Background/Purpose: Worldwide, 650 million adults (39%) are overweight or obese. The combined overweight and obesity rates for adults in the United States and Canada are 67.9% and 64.1% respectively. These overweight and obesity rates have increased more in women than men. Global overweight and obesity rates in men have increased from 3% in 1975 to 20% in 2016. Global overweight and obesity rates in women have increased from 6% in 1975 to 23% in 2016. (World Health Organization, 2016). Subsequently there has been an increase in obesity related health conditions including diabetes and cardiovascular disease and an increased risk in women for reproductive disorders such as polycystic ovarian syndrome and infertility (Fingeret, Marques-Vidal & Vollenweider, 2018; Silvestus, dePergola, Rosania & Loverro, 2018). Despite the fact that obesity carries significant health risks, persons who are obese face stigma and bias from health care providers that affects the quality of care and increases health care avoidance (Phelen et al., 2015). Women who are obese face more stigma than men (Dutton et al. 2014) and may delay or avoid gynecological care to due fear of embarrassment and a care environment that may make them uncomfortable and does not meet their needs. Methods: A quality improvement project was conducted from November to February 2017, in an obstetrical/gynecological practice that included physicians, nurse- midwives, nurses and medical assistants in the Northeast United States. Participants were presented with a 17-minute video and 20-minute oral presentation. The video included: (1) bias faced by patients who are obese when receiving health care and (2) strategies on how to make a health care practice more welcoming for the client with obesity. The oral presentation included a discussion of controllable and uncontrollable causes of overweight and obesity as well as specific suggestions to make a practice more welcoming and comfortable for the patient with obesity including environmental modifications and best practices for performing a pelvic exam. A Pre and Post assessment of the participants for implicit and explicit bias using the Thin-Fat Implicit Bias Test (IAT) and the Anti-Fat Attitudes Test (AFAT) for explicit bias was used (Elran-Barak & Bar-Anan, 2018; Tanneberger; & Ciupitu-Plath, 2018) to determine effectiveness of the intervention and need for plan modification. The assessments were administered to participants immediately before the intervention, immediately after the intervention and again 3 months after the intervention. The Thin-Fat IAT uses word association presented in rapid sequence with a particular trait in order to measure unconscious bias in individuals for a specific character trait. The IAT is a measure of implicit bias (subscales stupid/smart, lazy/motivated, and good/bad). A score of zero indicates total non-bias, a score with a positive number indicates bias toward thin and a score with a negative number indicates bias toward fat. The AFAT is a 47-item measure of explicit bias (3 subscales; social/character disparagement, physical/romantic attractiveness, and weight control/blame) on a 5-point Likert scale with responses ranging from “definitely disagree” to “definitely agree” to statements about obese/overweight people. Scores range from 47-235 with higher scores indicating higher bias. Results: Immediate post-intervention explicit bias (AFAT) scores decreased by 11.6% and implicit scores (IAT) increased by 12%. Specifically, AFAT subscale measurements overall scores for physical/romantic attractiveness and weight control/blame decreased by 20% and the subscale measurement of social/character disparagement decreased by 17%. Based on these results, it is possible that the intervention had an effect on the participants and resulted in a decreased in explicitly biased attitudes towards obese patients immediately after the intervention.
The results of the IAT to test for implicit bias, done immediately post-intervention tell a different story. The total IAT scores increased by 12% and the subscale for lazy/motivated increased by 3.6%. The subscale for smart/stupid decreased by 15%. The results of the three months follow up surveys indicate a continued decreased explicit bias score in the Antifat Attitudes test from the initial pre-test for those participants surveyed. The total mean AFAT score was 7.3% lower than the initial score, but 4.3% higher than the immediate post-test score. Scores for all three subscales were decreased both from the pre- intervention test and immediate post-test scores.
Also, the 3 months follow-up IAT scores for implicit bias were increased from both the pre-test scores and the immediate post test scores. The total IAT mean scores were 33% increased from pre-intervention test scores and the lazy/motivated subscale score was increased 45% from pre-intervention test scores. Only the smart/stupid subscale of the IAT revealed a 5.8% decrease in the mean score for bias from the initial score. Based on these results it is suggested that the providers have increased awareness of their attitudes and how they should treat patients but have implicit bias that is possibly more pronounced on follow up testing as the participants become more proficient and familiar with the IAT test. Qualitative feedback from participants ranged from the expression of an increased awareness of obesity bias in the healthcare setting to avoidance of discussion or disclosures of feelings of shame and embarrassment for personal or family members experiencing obesity. Conclusion: Education and discussion about stigma toward patients with obesity may bring an awareness of bias and opens discussions to provide respectful and improved medical care. Providers demonstrated some sustained decrease in explicit bias toward obese patients over time. However, implicit bias that is more unconscious may have deeper, more personal roots and presents greater challenges in decreasing providers implicit attitudes toward obese patients. Some providers were eager to confide their experiences both professionally and personally with obesity stigma while others noted a degree of discomfort with the topic and preferred not to discuss it further. More research is needed into the origins of bias and effective interventions to decrease bias in order to improve patient care. Qualitative research which focuses on the reflections and lived experiences of both those who provide care for obese women and the lived experiences of obese women seeking gynecological care may provide greater insight into the origins of obesity bias and provide guidance towards improved methods of decreasing bias and improving the quality of care for these patients.