Obesity is a chronic disease and a leading public health concern in America today, affecting 39.8% of the U.S. adult population (Hales et al., 2017; Jastreboff et al., 2019). Obesity is associated with health care costs of approximately $147 billion per year due to numerous obesity-related illnesses, including metabolic syndrome, cardiovascular disease, stroke, type 2 diabetes, and sleep apnea (Finkelstein et al., 2009). Further, the psychological challenges faced by individuals with obesity often compound the associated physical health risks. Individuals with obesity are often the targets of weight bias, stigma, and discrimination based on their body size. Self-reports of weight-based discrimination have increased by 66% since 1995; it remains the last socially acceptable form of prejudice in society today and is rarely challenged (Obesity Action Coalition, 2017; Puhl et al., 2008).
Weight bias is defined as having negative attitudes toward and beliefs about others because of their weight (World Health Organization, 2017). Perceptions of the causes of obesity may stem from assumptions that weight is entirely under one's control or that the failure to achieve a normal body weight is due to a mere lack of willpower (Washington, 2011). These negative attitudes, beliefs, or misconceptions may contribute to weight bias and subsequently manifest as stereotyping and discrimination toward individuals with obesity, leading to obesity stigma. Obesity stigma involves taking actions against a person based on subtle or apparent differences in weight status. Such stigmatization can lead to shaming, labeling, or stereotyping, resulting in the individuals with obesity exclusion or inequity (Obesity Action Coalition, 2017; World Health Organization, 2017). Weight stigma occurs in a variety of settings such as school or work, but it is particularly damaging when it pervades health care settings, causing disparities or inequalities in care.
Health care settings are not exempt from obesity stigma, and there is mounting concern that patients with obesity experience discrimination during their routine medical visits (Budd et al., 2011; Phelan et al., 2015). The National Institute for Health and Care Excellence (2014) reinforced the need for health care professionals to be more acutely aware of the obesity stigma experienced by their patients and the role that providers may have in perpetuating it. Currently, health care providers, including physicians, nurses, nursing students, and dietitians, are among those who have been reported to harbor biased attitudes and beliefs, knowingly or not, about weight, contributing to obesity stigma among their patients (Budd et al., 2011; Schwartz et al., 2003). Nurses represent the largest sector of health professionals and provide regular care to patients with obesity; therefore, they must be adequately prepared to deliver equal and unbiased patient care regardless of patients' body weight or size (Institute of Medicine of the National Academies, 2010).
Nursing education teaches essential knowledge and skills throughout the nursing curriculum that affect the quality of future health care practice (Poon & Tarrant, 2009). There is also a consensus that nursing skills develop and improve over time, but many skills need to be identified and addressed at the start of a nurse's career in the undergraduate curriculum (Dunn & Hansford, 1997). Raising awareness about weight-related bias and stigma and identifying beliefs and attitudes are important; however, merely identifying the presence or existence of weight bias and obesity stigma among nursing students is not sufficient. More must be done to advocate for patients who experience such discrimination by delivering weight sensitivity training program to nursing students as part of their undergraduate nursing curriculum. This may be an effective strategy to teach the complexities of obesity, as well as educate students about the detrimental effects of weight bias and obesity stigma. Due to the dearth of studies that have evaluated the effect of weight sensitivity training on undergraduate nursing students, the purpose of this study was to conduct and evaluate a semester-long weight sensitivity intervention to test whether a reduction in negative attitudes and beliefs toward individuals with obesity can be achieved.
This study was guided by the attribution theory, which suggests that negative stereotypes and bias toward individuals are based on the belief that weight is a matter of personal responsibility and control. Thus, this intervention study was conducted to determine whether negative attitudes and beliefs toward those with obesity can be improved.
A one-group pretest–posttest repeated measures, concurrent mixed-methods study was conducted in which the intervention group received the Curriculum Embedded Weight Sensitivity (CeWebs) training. The project was at a 4-year prelicensure baccalaureate nursing program with third-year clinical students in a private Catholic university. Data collection occurred on the first day of the medical–surgical nursing clinical experience and again at the conclusion of the semester. The study was approved by Villanova University Institutional Review Board (IRB) as exempt and considered part of the educational curriculum.
Sample and Setting
The CeWebs training was designed for nursing student clinical curricula with the intent to improve attitudes and beliefs toward patients with obesity when providing nursing care. CeWebs was introduced on the first day of the medical–surgical clinical practicum, to all 17 clinical groups by the trained research team. Each clinical group had six to eight students. A total of 125 students at least 18 years old who enrolled in this required course in the first semester of their third-year were eligible to be included in this study.
The CeWebs Training
The CeWebs training was embedded in the curriculum content, and all students were required to participate in the educational aspects of the training. The students were informed that the project was a general sensitivity program related to patient care, rather than a program that focused on obesity. This approach, which was approved by the IRB, was used to reduce social desirability during students' completion of initial pre-intervention questionnaires. Students were then asked if they were interested in volunteering to complete the evaluation portion through the completion of the Attitudes Toward Obese Persons (ATOP) and Beliefs About Obese Persons (BAOP) questionnaires. If students agreed to participate, they consented and then were invited to participate in the research aspects, and any student who decided not to participate in the evaluation portion was asked not to complete or return the questionnaires. Identification codes were used to protect students' identity and to ensure faculty did not know which students were participating. All students were assured that participation or nonparticipation would not affect their course grades in any way. After the baseline questionnaires were completed, the CeWebs intervention was conducted by the principal investigator and the real focus of the sensitivity training on obesity was revealed to the students.
In this interdisciplinary training program, registered dietitians trained in weight management delivered the CeWebs intervention, which included a slide presentation on the prevalence of obesity, genetic influences related to obesity, the presence and negative impact of weight bias within health care, and the steps health care providers can take to reduce weight bias in their clinical practice (Obesity Action Coalition, 2017; University of Conn Rudd Center for Food Policy and Obesity, 2017). Additionally, a 17-minute video, “Weight Bias in Healthcare,” was used in the training (UConn Rudd Center for Food Policy and Obesity, 2017).
After the slide and video presentation, the investigator engaged the students in a dialogue using five questions adapted from the video discussion guide. Sample questions included, “What are your current views toward patients with obesity?” and “Are you sensitive to the needs and concerns of individuals with obesity?” Students actively shared their reactions to the video and discussed the concept of weight bias in health care while responding to questions and prompts. Throughout the semester, the students also completed biweekly reflective journaling assignments discussing aspects related to obesity and patient care. The qualitative findings from the reflective journals will be detailed and reported elsewhere.
At the end of the semester, the research team revisited the clinical groups to conclude the 14-week project and conduct the postintervention evaluation. ATOP and BAOP questionnaires were repeated and a debriefing session was held to discuss any challenges related to weight bias and obesity stigma the students experienced over the semester. Students were also prompted to consider how to apply the program principles in clinical care and future practice.
ATOP Scale. The ATOP is a 20-item 6-point Likert rating scale commonly used to measure explicit perceptions and attitudes about obese people compared with others. The scale asks participants to indicate the degree to which they agree with statements such as “Most obese people feel that they are not as good as other people.” The scale measures common perceptions against obese individuals (e.g., dissatisfaction, unhappiness, and self-consciousness) (Allison et al., 1991). Responses on the scale range from strongly disagree (−3) to strongly agree (+3). A scoring rubric was used as designed by the questionnaire author. ATOP scores range from 0 to 120, with higher scores reflecting more positive attitudes toward obese people. It has established evidence of reliability and validity for use in adult populations with a reliability range of 0.76 to 0.84 in previous studies (Allison et al., 1991; Lillis et al., 2010). The Cronbach's alpha coefficients for the present study were .82 and .85 for the pretests and posttests, respectively.
BAOP Scale. The BAOP is an 8-item 6-point Likert rating scale used to assess the strength of explicit beliefs about the causes of obesity or whether obesity is thought to be within one's control (Allison et al., 1991). Study participants were asked to indicate the extent to which they strongly agree (+3) or strongly disagree (−3) with specific statements focusing on genetics, eating patterns, overeating, or lack of willpower, such as “Obesity is really caused by a lack of willpower.” A scoring rubric was used as designed by the questionnaire author. The highest possible score is 48, and higher scores indicate a stronger belief that obesity is not under the obese person's control (Allison et al., 1991). The BAOP scale has an alpha reliability range of .65 to .82 (Allison et al., 1991). In this study, the Cronbach's alpha score for the BAOP was .68 for the pretest and .72 for the posttest.
Data were analyzed using SPSS® version 25.0. Descriptive statistics were used to analyze the demographic variables. Paired t tests were used to detect differences in the pre- and postintervention in ATOP and BAOP scores. No data transformations were performed to correct the violation of the normality assumption for repeated measure at baseline for any of the outcome measures. Statistical significance was set at p < .05.
All third-year nursing students (6 males, 119 female) eligible for the study consented to participate in the semester-long intervention, providing a sample of 125 for analysis.
ATOP Scale. Preintervention ATOP scores ranged from 38 to 110 with a mean score of 74.30 ± 14.61 and post-intervention ATOP scores ranged from 46–119 with a mean score of 84.54 ± 15.33 with higher scores demonstrating more positive attitudes toward individuals with obesity. The paired t-test comparing pre- and post-intervention scores revealed a significant improvement in attitudes toward individuals who were obese (t = −9.026, df = 113, p < 0.001). The size of this effect was moderate (d = 0.70).
BAOP Scale. Preintervention BAOP scores ranged from 3 to 37, with a mean score of 18.25 ± 6.80, and postintervention BAOP scores ranged from 7 to 45, with a mean score of 22.22 ± 7.87, with higher scores indicating a stronger belief that other factors may contribute to obesity and that obesity was not under one's control. The paired t test comparing pre- and postintervention scores revealed a significant improvement in beliefs regarding the controllability of obesity (t = −.7.202, df = 115, p < .001). More positive BAOP scores suggest fewer negative assumptions that individuals with obesity can control their weight status and other factors related to weight, such as genetics, may be considered. The effect size was moderate (d = 0.55).
Weight bias is pervasive in health care, and it is a priority for nursing students to receive education to mitigate bias as an essential component of their undergraduate nursing education. This CeWebs training program used an interdisciplinary teaching model with weight bias education, concurrent self-reflection of weight bias through reflective journaling, and structured debriefing, conducted over one academic semester. The research team used strategies to ensure that each student understood the negative impact of weight bias from a holistic and humanistic standpoint. This multicomponent approach was a robust and collaborative strategy to provide the educational component within an existing nursing course.
The findings of this study support previous research findings that indicate that undergraduate students who are exposed to weight sensitivity training exhibit improvements in both their attitudes toward and beliefs about patients with obesity (Barra & Singh Hernandez, 2018; Diedrichs & Barlow, 2011; O'Brien et al., 2010). The current study's findings are consistent with those of other studies using similar interventions, including a brief education component and the use of anti-obesity films to improve beliefs and attitudes toward individuals with obesity (Swift et al., 2013). This is the first study to embed weight sensitivity education over the entire semester in nursing clinical curriculum and use of two validated questionnaires to assess improvements in attitudes and beliefs about individuals with obesity.
Strengths and Limitations
Strengths of this study included the use of two validated questionnaires, which allowed the comparisons of findings with those of other studies, and a longer educational intervention than in previous studies. A limitation of this study included use of a convenience sample from a single academic institution, which limits the generalizability of the findings. Also, the design as a curriculum-based educational intervention precluded the ability to randomly assign students to intervention and control groups. Additionally, despite the intentional use of deception in which we did not disclose the nature of the intervention, the use of self-report questionnaires may inherently alter student responses due to perceived social desirability. Knowledge of the complexities of obesity may have also been gained through theory courses over the semester and may have influenced the findings. Future research may include enhancements to the methodology, such as the addition of weight bias dialogue during a clinical postconference to allow the clinical instructors to reinforce these concepts immediately following students' clinical experience. An introduction of weight sensitivity training earlier in the curriculum, possibly in theory courses, may potentially enhance the robustness of this training and may also capture whether the positive changes in attitudes and beliefs can be sustained beyond one semester. Additionally, this study focused on improving attitudes and beliefs but there was no measure of behavior change. Future interventions may benefit from simulations and unfolding case studies in which changes in student behavior can also be observed.
This study's findings suggest that increasing nursing students' awareness of the prevalence of weight bias in health care, including its detrimental effects, can be achieved through a weight sensitivity training program. Additionally, the findings suggest that providing weight bias education within the nursing curriculum at the start of students' clinical encounters with patients may improve their attitudes and beliefs toward patients with obesity. Insights gained from our study may inform curriculum and program directors about the importance of inclusion of more specific obesity-related training as part of undergraduate nursing education.
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