Strategies to reduce weight stigmatisation of people with overweight or obesity in the healthcare sector

Research areas: Prevention and screening, Psychological & psychiatric interventions

Duration: Mid-April 2024 until Mid-November 2024
Language: German (with English executive summary)
Publication: HTA Project Report No. 160: https://eprints.aihta.at/1547/

Background:
Rising global overweight and obesity rates coincide with increasing weight stigmatisation [1, 2]. Weight or obesity stigma refers to the societal devaluation of people because of their body weight or size [3, 4]. It is facilitated by social norms and instigated by weight bias, defined as negative attitudes and beliefs about others because of their weight [2, 5, 6]. Weight discrimination describes the overt behavioural manifestation of weight bias [5]. In this project, "weight stigma" will be used as an umbrella term.

Weight stigma exists in various contexts, including healthcare [4, 5, 7]. Multinational evidence showed that around two-thirds of adults with high weight reported experiencing weight stigma from healthcare professionals [2]. Healthcare providers from various professions often express conscious and unconscious weight-biased attitudes and stereotypes towards patients who are overweight or obese, e.g. that these patients are lazy, lack motivation and willpower, have poor self-control, have poor self-management behaviours, are at fault for their weight, and are less compliant with treatments. This professional weight bias can translate into poor patient communication (e.g., insensitive, stigmatising language, less patient-centred approaches) [1, 2, 4, 6]. In addition, there are structural stigmatising barriers in the healthcare setting, such as small waiting room chairs and equipment like blood pressure cuffs that are too small or weight scales that don’t fit high weights [5]. As a result, from the patient's perspective, weight stigma and discrimination can contribute to lower trust in healthcare professionals, lower treatment adherence, delay and avoidance of health care and clinical attrition. Moreover, there can be misdiagnoses and inadequate treatments, for example, if the prejudices mentioned above influence the medical history [1, 4, 6, 7]. Thus, experiencing weight discrimination can increase the risk of poor health regardless of gender, race, ethnicity, or sexual orientation [4]. Nevertheless, the health consequences of weight discrimination may be elevated in specific minoritised communities, e.g. racial and ethnic minority groups, due to their higher prevalence of obesity and consequently increased risk for weight stigma [4].

In 2016, the World Health Organization (WHO) called for eliminating discrimination in healthcare settings, including removing weight bias and obesity stigma [8]. In addition, the background literature highlights the need for health equity by reducing weight stigma and discrimination in the healthcare sector [4, 9]. In doing so, approaches addressing health care professionals (e.g., through weight bias education and communication training), structural barriers, as well as new weight-neutral concepts (e.g., health at every size) need to be taken into account [1, 10].

Project aims:
The project's main objective is to systematically review the scientific literature on strategies to reduce the stigmatisation of people with overweight or obesity in the healthcare system. This leads to the following two research questions:

1. What strategies are recommended to reduce weight stigma in the healthcare sector, or what strategies are reported in the literature?
2. How effective are strategies to reduce the stigmatisation of people with overweight or obesity in the healthcare system?

In addition, a comprehensive background chapter will deal with the types and extent of stigmatisation of people with overweight or obesity in the healthcare system and the consequences this can have. This thorough background chapter will help facilitate understanding of the topic.

Non-objectives:

The project does NOT aim:

• to provide an overview of projects from different countries outside of guidelines and scientific literature.
• to conduct a systematic review of the prevalences, causes and consequences of stigmatisation of people who are overweight or obese in the healthcare system.

Methods:
Guideline synopsis & Overview of Reviews

A manual search for international guidelines and published position and consensus papers will be conducted to answer the first research question. In addition, a systematic literature search will be carried out in several databases, from which relevant reviews will be identified. Once the relevant literature has been identified, the recommended strategies for reducing weight stigma in healthcare, divided into predefined categories, will be extracted into prefabricated tables and summarised narratively. A quality assessment of the selected literature will not be conducted to answer the first research question.

Systematic review of the effectiveness

To answer the second research question, targeted manual searches will be carried out in addition to the systematic literature search. After selecting the literature, the identified evidence on the effectiveness of strategies that can be used to reduce weight stigma in the healthcare system will be extracted into prefabricated tables and then summarised narratively. The same categorisation will be used as for research question 1. Primary studies will be included or excluded depending on the number of systematic reviews identified. A quality assessment will be conducted for the selected literature using a suitable tool depending on the study design.

All steps to answer the two research questions (literature selection, quality assessment, data extraction and synthesis) will be carried out by the two authors (SW and JK) using the dual control principle.

Inclusion criteria (PICO):

Population	Addressees of the intervention, e.g. healthcare professionals (doctors, nurses, therapists), healthcare professionals in training, healthcare organisations and their management level, healthcare policy, people with overweight or obesity Key words: weight bias/stigma*/discrimination; obesity bias/stigma*/discrimination; fat phobia; anti-weight bias; sizeism
Intervention	Strategies … … that can be used to reduce weight stigmatisation in the healthcare system or … to achieve a stigma-free approach to people with overweight or obesity in the healthcare sector.
Control	-
Outcomes	Research question 1: Recommendations for strategies Characteristics of the strategies Research question 2: Effectiveness of the strategies concerning, e.g.: Implementation of strategies (e.g., provision of wider chairs in waiting rooms, use of a sensitive communication style) Weight bias among healthcare professionals measured using questionnaires, e.g., Anti-Fat Attitudes Questionnaire (AFA), Fear of Fat Scale, Fat Phobia Scale (FPS), Beliefs About Obese Persons Scale (BAOP) Experienced weight stigmatisation (ESW) among affected persons measured by questionnaires, e.g., 10-item Weight Bias Internalisation Scale – Modified (WBIS-M) Clinical attrition (early treatment discontinuation among people experiencing weight stigma) measured by, e.g., attrition rate
Publication type	Research question 1: Guidelines and published position and consensus papers Reviews Research question 2: Systematic reviews and meta-analysis (preferred) Primary studies (alternatively)
Countries	Global north
Languages	Research question 1: English, German, other national languages[1] Research question 2: English, German

Timetable:

Period	Tasks
April 2024	Scoping and finalising the project protocol
May 2024	Systematic literature search and manual searches Selection of literature
June 2024	Data extraction and quality assessment
July – August 2024	Writing the report
September - October 2024	Internal and external review
November 2024	Layout and publication

References:

[1]          Forray A., Johnson K. and Chereche? R. M. Combating Weight Stigma in Healthcare: A Cross-Country Analysis and Intervention Initiative. Eur J Public Health. 2023;33(Suppl 2). DOI: 10.1093/eurpub/ckad160.887.

[2]          O'Donoghue G., Cunningham C., King M., O'Keefe C., Rofaeil A. and McMahon S. A qualitative exploration of obesity bias and stigma in Irish healthcare; the patients' voice. PLoS One. 2021;16(11):e0260075. DOI: 10.1371/journal.pone.0260075.

[3]          Westbury S., Oyebode O., van Rens T. and Barber T. M. Obesity Stigma: Causes, Consequences, and Potential Solutions. Curr Obes Rep. 2023;12(1):10-23. DOI: 10.1007/s13679-023-00495-3.

[4]          Weight Stigma in Healthcare. Supportive Obesity Care [cited 17.04.2024]. Available from: https://supportiveobesitycare.rudd.center.uconn.edu/weight-stigma-in-healthcare/.

[5]          Alberga A. S., Pickering B. J., Alix Hayden K., Ball G. D., Edwards A., Jelinski S., Nutter S., Oddie S., Sharma A. M. and Russell-Mayhew S. Weight bias reduction in health professionals: a systematic review. Clin Obes. 2016;6(3):175-188. DOI: 10.1111/cob.12147.

[6]          Ryan L., Coyne R., Heary C., Birney S., Crotty M., Dunne R., Conlan O. and Walsh J. C. Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis. Obes Rev. 2023;24(10):e13606. DOI: 10.1111/obr.13606.

[7]          Gupta N., Bombak A., Foroughi I. and Riediger N. Discrimination in the health care system among higher-weight adults: evidence from a Canadian national cross-sectional survey. Health Promot Chronic Dis Prev Can. 2020;40(11-12):329-335.

[8]          Weight bias and obesity stigma: considerations for the WHO European Region. World Health Organization: 2017 [cited 17.04.2024]. Available from: https://iris.who.int/bitstream/handle/10665/353613/WHO-EURO-2017-5369-45134-64401-eng.pdf?sequence=1&isAllowed=y.

[9]          van der Voorn B., Camfferman R., Seidell J. C., Puhl R. M. and Halberstadt J. Weight-biased attitudes about pediatric patients with obesity in Dutch healthcare professionals from seven different professions. J Child Health Care. 2023;27(2):243-252. DOI: 10.1177/13674935221133953.

[10]       Fruh S. M., Nadglowski J., Hall H. R., Davis S. L., Crook E. D. and Zlomke K. Obesity Stigma and Bias. J Nurse Pract. 2016;12(7):425-432. DOI: 10.1016/j.nurpra.2016.05.013.