relation
ship
betw
eenpa
tien
t-pe
rceived
judg
men
tsab
out
weigh
tby
prim
ary
care
providersan
dself-repo
rted
weigh
tloss
Gen
eral
practice
N=600(M
=312,
F=288)
adults
enga
gedin
prim
ary
care
in2012
Overw
eigh
tan
dob
ese
Qua
ntitativecross-
sectiona
lsurvey
Survey
question
sassessed
weigh
tloss
outcom
es,d
octor
shop
ping
beha
vior,
andpa
tien
t-provider
relation
ship
variab
les
includ
ingdu
ration
,trustin
PCP
,and
perceivedweigh
tjudg
men
t
Participa
ntswho
perceivedweigh
t-relatedjudg
men
tfrom
theirprim
arycare
providers(21%
)were
morelikelyto
attempt
weigh
tloss.H
owever,
percep
tion
sof
judg
men
twereno
tassociated
with
greaterweigh
tloss.
11Gud
zune
,K.A.,
Ben
nett,
W.L.,
Coop
er,
L.A.,C
lark,
J.M.,Bleich,
S.N.
2014
Prior
doctor
shop
ping
resulting
from
differen
tial
treatm
ent
correlated
with
differen
cesin
curren
tpa
tien
t-provider
relation
ships
USA
Tode
term
inethe
prevalen
ceof
doctor
shop
ping
that
istheresult
ofdifferen
tial
treatm
entan
dto
explore
relation
ships
betw
eendo
ctor
shop
ping
and
curren
tprim
ary
care
relation
ships
Gen
eral
practice
N=600(M
=312,
F=288)
adults
enga
gedin
prim
ary
care
in2012
Overw
eigh
tan
dob
ese
Qua
ntitativecross-
sectiona
lsurvey
Survey
question
sassessed
weigh
tloss
outcom
es,d
octor
shop
ping
beha
vior,
andpa
tien
t-provider
relation
ship
variab
les
includ
ingdu
ration
,trustin
PCP
,and
perceivedweigh
tjudg
men
t
13%
ofpa
rticipan
tsrepo
rted
previous
doctor
shop
ping
beha
vior
asaresultof
weigh
t-ba
sed
differen
tial
treatm
ent.
Doctorshop
ping
beha
vior
was
associated
with
shorterdu
ration
sof
theircurren
tpa
tien
t-provider
relation
ships.
12Gud
zune
,K.A.,Beach,
M.C.,Roter,
D.L.,
Coop
er,
L.A.
2013
Physician
sbu
ildless
rapp
ortwithob
ese
patien
ts
Baltimore,
Marylan
d,USA
Tode
scribe
the
relation
ship
betw
eenpa
tien
tBMIan
dph
ysician
commun
ication
beha
viorsdu
ring
atypicalo
utpa
tien
tprim
arycare
visit
Rou
tine
follo
w-ups
withprim
ary
care
providersN
=39
prim
arycare
physicians
(PCP
s)an
dN=208of
theirpa
tien
ts18
yearsan
dolde
rdiag
nosedwith
hype
rten
sion
within12
mon
ths
ofpa
tien
trecruitm
ent
Normal
(n=28),
overweigh
t(n
=60),an
dob
ese(n
=120)
Qua
ntitativecross-
sectiona
lstudy
Audio-recorded
outpatient
encoun
ters
used
toexam
inethe
freq
uencyof
commun
ication
beha
viorsin
the
patien
t-ph
ysician
relation
ship
Primarycare
physicians
enga
gedin
less
emotiona
lrap
port
withpa
tien
tswith
obesityor
overweigh
t,compa
redto
norm
alweigh
tpa
tien
ts. (Con
tinued)
Primary Health Care Research & Development 5
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000227Downloaded from https://www.cambridge.org/core. IP address: 54.39.106.173, on 05 Oct 2020 at 02:32:03, subject to the Cambridge Core terms of use, available at
Table
1.(Con
tinued)
No.
Author
Year
Title
Geo
grap
hical
location
Stud
ypu
rpose
Primaryhe
alth
sector
Samplede
scription
SampleBMI
classification
Stud
yde
sign
Measuresused
Mainfin
ding
s
13Han
sson
,L.M.,
Rasmussen,
F.
2014
Associationbe
tween
perceivedhe
alth
care
stigmatization
andBMIc
hang
e
Swed
enTo
exam
inethe
association
betw
een
expe
rien
cesof
health
care
stigmatizationan
dBMIc
hang
esin
men
andwom
enwithno
rmal
weigh
tan
dob
esity
Gen
eral
practice
N=2788
adults
aged
25–64years
in2008
Normal
weigh
t(n
=1064),
mod
erate
obesity
(n=1273),an
dsevere
obesity
(n=291)
atthetimeof
participation
intheULF
survey
Qua
ntitative
survey
One
question
inthe
survey
concerne
dpe
rceivedhe
alth
care
stigmatization.
The
Rosen
berg’sSe
lf-Esteem
Scalean
dthe
Marlowe-Crow
nesocial
desirability
scale
Inthesevere
obesity
grou
p,he
alth
care
stigmatizationwas
associated
withan
increase
inBMIby
1.5
kg/m
2 .Withthose
classifie
das
mod
eratelyob
ese,
increasesin
BMIwas
associated
with
avoida
nceof
health
care
andpe
rcep
tion
sof
insultingtreatm
ent.
14Hilb
ert,A.,
Braeh
ler,
E.,H
aeuser,
W.,Ze
nger,
M.
2014
Weigh
tbias
internalization,
core
self-
evalua
tion
,and
health
inoverweigh
tan
dob
esepe
rson
s
German
yTo
exam
inea
processmod
elof
self-stigmaas
wella
stheim
pact
ofcore
self-
evalua
tion
asa
med
iatorbe
tween
weigh
tbias
internalization,
health
outcom
es,
andhe
alth
care
utilization
Did
not
involve
specific
health
care
settings
N=1158
(M=629,
F=529)
represen
tative
sampleof
German
popu
lation
14–89yearsold
Overw
eigh
t(n
=931),
obese
(n=227)
Qua
ntitative
survey
TheWeigh
tBias
InternalizationScale
(WBIS),theCo
reSe
lf-Evalua
tion
Scale
(CSE
S),the
Patient
health
Que
stionn
aire-
2(PHQ-2),the
Gen
eralized
Anxiety
Disorde
r-2(GAD
-2),the
Visual
Analog
ueScale
(VAS
)of
health
status,
andtheHealthCa
reUtilization
Que
stionn
aire
Inpa
rticipan
tswith
overweigh
tan
dob
esity,lower
core
self-evalua
tion
acts
asamed
iatorin
the
relation
ship
betw
een
weigh
tbias
internalization,
health-
relatedou
tcom
es,a
ndhe
alth
care
utilization
.
15Kam
insky,
J.,
Gad
aleta,
D.
2002
Astud
yof
discrimination
withinthemed
ical
commun
ityas
view
edby
obese
patien
ts
Great
Neck,
New
York,
USA
Topresentthe
view
sandop
inions
ofob
esity
surgery
patientsregarding
care
received
before,d
uring,and
afterweightloss
surgery
Did
not
exclusively
exam
ineon
ehe
alth
sector
(primarycare
physicians
and
specialists)
N=40
(M=6,
F=34)ob
ese
adults
21–61years
oldfrom
four
East
Coastba
riatric
practices.Averag
epreo
perative
weigh
tof
145kg
Obe
seQua
ntitative
survey
Survey
assessingpa
tien
tpe
rcep
tion
sof
physicianan
dho
spital
staffattitude
s,ap
prop
riaten
essof
equipm
ent,an
dlevel
ofcare
received
from
profession
alan
dno
n-profession
almed
ical
person
nel
17%
ofpa
tien
tsrepo
rted
chan
ging
prim
arycare
physicians
dueto
perceivedph
ysician
indifferen
ce,lackof
concern,
orne
gative
attitude
stoward
bariatricsurgery.
16Merill,E
.,Grassley,
J.2008
Wom
en’sstoriesof
theirexpe
rien
ces
asoverweigh
tpa
tien
ts
Texas,USA
Toillum
inatethe
meaning
ofwom
en’s
expe
rien
cesas
overweigh
tpa
tien
tsin
their
encoun
ters
with
health
care
services
and
health
care
providers
General
practicean
dspecialists
N=8wom
enself-
iden
tifie
das
being
overweigh
tpa
tien
ts.A
ges
21–60yearsold
Overw
eigh
tan
dob
ese
Qua
litative
interviews.A
herm
eneu
tic
phen
omen
olog
ical
approa
ch
Inde
pth,
face-to-face
50–90min
interviews.
Participa
ntswere
asked‘Tellm
eastory,
oneyouwill
never
forget
abou
tgo
ingto
your
healthcare
provider
andyour
expe
rien
ceof
being
overweigh
t’
Four
major
them
eswere
iden
tifie
d:strugglin
gto
fitin,b
eing
dism
issed,
feelingno
tqu
itehu
man
,and
refusing
togive
up.
6 Angela S. Alberga et al.
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000227Downloaded from https://www.cambridge.org/core. IP address: 54.39.106.173, on 05 Oct 2020 at 02:32:03, subject to the Cambridge Core terms of use, available at
17Olson
,C.L.,
Schu
maker,
H.D.,Yawn,
B.P.
1994
Overw
eigh
twom
ende
laymed
ical
careLa
Crosse,
Wisconsin,
USA
Tode
term
ine
whe
ther
wom
ende
layor
avoid
health
care
becausethey
are
overweigh
t
Commun
ity
hospital
N=310female
registered
nurses
(n=225),licen
sed
practicaln
urses
(n=26),nu
rsing
assistan
ts(n
=13),
health
unit
coordina
tors
(n=28),gene
ral
psychiatric
assistan
ts(n
=1)
andothe
r(n
=17)
21–68yearsold
employed
atSt
Fran
cisMed
ical
Center
inJu
ly1992
Und
erweigh
t>20
kg/m
2 ,no
rmal
weigh
t20–24.9kg/m
2 ,mild
obesity
25–26.9kg/m
2
(n=35),ob
ese
>27–34.9kg/m
2
(n=75),
very
obese
>35
kg/m
2
(n=11)
Qua
ntitative
survey
Visual
analog
uescale
was
used
toassess
percep
tion
sof
body
weigh
t.Su
rvey
question
sassessed
levelo
fsatisfaction
withprevious
physicianinteractions
concerning
weigh
t
BMIw
aspo
sitively
associated
withthe
delayof
med
ical
care.
12.7%
ofpa
rticipan
tsrepo
rted
delaying
orcancelingaph
ysician
appo
intm
entdu
eto
weigh
tconcerns.
Anothe
rsm
all
percen
tage
(2.6)of
participan
tsrepo
rted
keep
ingtheir
appo
intm
ents
but
refusedto
beweigh
ed.
18Pryor,W
.2002
Thehe
alth
care
disadv
antagesof
beingob
ese
New
South
Wales,
Australia
Tode
scribe
the
obesepa
tien
ts’
view
sab
out
health
care,m
yths
andrealities
abou
tob
esity,
andsuggestion
sab
outho
wto
improvehe
alth
care
forob
ese
patien
ts
Gen
eral
practice
and
specialists
Aselectionof
messagespo
sted
bywom
enwith
obesityon
theBig
Bea
utifu
lWom
enDow
nUnd
erinternet
site
Obe
seInform
ative
bulletin
TheBig
Bea
utifu
lWom
enDow
nUnd
erinternet
site
Healthcare
profession
als’ne
gative
attitude
stowardtheir
patien
tswithob
esity
arepe
rceivedby
these
patien
ts.Ina
ccurate
health
profession
alassumptions
abou
ttheeating
habits
and
health
beha
viorsof
patien
tswithob
esity,
inad
equa
teeq
uipm
ent,an
davoida
nceof
gene
ral
health
care
checku
pswererepo
rted
bywom
enwithob
esity.
19Puh
l,R.,
Peterson,
J.L.,
Lued
icke,J
.
2013
Motivatingor
stigmatizing?
Pub
licpe
rcep
tion
sof
weigh
t-related
lang
uage
used
byhe
alth
providers
USA
Toexam
inepu
blic
preferen
cesan
dpe
rcep
tion
sof
weigh
t-ba
sed
term
inolog
y
Routine
checkupwith
aph
ysician
N=1064
(M=417,
F=636)
American
adults
18–88years
old
Und
erweigh
t(n
=47),
norm
al(n
=351),
overweigh
t(n
=321),
obese
(n=320)
Qua
ntitative
onlin
esurvey
Likertscale(5
point)
used
toassess
percep
tion
sof
10weigh
t-relatedterm
s.Weigh
tbias
was
assessed
withtheFat
Pho
biaScale.
Weigh
tvictim
izationwas
assessed
withthree
forced
choice
question
s(yes
orno
).Reactions
tostigmatizingsituations
wereassessed
witha
measure
develope
dspecifically
forthis
stud
y
Participa
nts(19%
)repo
rted
that
they
wou
ldavoidmed
ical
appo
intm
entifthey
feltstigmatized
abou
ttheirweigh
tby
their
doctor.P
articipa
nts
(21%
)also
repo
rted
that
they
wou
ldseek
ane
wdo
ctor
ifthey
felt
stigmatized
abou
ttheirweigh
tby
their
doctor.
(Con
tinued)
Primary Health Care Research & Development 7
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Table
1.(Con
tinued)
No.
Author
Year
Title
Geo
grap
hical
location
Stud
ypu
rpose
Primaryhe
alth
sector
Samplede
scription
SampleBMI
classification
Stud
yde
sign
Measuresused
Mainfin
ding
s
20Russell,
N.,
Carryer,J.
2013
Living
large:
the
expe
rien
cesof
large-bo
died
wom
enwhe
naccessinggene
ral
practice
services
New
Zealan
dTo
explorethe
expe
rien
cesof
large-bo
died
wom
en(LBW)
accessinggene
ral
practice
services
General
practice
N=8self-iden
tifie
dLB
WSe
lf-iden
tifie
d,large-bo
died
wom
en(No
BMI)
Aqu
alitative
descriptive
inqu
irythat
adop
tsapo
st-
structural
feminist
lens
during
them
atican
alysis
Face-to-face
interviews
basedon
interview
guideused
insimilar
stud
ies
Inap
prop
riatehu
mor,
verbal
insults,un
met
health
need
s,an
dne
gative
body
lang
uage
from
health
care
providerswere
expe
rien
cesof
explicit
nega
tive
weigh
tbias
repo
rted
byself-
iden
tifie
dlargebo
died
wom
en.
21Wad
den,
T.A.,
Ande
rson
,D.A.,
Foster,
G.D.,
Ben
nett,A
.,Steinb
erg,
C.,S
arwer,
D.B.
2000
Obe
sewom
en’s
percep
tion
sof
theirph
ysicians’
weigh
tman
agem
ent
attitude
san
dpractices
Philade
lphia,
Pen
nsylvania,
USA
Toexam
ineob
ese
wom
en’s
percep
tion
sof
theirph
ysicians’
weigh
tman
agem
ent
attitude
san
dpractices
Weigh
tman
agem
ent.
(Physician
,gyne
cologist,
ornu
rse
practition
er)
N=259wom
enseekingtreatm
ent
aton
eof
three
rand
omized
control
trialsat
the
Universityof
Pen
nsylvaniawith
ahistoryof
weigh
tloss
andrega
in.
Meanag
eof
44±10
years
Obe
seQua
ntitative
question
naire
Ahe
alth
care
question
naire
develope
dby
the
authorsmeasured
patien
tsatisfaction
,freq
uencyof
physician
discussion
sab
out
weigh
t,freq
uencyof
nega
tive
interactions
withph
ysicians
abou
tweigh
t,an
dweigh
tloss
metho
dsused
byph
ysicians.T
heBeck
Dep
ressioninventoryII
was
used
tomeasure
moo
d
Participa
ntswereless
satisfiedwiththecare
they
received
fortheir
obesitycompa
redto
thecare
they
received
fortheirgene
ral
health.A
small
percen
tage
ofpa
rticipan
tsrepo
rted
nega
tive
interactions
withtheirph
ysicians
whe
nweigh
tman
agem
entwas
discussed.
8 Angela S. Alberga et al.
https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000227Downloaded from https://www.cambridge.org/core. IP address: 54.39.106.173, on 05 Oct 2020 at 02:32:03, subject to the Cambridge Core terms of use, available at
Results
The literature search resulted in 720 unique articles. An additional12 articles were identified from other sources resulting in a total of732 articles. The 732 articles were screened and assessed for eli-gibility based on inclusion criteria. Of the 732 articles that wescreened as potentially relevant, 21 studies met the inclusion cri-teria and were included in the review (Figure 1).
Characteristics of included studies
Table 1 shows the characteristics of included studies. The majorityof studies included in this review were carried out in the UnitedStates [n= 15 (71.4%)] and used quantitative methods [n= 13(62%)]. Surveys were the most commonly used measure in quan-titative studies [n= 13 (62%)]. The most commonly used qualita-tive method was interviews [n= 7 (33%)] including focus groups[n= 1 (4.8%)], telephone [n= 1 (4.8%)], face-to-face [n= 4(19%)], or a combination of face-to-face and telephone [n= 1(4.8%)].
The majority of the studies included mixed samples of bothfemale and male participants [n= 11 (52.4%)]. The remaining47.6% included only female participants (n= 10). Only partici-pants with obesity were included in 38.1% (n= 8) of the studies.Other studies [n= 12 (57%)] compared different combinationsof underweight, normal weight, overweight, and obese BMI classi-fications. One study did not measure participant BMI (4.8%).
Almost half of the studies [n= 9 (42.9%)] exclusively involvedprimary care physicians or nurse practitioners whowork in generalpractice. These studies did not explicitly mention the types of pri-mary health care services that the health professionals performed.Another 28.6% of studies did not exclusively examine one healthsector (n= 6).
Themes
The following 10 themes were identified after reviewing all articles:contemptuous, patronizing, and disrespectful treatment, lack oftraining, ambivalence, attribution of all health issues to excessweight, assumptions about weight gain, barriers to health care uti-lization, expectation of differential health care treatment, low trustand poor communication, avoidance or delay of health services,and ‘doctor shopping’. While reviewing the article summaries,the researchers compared the results of each article highlightingthe emerging themes from the results. Next, relevant data fromeach study for a specific theme were sorted and charted together.The following section utilizes the data from the included studies todescribe each theme.
Contemptuous, patronizing, and disrespectful treatment
Four studies (Amy et al., 2006; Merrill and Grassley, 2008; Russelland Carryer, 2013; Buxton and Snethen, 2013) reported that par-ticipants with overweight and obesity experienced contemptuous,patronizing, and/or disrespectful treatment from healthprofessionals. Contemptuous and patronizing behaviors involvedverbal insults and inappropriate humor (Russell and Carryer,2013). Participants with overweight and obesity reported feelingthat they were being treated less respectfully than individuals clas-sified as having a normal BMI (Amy et al., 2006). Participants per-ceived that weight-related advice from health professionals wasdelivered in a patronizing manner when health professionalsinsinuated that there was a simple solution to patients’ excess
weight (Merrill and Grassley, 2008). Describing her experience,one woman stated:
The doctor said, ‘Well, your blood pressure is high. You need to lose weight’.And I said, ‘I realize that’. He said, ‘Well, you just have to stop eating’. And Isaid, ‘If it would have been easy for me, I would have done it a long timeago : : : (Merrill and Grassley, 2008)
Buxton and Snethen also reported that patients with obesityreceived insensitive comments about their weight from their pri-mary care practitioners (Buxton and Snethen, 2013). This wascommon when accessing emergency services where the patientshad no established relationships with the primary care practitioner.One study that exclusively examined women with obesity reportedthat almost 80% of participants rarely or never had been treateddisrespectfully (e.g., insulted or criticized for not trying hardenough) by their health professionals when discussing weightmanagement (Wadden et al., 2000).
Lack of training
Participants living with overweight and obesity perceived a lack oftraining among health professionals (Amy et al., 2006; Forhanet al., 2013; Russell and Carryer, 2013). Participants with obesitycomplained that health professionals involved in preventivescreening and general practice did not demonstrate having knowl-edge about weight management and treatment services availablefor individuals living with obesity. Patients perceived the adviceoffered by their general practitioner as ineffective (Russell andCarryer, 2013). Amy et al. showed that over half of their sampledhealth professionals reported that they had no specific educationon providing clinical gynecological examinations for patients withobesity (Amy et al., 2006).
Ambivalence
Two studies (Brown et al., 2006; DeJoy et al., 2016) reported onpatient ambivalence concerning the use of health services.Patients also perceived health professional ambivalence duringweight-related health visits (Brown et al., 2006). In maternity care,women with obesity reported mixed feelings about whether or notto attend their antenatal and postpartum appointments as a resultof the insensitive behavior they received from both past and cur-rent health professionals (DeJoy et al., 2016).
Attribution of all health issues to excess weight
Patients with obesity complained of health professionals’ tenden-cies to attribute all of their other health issues to their excess weight(Amy et al., 2006; Brown et al., 2006; Merrill and Grassley, 2008;Forhan et al., 2013; Russell and Carryer, 2013; Ferrante et al., 2016).Patients felt that the emphasis health professionals put on theirweight distracted from other health issues and resulted in feelingsof not being listened to (Brown et al., 2006; Russell and Carryer,2013). Attribution of all health issues to excess weight affectedpatients’ health utilization by increasing their reluctance to disclosethe events surrounding the emergence of their symptoms, to seetheir general practitioner, or to express concern about a healthissue (Brown et al., 2006). Patients wanted to avoid being weighedso as to keep the focus away from their weight and on the reasonswhy they visited their doctor (Forhan et al., 2013). Some partici-pants (2.6%) reported attending their scheduled appointmentsbut refused to be weighed (Olson et al., 1994). Collectively, theresults of these studies were observed in preventive screening, inprimary care services, and with general practitioners.
Primary Health Care Research & Development 9
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Health professional assumptions about a patient’s weightgain
Patients indicated that health professionals often made assump-tions about what it is like to live with obesity (Wadden et al.,2000; Pryor, 2002; Merrill and Grassley, 2008; Forhan et al.,2013; DeJoy et al., 2016; Ferrante et al., 2016). A participant inone study said:
I guess I wonder if they may think why I don’t make the extra effort. Thatmight be on the back of their head but they never actually say so. But, you getgood at reading people when you are obese. You see it and you kind of knowwhat they are thinking. (Forhan et al., 2013)
These assumptions were reported in both general practice andmaternity care. Assumptions were made about how women’sweight gain occurred (e.g., being the result of lack of exerciseand/or eating fast food and sweets) (DeJoy et al., 2016). One par-ticipant in this study said:
They [health professionals] made judgments about what I ate, about howmuch I exercised. They never asked me; they just said things like ‘Don’t drinksoda,’ which I don’t, and ‘Don’t eat candy bars’, which I don’t. (DeJoyet al., 2016)
These types of assumptions were often inaccurate, but healthprofessionals did not listen when patients made efforts to correctthem (Pryor, 2002; Merrill and Grassley, 2008; DeJoy et al., 2016).Wadden et al. showed that over 60% of patients complained thattheir physicians did not truly understand how difficult it was to beoverweight (Wadden et al., 2000). In the same study, 24% ofpatients reported that their primary care practitioners sometimesdid not believe them when they told them they do not eatthat much.
Barriers to health care utilization
Seven studies (Olson et al., 1994; Drury and Louis, 2002; Pryor, 2002;Amy et al., 2006; Forhan et al., 2013; Russell and Carryer, 2013;Ferrante et al., 2016) cited reasons for avoidance, delay, or cancella-tion of health care services observed with individuals with overweightor obesity. Barriers to health care utilization included unsolicited lec-turing about weight loss (Olson et al., 1994; Wadden et al., 2000;Drury and Louis, 2002; Pryor, 2002; Amy et al., 2006; Ferranteet al., 2016); not wanting to get weighed (Olson et al., 1994; Druryand Louis, 2002); feeling embarrassed about their weight (Amyet al., 2006; Forhan et al., 2013); a fear of exposing their bodies(Russell and Carryer, 2013); undressing in health professionals’offices (Drury and Louis, 2002); and inadequate hospital equipmentsuch as small gowns, examination tables, chairs, and blood pressurecuffs (Pryor, 2002; Kaminsky and Gadaleta, 2002; Amy et al., 2006;Merrill andGrassley, 2008). A female participant expressed having towait half an hour for a nurse to find an appropriately sized bloodpressure cuff (Merrill and Grassley, 2008).
Expectation of differential health care
Patients with obesity expected to receive different health care treat-ments because of their weight (Brown et al., 2006; DeJoy et al.,2016). Patient perceptions of weight bias resulted in the develop-ment of expectations of negative stereotypes in both social inter-actions and, to a lesser extent, health services (Brown et al.,2006). This was observed both during general practitioner visitsand during maternity appointments. A study that exclusivelyinvolved pregnant or postpartum women with obesity reported
that most participants expected differential maternity care dueto their weight (DeJoy et al., 2016). Two-thirds of the participantsreported at least one negative maternity care experience withhealth professionals when their weight was the focus of the inter-action. Participants were suspicious that the care they received wasa result of their size. The participants in this study perceived anincreased medicalization of their pregnancy. Contrary to theseresults, a qualitative study conducted with women with obesityin a general practice setting reported that many participants deniedbeing treated differently because of their weight and did not believethat they received less care (Buxton and Snethen, 2013).
Low trust and poor communication
Several studies investigated the influence of weight bias on com-munication and level of trust in the patient–health professionalrelationship (Brown et al., 2006; Forhan et al., 2013; Russell andCarryer, 2013; Gudzune et al., 2013; 2014a). Patients were reluctantto initiate and express concerns about their weight to their healthprofessionals (Brown et al., 2006). In this same study, patientsreported not getting full explanations of why their weight wasbeing raised by the health care professional as an issue for discus-sion. A small percentage of participants (10.9%) reported that theyusually felt that they could not speak freely with doctors about theirweight (Wadden et al., 2000). Patient awareness of their generalpractitioner’s negative preconceived notions limited the amountof information they were willing to share (Forhan et al., 2013).Patients with overweight and obesity who felt their primary careproviders judged their weight were less likely to report high trustin these primary care practitioners (Gudzune et al., 2014a).Patients undergoing preventive screening were also dissatisfiedwith the insensitive and rushed communication from healthprofessionals (Brown et al., 2006). During physician visits, primarycare providers demonstrated lower levels of emotional rapportwith patients with obesity and overweight compared to normalweight patients (Gudzune et al., 2013). On the contrary, a study,which asked participants to rate on a scale of 0–10 their level oftrust in their current primary care practitioner, indicated that74% of patients with overweight and obesity reported a high levelof trust (scores ≥ 8) in their primary care practitioner. This highlevel of trust occurred regardless of whether or not participantshad taken part in prior ‘doctor shopping’ (Gudzune et al., 2014b).
‘Doctor shopping’ as a result of the differential health caretreatment
Studies have introduced the notion ‘doctor shopping’ as a conse-quence of experiencing weight bias in health care (Kaminsky andGadaleta, 2002; Puhl et al., 2013; Gudzune et al., 2014b). If generalpractitioners did not provide the quality of care that the patientssought, they often searched for other health professionals whowerebetter able to work with patients with obesity. In one study, 21% ofparticipants reported that they would look for a new doctor if theyperceived stigmatization about their weight (Puhl et al., 2013).Another study reported that 17% of participants changed primarycare physicians due to physician indifference and negative attitudestoward bariatric surgery (Kaminsky and Gadaleta, 2002). Gudzuneet al. reported that 13% of participants with overweight and obesityhad cited previous doctor shopping as a result of differential treat-ment (Gudzune et al., 2014b).
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Avoidance or delay of health services
Seven studies found that weight bias among health professionalswas associated with patient avoidance or delay of preventivescreening, maternity, and general practitioner healthcare services(Olson et al., 1994; Drury and Louis, 2002; Pryor, 2002; Amyet al., 2006; Russell and Carryer, 2013; Puhl et al., 2013;Hansson and Rasmussen, 2014). Olson et al. reported that 32%of women with obesity and 55% of women with severe obesityreported delaying or canceling health care appointments becausethey knew they would have to be weighed during the appointment(Olson et al., 1994). Similarly, Russell and Carryer found that themajority of self-identified large-bodied women (BMI not reported)admitted to delaying and avoiding pelvic and breast examinationsdue to fears of judgment when exposing their bodies (Russell andCarryer, 2013). In terms of routine checkups, Puhl et al. reportedthat 19% of participants stated that they would avoid medicalappointments if they perceived weight stigma (Puhl et al., 2013).Although seven studies reported the association between weightbias and decreased health care utilization, four studies reported dif-ferent findings (Merrill and Grassley, 2008; Buxton and Snethen,2013; Hilbert et al., 2014; Bottone et al., 2014). Buxton and Snethenreported that themajority of participants with obesity did not delaynor avoid health care (Buxton and Snethen, 2013). Further,Bottone et al. reported that 29.6% of patients with obesity reportedvisiting with their primary care provider three or more times in thepast six months compared to 23.4% of patients with normal weight(Bottone et al., 2014). Hilbert et al. reported that a greater BMI pre-dicted greater weight bias internalization and greater health careutilization (Hilbert et al., 2014). However, this study exclusivelyexamined the influence of weight bias internalization on healthcare utilization. The theme ‘refusing to give up’ was highlightedin a study that reported on the experiences of patients classifiedas overweight in their encounter with health care professionals(Merrill and Grassley, 2008). ‘Refusing to give up’ illustrates thepersistence of individuals with obesity to continue to try to controlor lose weight. A female participant expressed that she would con-tinue to pursue help from her physician:
I was in her office a month ago and I said, ‘I want gastric bypass’. And shesaid, ‘Okay’. I said, ‘What?’ And she goes, ‘Okay’. I said, ‘You’re not going toargue withme about this and tell me to go eat less and exercise?’And she said,‘No’. And that was it. (Merrill and Grassley, 2008)
Discussion
In this scoping review, we reviewed 21 published studies to exam-ine the influence of weight bias on engagement in primary healthcare.We have highlighted the themes that emerged from an exami-nation of these studies. In this section, we highlight inconsistencies,make recommendations for future research, and outline thestrengths and limitations of this scoping review.
Inconsistencies
The results of this review indicate that patients with overweightand obesity delay or avoid health care services as a result of healthprofessionals’ weight bias. Receiving unsolicited lecturing aboutweight loss (Olson et al., 1994; Drury and Louis, 2002; Pryor,2002; Amy et al., 2006; Ferrante et al., 2016), not wanting to getweighed (Olson et al., 1994; Drury and Louis, 2002), feeling embar-rassed about their weight (Amy et al., 2006; Forhan et al., 2013),fear of exposing their bodies (Russell and Carryer, 2013), and
inadequate hospital equipment such as small gowns, examinationtables, chairs, and blood pressure cuffs (Pryor, 2002; Amy et al.,2006) were reported by participants as reasons for avoiding healthcare.
On the contrary, four studies in this review did not report adecreased use of health care services (Merrill and Grassley,2008; Buxton and Snethen, 2013; Hilbert et al., 2014; Bottoneet al., 2014). Hilbert et al. reported that a greater BMI predictedgreater weight bias internalization known as greater health careutilization (Hilbert et al., 2014). However, this study exclusivelyexamined a specific type of weight bias called weight bias internali-zation. Buxton and Snethen reported that the majority of partici-pants with obesity did not delay nor avoid health care (Buxtonand Snethen, 2013). Bottone et al. also reported that individualswith obesity were more likely to use more health care services(have three or more visits with their personal doctor in the past6 months) (Bottone et al., 2014).
We speculate that these inconsistencies can be attributed to thefact that perceptions of weight bias in primary health care coulddiffer depending on the sample being examined. For example,females might have different perceptions of weight bias comparedto their male counterparts, and this might influence their engage-ment in primary health care services. Such inconsistencies inresearch examining the relationship between weight bias andhealth care utilization indicates that further study is warranted.Future studies should examine how weight bias influences thenumber of health care visits and should compare between sexesand ages. In addition, future studies should examine exclusivelythe different types of weight bias (explicit, implicit, and internal-ized) and the impact each type may have on health care utilization.
Future research and recommendations
For improvements in patient engagement in the primary healthcare to occur, health professionals must first become aware of theirweight bias attitudes and beliefs that could impact patient engage-ment in primary health care. It is only through awareness of one’sbiases that conscious efforts can be made to impede their influenceon behavior. Weight bias reduction interventions that promotediscourse and positive interactions between patients with obesityand health professionals are recommended to improve patientand health provider communication (Alberga et al., 2016b) andmitigate the issue of differential perceptions of weight bias.Future research is needed to examine the effects of robust weightbias reduction interventions among pre-service and practicinghealth professionals.
The provision of health care equipment that is adequate andappropriate for all body types has the potential to influence healthcare utilization by individuals with obesity. Participants in fourstudies cited inadequate or inappropriately sized equipment as abarrier to health care utilization (Pryor, 2002; Kaminsky andGadaleta, 2002; Amy et al., 2006; Merrill and Grassley, 2008).Addressing this barrier to health care utilization may result inpatients feeling less embarrassed about attention being drawn totheir body size due to inappropriate medical equipment.
There is a major gap in health professional training programson obesity and weight bias (Amy et al., 2006; Forhan et al., 2013;Russell and Carryer, 2013). The need for educational programsaimed to improve knowledge of weight management and weightbias in primary health care has been identified by patients livingwith obesity (Amy et al., 2006; Forhan et al., 2013; Russell andCarryer, 2013). Improved training not only refers to providing
Primary Health Care Research & Development 11
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educational information on the complexity of weight and thephysiological aspects of obesity but also improving clinical skillsto conduct sensitive and unbiased measurements of preventivescreening tests or other health services. Such interventions couldimprove the effectiveness of treatment plans prescribed for patientswith obesity and reduce ambivalence about obesity among patientsand their health professionals. Avoidance or ambiguity of discus-sing weight is not an effective strategy to avoid weight stigmatiza-tion. Obesity Canada's 5As of obesity management (Ask, Assess,Advise, Agree, Assist) are recommended for health practitionersusage in primary care to maintain sensitive, respectful, and non-judgmental conversations about weight management with peopleliving with obesity (Rueda-Clausen et al., 2014).
More research is needed to fully examine the effects of weightbias in primary health care and on patient engagement in healthcare before a systematic review can be performed. As illustratedin this scoping review, many of the studies utilized a quantitativestudy design such as surveys. More qualitative research such asinterviews and focus groups that examine patients’ perceptionsand experiences of weight bias in primary health care are needed.Qualitative research and the lived experience of weight bias wasidentified as a strategic research priority among stakeholders inthe field of obesity (Alberga et al., 2016a). In addition, this scopingreview highlighted the lack of literature that exclusively examinedthe effects of health professional weight bias on men’s engagementin health care. More research on sex differences in health careengagement is needed before a systematic review may beperformed.
Strengths and limitations
The present study is the first, to our knowledge, that summarizesthe existing literature on weight bias and patient engagement inprimary health care. This scoping review provides a comprehen-sive summary of the results of the different studies that exploredthis topic. However, because our scoping review focused primarilyon weight bias in primary care health professionals, conclusionsdrawn from this scoping review can only be made about primarycare health professionals. We included three papers in this scopingreview that reported three different outcomes albeit from the samesample of participants, whichmay be viewed as a limitation. Futureresearch is warranted to examine the influence of weight bias onengagement in other health sectors and settings (e.g., diet and fit-ness industry, public health).
Conclusion
This scoping review first identified perceived weight bias in pri-mary health care evidenced by health care providers’ contemptu-ous, patronizing, and disrespectful treatment, lack of training,ambivalence, attribution and assumptions about patients’ weightand health. Second, it is clear that weight bias negatively affectspatients’ engagement in primary health care through their per-ceived barriers to health care utilization, expectations of differen-tial health care treatment, low trust and poor communication,avoidance or delay of health services, and ‘doctor shopping’.Future research and advocacy initiatives are needed to reduceweight bias among health professionals and improve quality of careand engagement in primary health care among patients living withobesity.
Author ORCIDs. Angela S Alberga 0000-0003-3858-9482
Acknowledgments.Wegratefully acknowledge K.H. for her help in solidifyingthe search strategy and conducting the database search.
Author’s Contribution. Alberga AS, Forhan M, and Russell-Mayhew S wereinvolved in the conception of this scoping review. All authors screened titles,abstracts, full text articles and charted data for study characteristics. All authorsverified the data for accuracy and completeness. Edache IY was responsible forconducting the thematic analysis with guidance from Alberga AS, Forhan Mand Russell-Mayhew S. Alberga AS and Edache IY drafted the manuscriptwhich was revised and edited by Forhan M, and Russell-Mayhew S. All authorsapproved the final version of this manuscript.
Financial support. The second author was supported by a ResearchAssistantship from Concordia University. The first author was previouslyfunded by a Banting Canadian Institutes of Health Research PostdoctoralFellowship and is currently supported by a Research Scholar Junior 1 awardfrom les Fonds de Recherche du Québec- Santé.
Conflict of interest. None.
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Appendix
Search 2017
Concept: Weight bias
S1 ‘Weight Bias’ antifat[tiab] OR ‘anti fat’[tiab] OR ‘fat phobia’[tiab] OR ‘fat phobic’[tiab]
S2 Weight ‘Body Mass Index’[Mesh] OR ‘Body Weight’[Mesh] OR ‘obesity’[MeSH Terms] OR‘overweight’[MeSH Terms] OR obese[tiab] OR obesity[tiab] OR overweight[tiab] OR ‘overweight’[tiab] OR weight[tiab]
S3 Bias ‘Bias (Epidemiology)’[Mesh] OR ‘prejudice’[MeSH Terms] OR ‘Social Stigma’[Mesh] OR‘stereotyping’[MeSH Terms] OR bias[tiab] OR biased[tiab] OR biases[tiab] ORdiscriminate[tiab] OR discriminates[tiab] OR discriminated[tiab] OR discrimination[tiab] ORprejudice[tiab] OR prejudiced[tiab] OR stereotype[tiab] OR stereotypes[tiab] ORstereotyped[tiab] OR stereotyping[tiab] OR stigma[tiab] OR stigmas[tiab] ORstigmatization[tiab] OR stigmatize[tiab] OR stigmatized[tiab] OR stigmatizes[tiab] ORstigmatizing[tiab] OR stigmatisation[tiab] OR stigmatise[tiab] OR stigmatised[tiab] ORstigmatises[tiab] OR stigmatising[tiab] OR empathy[tiab] OR trust[tiab] OR ‘Negativeinteraction’[tiab] OR ‘negative encounter’[tiab] OR ‘negative experience’[tiab] OR shame[tiab]OR shaming[tiab] OR shamed[tiab] OR ‘Attitude of Health Personnel’[Mesh] OR ‘Physician-Patient Relations’[Mesh] OR ‘Nurse-Patient Relations’[Mesh]
S4 ‘Weight Bias’ OR (Weight AND Bias) S1 OR (S2 AND S3)
Concept: Health care utilization
S5 ‘Healthcare utilization’ ‘Health Resources/utilization‘ [Mesh] OR ‘Patient Acceptance of Health Care’[Mesh] OR‘Primary Health Care/utilization’[Mesh] OR ‘treatment seeking’[tiab]
S6 Healthcare ‘health care’[tiab] OR ‘health service’[tiab] OR ‘health services’[tiab] OR ‘family doctor’[tiab]OR ‘family practitioner’[tiab] OR ‘general doctor’[tiab] OR ‘general doctors’[tiab] OR ‘generalpractitioner’[tiab] OR ‘general practitioners’[tiab] OR GP[tiab] OR GPs[tiab] OR ‘primarycare’[tiab] OR ‘medical care’[tiab] OR ‘Physicians, Primary Care’[Mesh] OR ‘familyphysician’[tiab] OR ‘primary care physician’[tiab]
S7 Utilization avoid[tiab] OR avoidance[tiab] OR avoids[tiab] OR avoided[tiab] OR avoiding[tiab] ORconsume[tiab] OR consumed[tiab] OR consumer[tiab] OR consumes[tiab] OR consuming[tiab]OR consumption[tiab] OR seek[tiab] OR seeking[tiab] OR seeks[tiab] OR sought[tiab] ORuse[tiab] OR used[tiab] OR using[tiab] OR utilisation[tiab] OR utilise[tiab] OR utilised[tiab] ORutilises[tiab] OR utilization[tiab] OR utilize[tiab] OR utilized[tiab] OR utilizes[tiab] ORvisit[tiab] OR visits[tiab] OR visited[tiab] OR visiting[tiab] OR engaged[tiab] ORengagement[tiab]
S8 ‘Healthcare utilization’ OR (healthcareAND utilization)
S5 OR (S6 AND S7)
Final search’ weight bias AND healthcare utilization
S9 Non-research articles ‘comment’[Publication Type] OR ‘editorial’[Publication Type] OR ‘letter’[Publication Type]
S10 Final search (S4 AND S8) NOT S9
Filter Publication date 2000/01/01 to 2017/12/31
Filter Language English OR French
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