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Primary Health Care Research & Development cambridge.org/phc Review Cite this article: Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. (2019) Weight bias and health care utilization: a scoping review. Primary Health Care Research & Development 20(e116): 1–14. doi: 10.1017/ S1463423619000227 Received: 15 March 2018 Revised: 19 November 2018 Accepted: 19 November 2018 Key words: obesity; primary health care; weight stigma Author for correspondence: Angela S. Alberga, Assistant Professor, Department of Health, Kinesiology & Applied Physiology, Concordia University, 7141 Sherbrooke Street West, SP-165.31, Montreal, QC H4B1R6, Canada. E-mail: [email protected] © The Author(s) 2019. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Weight bias and health care utilization: a scoping review Angela S. Alberga 1 , Iyoma Y. Edache 1 , Mary Forhan 2 and Shelly Russell-Mayhew 3 1 Department of Health, Kinesiology & Applied Physiology, Concordia University, Montreal, QC, Canada; 2 Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada and 3 Werklund 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/or experiences of weight bias in primary health care influence engagement with and utilization of health 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 mass index 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 searched from January 2000 to July 2017. Four reviewers independently selected 21 studies examining perceptions 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 scoping review. The following 10 themes were identified: contemptuous, patronizing, and disrespectful treatment, lack of training, ambivalence, attribution of all health issues to excess weight, assumptions about weight gain, barriers to health care utilization, expectation of differential health 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 experiences of weight bias from primary care health professionals negatively influence patient engagement with 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 individuals living with obesity have been reported in prior research (Drury and Louis, 2002; Coughlin et al., 2004; Ferrante et al., 2007; Aldrich and Hackley, 2010). In fact, it has been shown that having obesity impedes access to health care (Drury and Louis, 2002; Amy et al., 2006). Studies have documented a decrease in the use of health care services associated with an increasing body mass index (BMI) (Olson et al., 1994; Fontaine et al., 1998; Amy et al., 2006; Aldrich and Hackley, 2010). This includes reduced rates of routine breast and gynecological cancer screening tests among individuals with obesity compared to individuals with a BMI classified as normal (Adams et al., 1993; Fontaine et al., 1998; Aldrich and Hackley, 2010). When individuals with obesity avoid or 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 care services could have detrimental implications for the prevention and management of obesity, its possible comorbidities, and other diseases (Phelan et al., 2015). Weight bias and stigma, known as negative, prejudicial, or stereotypical beliefs and attitudes toward individuals based on their size, has been identified as a barrier to seeking health care services (Drury and Louis, 2002; Puhl and Heuer, 2009; Washington, 2011). Weight bias was 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 States by 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 attitudes about 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 creation of multiple barriers to health care utilization (Drury and Louis, 2002). Not only does weight bias pose adverse mental and physical health consequences such as exercise 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 health care treatment outcomes (Carels et al., 2009). For example, a study compared people with severe obesity who experienced weight bias and those with severe obesity who did not experience weight bias. Those who experienced weight bias had a 1.5 kg/m 2 greater BMI compared to those who did not report weight bias (Hansson and Rasmussen, 2014). In another study, participants https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423619000227 Downloaded 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

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Page 1: Weight bias and health care utilization: a scoping review...Review and Meta-Analyses extension for Scoping Reviews (PRISMA- ScR) was used to guide the reporting for this scoping review

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

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Page 2: Weight bias and health care utilization: a scoping review...Review and Meta-Analyses extension for Scoping Reviews (PRISMA- ScR) was used to guide the reporting for this scoping review

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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Page 4: Weight bias and health care utilization: a scoping review...Review and Meta-Analyses extension for Scoping Reviews (PRISMA- ScR) was used to guide the reporting for this scoping review

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.

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

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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

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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

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.

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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

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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.

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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

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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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Primary Health Care Research & Development 13

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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

14 Angela S. Alberga et al.

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