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Abstract
Weight stigma is prevalent with negative consequences for health and well-being. This problem is present in health care; stigmatizing attitudes toward patients with obesity are expressed by medical professionals across diverse specialties and patient care settings. This article summarizes the ways in which weight stigma creates barriers to effective care, including poor patient-provider communication, reduced quality of care, and healthcare avoidance. Priorities for stigma reduction in healthcare are discussed, with a clear need for multifaceted approaches and inclusion of people with obesity whose perspectives can inform strategies to effectively remove bias-related barriers to patient care.
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Affiliation(s)
- Rebecca M Puhl
- Rudd Center for Food Policy & Health, University of Connecticut, One Constitution Plaza, Suite 600, Hartford, CT 06103, USA; Department of Human Development & Family Sciences, University of Connecticut, Storrs, CT, USA.
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Chang JE, Lindenfeld Z, Chang VW. Obesity and Patient Activation: Confidence, Communication, and Information Seeking Behavior. J Prim Care Community Health 2022; 13:21501319221129731. [PMID: 36222682 PMCID: PMC9561656 DOI: 10.1177/21501319221129731] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION/OBJECTIVES Patient activation describes the knowledge, skills, and confidence that allow patients to actively engage in managing their health. Prior studies have found a strong relationship between patient activation and clinical outcomes, costs of care, and patient experience. Patients who are obese or overweight may be less engaged than normal weight patients due to lower confidence or stigma associated with their weight. The objective of this study is to examine whether weight status is associated with patient activation and its sub-domains (confidence, communication, information-seeking behavior). METHODS This repeated cross-sectional study of the 2011 to 2013 Medicare Current Beneficiary Survey (MCBS) included a nationally representative sample of 13,721 Medicare beneficiaries. Weight categories (normal, overweight, obese) were based on body mass index. Patient activation (high, medium, low) was based on responses to the MCBS Patient Activation Supplement. RESULTS We found no differences in overall patient activation by weight categories. However, compared to those with normal weight, people with obesity had a higher relative risk (RRR 1.24; CI 1.09-1.42) of "low" rather than "high" confidence. Respondents with obesity had a lower relative risk (RRR 0.82; CI 0.73-0.92) of "low" rather than "high" ratings of communication with their doctor. DISCUSSION AND CONCLUSIONS Though patients with obesity may be less confident in their ability to manage their health, they are more likely to view their communication with physicians as conducive to self-care management. Given the high receptivity among patients with obesity toward physician communication, physicians may be uniquely situated to guide and support patients in gaining the confidence they need to reach weight loss goals.
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Affiliation(s)
- Ji Eun Chang
- New York University, New York, NY,
USA,Ji Eun Chang, College of Global Public
Health, New York University, 708 Broadway, New York, NY 10003, USA.
| | | | - Virginia W. Chang
- New York University, New York, NY,
USA,NYU Grossman School of Medicine, New
York, NY, USA
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McHale CT, Laidlaw AH, Cecil JE. Predictors of weight discussion in primary care consultations: A multilevel modeling approach. PATIENT EDUCATION AND COUNSELING 2022; 105:502-511. [PMID: 34253384 DOI: 10.1016/j.pec.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/14/2021] [Accepted: 07/03/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To understand how primary care weight-related communication processes are influenced by individual differences in primary care practitioner (PCP) and patient characteristics and communication use. METHODS Two multilevel logistic regression models were calculated to predict the occurrence of 1) weight-related discussion and 2) weight-related consultation outcomes. Coded communication data (Roter Interaction Analysis System) from 218 video-recorded consultations between PCPs and patients with overweight and obesity in Scottish primary care practices were combined with their demographic data to develop the multilevel models. RESULTS Weight-related discussions were more likely to occur when a greater proportion of PCP's total communication was partnership building and activating communication. More discrete weight discussions during a consultation predicted weight-related consultation outcomes. Patient BMI positively predicted both weight-related discussion and consultation outcomes. CONCLUSION This work demonstrates that multilevel modeling is a viable approach to investigating coded primary care weight-related communication data and that it can provide insight into the impact that various patient and PCP factors have on these communication processes. PRACTICE IMPLICATIONS Through the increased use of partnership building and activating communications, and by engaging in shorter, but more frequent, discussions about patient weight, PCPs may better facilitate weight-related discussion and weight-related consultation outcomes for their patients.
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Affiliation(s)
- Calum T McHale
- School of Medicine, University of St Andrews, St Andrews, UK.
| | - Anita H Laidlaw
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Joanne E Cecil
- School of Medicine, University of St Andrews, St Andrews, UK
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Albury C, Webb H, Ziebland S, Aveyard P, Stokoe E. What happens when patients say "no" to offers of referral for weight loss? - Results and recommendations from a conversation analysis of primary care interactions. PATIENT EDUCATION AND COUNSELING 2022; 105:524-533. [PMID: 34489149 DOI: 10.1016/j.pec.2021.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/23/2021] [Accepted: 08/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Guidelines recommend that clinicians should offer patients with obesity referrals to weight management services. However, clinicians and patients worry that such conversations will generate friction, and the risk of this is greatest when patients say no. We examined how doctors actually respond to patient refusals, and how patients reacted to clinicians in turn. METHODS Conversation analysis of 226 GP-patient interactions recorded during a clinical trial of weight management referrals in UK primary care. RESULTS Some clinicians responded to refusals by delivering further information or offering referral again. These actions treated patient refusals as unwelcome, and acted to pursue acceptance instead. However, pursuit did not lead to acceptance. Rather, pursuing acceptance lengthened consultations and led to frustration, offence, or anger. Clinicians who accepted refusals and closed the consultation avoided friction and negative emotional displays. CONCLUSION Patient refusals have the potential to create negative consequences in the consultation and clinician responses were key in avoiding these. When clinicians acknowledged the legitimacy of patient refusals, negative consequences were avoided, and the conversation was briefer and smoother. PRACTICE IMPLICATIONS When patients refuse the offer of a free weight management referral, GPs should accept this refusal, rather than trying to persuade patients to accept.
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Affiliation(s)
- Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Helena Webb
- Department of Computer Science, Human Centred Computing, University of Oxford, Oxford, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Stokoe
- Discourse and Rhetoric Group, Loughborough University, Loughborough, UK
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Phelan SM, Bauer KW, Bradley D, Bradley SM, Haller IV, Mundi MS, Finney Rutten LJ, Schroeder DR, Fischer K, Croghan I. A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network. Obes Sci Pract 2021; 8:139-146. [PMID: 35388341 PMCID: PMC8976541 DOI: 10.1002/osp4.553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/19/2021] [Accepted: 07/25/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Obesity is stigmatized and people with obesity report experiencing stigmatizing situations when seeking health care. The implications of these experiences are not well understood. This study tests an indirect effects model of negative care experiences as an intermediate variable between obesity and care avoidance/utilization and switching primary care doctors. Methods A survey was completed by 2380 primary care patients in the Learning Health Systems Network (LHSNet) Clinical Data Research Network with a BMI >25 kg/m2. Measures included scales assessing stigmatizing situations, perceived patient-centered communication, perceived respect, having delayed needed care, and having looked for a new primary doctor in the past 12 months. Sequential and serial indirect effects of care experiences and respect in the association between BMI and care utilization outcomes was modeled. Results The hypothesized model was supported by findings. The associations between BMI and delaying needed care (OR = 1.06, p < 0.001) and attempting to switch primary doctors (OR = 1.02, p = 0.04) was mediated by both stigmatizing situations experienced in a health care context and lower patient-centered communication. Lower perceived respect mediated the association between care experiences and utilization outcomes. Conclusions People with higher BMIs may avoid care or switch doctors as a result of stigmatizing experiences and poor communication with doctors. These outcomes may contribute to morbidity in people with obesity if they delay or avoid care for health concerns when symptoms first present.
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Affiliation(s)
- Sean M. Phelan
- Division of Health Care Delivery ResearchMayo ClinicRochesterMinnesotaUSA,Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
| | - Katherine W. Bauer
- Department of Nutritional SciencesUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | | | - Steven M. Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute FoundationMinneapolisMinnesotaUSA
| | - Irina V. Haller
- Essentia Institute of Rural Health, Essentia HealthDuluthMinnesotaUSA
| | - Manpreet S. Mundi
- Division of Endocrinology, Diabetes, Metabolism, and NutritionMayo ClinicRochesterMinnesotaUSA
| | | | | | - Kristin Fischer
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
| | - Ivana Croghan
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA,Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA,Department of MedicineDivision of General Internal MedicineMayo ClinicRochesterMinnesotaUSA
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Association between patients' body mass index and emergency department wait times: A multicenter observational cohort investigation by the reducing disparities increasing equity in emergency medicine (REDEEM) study group. Am J Emerg Med 2021; 49:178-184. [PMID: 34119812 DOI: 10.1016/j.ajem.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/31/2021] [Accepted: 06/03/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Numerous studies have demonstrated evidence of obesity bias in healthcare settings, however, little is known about obesity bias in the Emergency Department (ED). The objective of this study was to investigate obesity bias in an ED setting by assessing the association between body mass index (BMI) and door-to-room (DTR) or door-to-provider (DTP) times among ED patients. METHODS We conducted an observational cohort study of all adult patient (age ≥ 18 years of age) visits to 21 Mayo Clinic and Mayo Clinic Health System EDs between November 1, 2018 and March 31, 2020. We compared DTR and DTP times based on BMI category. RESULTS We found that median DTR and DTP times for adults with class 3 obesity are significantly shorter than patients in the normal weight category. For men with class 3 obesity, median DTR and DTP times were 7.5% and 5.4% shorter than men in the normal weight category. Relative to women in the normal weight category, the median DTR and DTP times were 4.6% and 3.8% faster for women in obesity class 1, 4.9% and 5.1% faster for women in obesity class 2, and DTR was 4.4% faster for women in obesity class 3. These percentage differences translated to slightly shorter wait times of 0.4-1.2 min compared to median wait times for patients with normal BMI. CONCLUSION We did not find evidence of longer wait times experienced by people with obesity. Rather, patients with obesity often experienced wait times that were shorter than patients of normal weight.
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McClure‐Brenchley KJ, Pitpitan EV, Quinn DM. Prejudice against higher‐weight health providers: Implications for patients and providers. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY 2020. [DOI: 10.1111/jasp.12655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - Diane M. Quinn
- Department of Psychological Sciences University of Connecticut Storrs CT USA
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Tilburt JC, O Byrne T, Branda ME, Phelan S. Higher BMI associated with shorter visits in male oncology patients: An exploratory analysis. PATIENT EDUCATION AND COUNSELING 2019; 102:2353-2357. [PMID: 31331706 PMCID: PMC6851463 DOI: 10.1016/j.pec.2019.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 06/28/2019] [Accepted: 07/09/2019] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To determine the potential relationship between measures of patient-provider communication and patient body mass index (BMI) and gender in cancer care. METHODS We audio-recorded cancer patients' communication with their clinicians in an academic medical oncology practice from 2012-2014. We coded audio-recordings with the Roter Interaction Analysis System. We then examined whether BMI was associated with patient centeredness, time with doctor, global affect, and patient self-reported communication quality. Univariate associations with BMI were assessed with Chi-square and Kruskal-Wallis tests. A cumulative logit model adjusted for patient and visit characteristics in a multivariable model. RESULTS We recorded 327 patient interactions with 37 clinicians. After adjusting for patient sex, and visit characteristics, visit length, patient-centeredness, global affect (patient or clinician) and satisfaction did not differ. However, higher BMI was associated with shorter visit length, and lower Negative Global Affect (p = 0.03 and p = 0.03, respectively) in men only. CONCLUSION In this exploratory analysis, communication characteristics did not vary by patient BMI overall. However, in men, higher BMI was associated with shorter visit length and more negative affect. Those differences did not persist after adjusting for multiple comparisons. PRACTICE IMPLICATIONS Patient body size may contribute to clinical communication in cancer care, particularly for obese men.
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Affiliation(s)
- Jon C Tilburt
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA; Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA; Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.
| | - Thomas O Byrne
- Division of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Megan E Branda
- Department of Biostatistics and Informatics, Colorado School of Public Health, Denver, CO, USA
| | - Sean Phelan
- Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA
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Huibregtse BM, Boardman JD. Provider bias as a function of patient genotype: polygenic score analysis among diabetics from the Health and Retirement Study. Obes Sci Pract 2018; 4:448-454. [PMID: 30338115 PMCID: PMC6180716 DOI: 10.1002/osp4.293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/10/2018] [Accepted: 07/12/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Poor patient-provider interactions due to provider bias are associated with worse physiological and behavioural health outcomes for patients. Prior research has shown that patients with obesity perceive less favourable interactions compared with those with lower weights. This paper explores whether this association depends on patients' cumulative polygenic score with respect to genes linked to obesity (i.e. a single variable quantifying the individual's genome-wide risk factors for high body mass index [BMI] or genetic liability) and whether providers react differentially to patients whose obesity is more genetic in nature compared with patients with diabetes caused by environmental factors. METHODS The association between patients' BMI category, their polygenic score for high BMI and their interaction was assessed for two measures of the patient-provider interaction within a sample of 521 older patients with diabetes from the Health and Retirement Study. RESULTS Particularly for patients with obesity, the quality of the patient-provider interaction depended on genetic liability for high BMI controlling for demographic and clinical covariates. Providers responded less favourably to patients with diabetes influenced by environmental factors compared with individuals with high genetic liability. CONCLUSIONS Results of this study suggest that a patient's genotype may elicit particular responses from their healthcare provider. When a provider judges a patient's high BMI to be environmentally driven rather than genetically oriented, patients receive reduced quality of care.
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Affiliation(s)
- B. M. Huibregtse
- Institute of Behavioral ScienceUniversity of Colorado BoulderBoulderCOUSA
- Institute for Behavioral GeneticsUniversity of Colorado BoulderBoulderCOUSA
| | - J. D. Boardman
- Institute of Behavioral ScienceUniversity of Colorado BoulderBoulderCOUSA
- Department of SociologyUniversity of Colorado BoulderBoulderCOUSA
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