SWIPE: a conceptual, multi-perspective model for understanding and informing interventions for weight stigma in preconception, pregnancy, and postpartum

ABSTRACT

Weight stigma is salient across the preconception, pregnancy, and postpartum (PPP) periods because of prevailing prescriptive norms and expectations about weight and weight gain during the reproductive period. Weight stigma is associated with negative physical and psychological health outcomes for mother and child. A clearly defined, multi-level conceptual model for interventions, research, and policy is critical to mitigating the adverse effects of weight stigma in PPP populations. Conceptual models of weight stigma towards PPP women have advanced our understanding of this issue and guided evidence accumulation but there remains a gap in informing the translation of evidence into action. Guided by evidence-based paradigms for conceptual model development, this paper has two primary objectives. First, we review and summarise theories, frameworks, and models from the PPP population and general literature to inform our understanding of the development and perpetuation of weight stigma for PPP women. Second, we propose a novel comprehensive intervention-guiding conceptual model that draws from and synthesises across multiple disciplines – the SWIPE (Stigma of Weight In the PPP Experience) model. This conceptual model will help to plan coordinated, multi-layered, and effective strategies to reduce and ultimately eliminate weight stigma for PPP women.

KEYWORDS:

• Weight stigma
• preconception
• pregnant
• postpartum
• obesity
• conceptual model

1. Introduction

Weight stigma is characterised by negative weight-related attitudes and beliefs manifested by prejudice, rejection, and stereotypes towards individuals because they live in a larger body (Puhl & Brownell, 2001). Weight stigma impacts the physiological and psychological health of individuals who are living with overweight or obesity. A systematic review of the body of evidence indicates that weight stigma is associated with increased risk of obesity and diabetes, level of cortisol, oxidative stress level, C-reactive protein level, eating disturbances, anxiety, depression, body image dissatisfaction, and decreased self-esteem (Wu & Berry, 2018).

Weight stigma is the most encountered form of stigma among people living in larger bodies. This is particularly salient across the preconception, pregnancy, and postpartum (PPP) periods (Hill & Incollingo Rodriguez, 2020; Puhl & Brownell, 2001) due to two main reasons. The first reason is prevailing prescriptive norms and expectations about weight and weight gain during the reproductive period and the susceptibility of women to gain weight during the reproductive years. The second reason is the negative impact of weight stigma on the health of women and the next generation (Hill & Incollingo Rodriguez, 2020; Wu & Berry, 2018). Preconception, pregnant and postpartum women experience weight stigma in almost all social domains including fertility treatment, antenatal and postpartum healthcare, employment, education, media, from other mothers (i.e., their peers), and in romantic relationships (Fikkan & Rothblum, 2012; Incollingo Rodriguez et al., 2020). Weight stigma towards women of reproductive age is associated with decreased access to and uptake of reproductive healthcare, poor mental health, stress, poor health behaviours, and negative health outcomes for mother and child (DeJoy & Bittner, 2015; Faucher & Mirabito, 2020; Fikkan & Rothblum, 2012; Incollingo Rodriguez et al., 2019; Parker & Pausé, 2019; Ward & McPhail, 2019). The additive effect of these negative experiences, such as psychological stress, avoidance of healthcare, reduced motivation to engage in healthy behaviours, and disordered eating contributes to maternal obesity (DeJoy & Bittner, 2015; Faucher & Mirabito, 2020; Fikkan & Rothblum, 2012; Incollingo Rodriguez et al., 2019; Parker & Pausé, 2019; Tomiyama, 2014; Ward & McPhail, 2019).

The most ethical and effective approaches to combat weight stigma require a multi-faceted strategy that should address the action and attitudes of the people and organisations that do the stigmatisation. Although patient self-advocacy plays an important role in culture change, focusing interventions on perpetrators helps to avoid victim blaming and lessen the burden of change on those facing stigma (Pearl, 2018; Tomiyama et al., 2018). Future attempts to minimise and ultimately eradicate weight stigma should strive to take an integrative approach across various layers of society (Hill & Incollingo Rodriguez, 2020; Incollingo Rodriguez et al., 2020). However, only a small amount of literature has concentrated on non-healthcare settings such as the media and community settings (Hill & Incollingo Rodriguez, 2020). There is also a lack of research that explores the interaction between socioecological layers. Socioecological theories are one of a range of theories, models, and frameworks that have been used to deepen our understanding of weight stigma (Hill, 2021).

There is a growing evidence base supporting intervention strategies to reduce weight stigma (Kaufmann & Bridgeman, 2021; Lee et al., 2014; Talumaa et al., 2022). These include education on obesity and weight stigma, changing beliefs about the causes and controllability of obesity, evoking empathy, building social consensus, taking a weight-inclusive approach, or a combination of approaches (Gloor & Puhl, 2016; Kaufmann & Bridgeman, 2021; Lee et al., 2014; Talumaa et al., 2022). Weight stigma reduction interventions in general are effective but the effects vary based on factors such as the type of weight stigma, participants’ characteristics, or how the intervention was measured. Additionally, the effectiveness of these interventions can wane over time (Kaufmann & Bridgeman, 2021; Lee et al., 2014; Talumaa et al., 2022). Existing interventions focus on concepts such as causal attribution and social consensus theories (Puhl et al., 2005) but they do not necessarily look at multiple levels of stigma settings, or types of stigma and steps leading to stigma formation simultaneously. This helps us to recognise that standalone interventions targeting specific attributes or socioecological layers may have a limited impact on the long-term elimination of weight stigma. Also, the existing interventions have mostly not considered a whole range of theories and frameworks with potential utility for informing intervention strategies to reduce weight stigma.

Furthermore, existing interventions are designed to prevent weight stigma towards the general public and are not specifically designed for PPP women; there is a paucity of evidence regarding how to design interventions to reduce weight stigma in PPP populations. Guided by evidence-based paradigms for conceptual model development (Brady et al., 2020), this paper has two primary objectives. First, we review and summarise theories, frameworks, and models from the PPP population and general literature to inform our understanding of the development and perpetuation of weight stigma for PPP women. Second, we propose a novel comprehensive intervention-guiding conceptual model that draws from and synthesises across multiple disciplines – the SWIPE (Stigma of Weight In the PPP Experience) model. The SWIPE conceptual model will facilitate the building of a broad scientific foundation to inform future research and assist with identifying intervention goals to reduce weight stigma in PPP women. Moreover, understanding how best to tackle weight stigma against women of reproductive age across the diverse environments where it is experienced will help channel research and funding to where it will have the most impact. The SWIPE model offers a novel perspective on the existing weight stigma frameworks and models by helping as an intervention-guiding tool. It also incorporates outlooks from multiple disciplines and concepts to emphasise potential areas of intervention across socioecological layers, which is crucial given the nuanced nature of weight stigma.

Developing and applying a clearly defined, multi-level conceptual model for the development of interventions, research, and policy is critical to mitigating the adverse effects of weight stigma in PPP populations (Stangl et al., 2019). To date, the conceptual models of weight stigma specific to women of reproductive age have contributed significantly to our understanding of weight stigma in this population in a variety of ways. These models have highlighted various psychophysiological processes that connect weight stigma during pregnancy to an increased risk of weight gain (Incollingo Rodriguez & Nagpal, 2021). They have also shed light on the prevention of maternal obesity by addressing socioecological relationships, as well as the socioecological factors that structure weight stigma and the facilitators of stigmatisation. Furthermore, these models have highlighted the overall impact of weight stigma on women's health (DeJoy & Bittner, 2015; Hanson et al., 2017; Hill, 2021; Hill & Incollingo Rodriguez, 2020; Incollingo Rodriguez & Nagpal, 2021).

Existing conceptual models of weight stigma for PPP women often focus on specific goals for addressing or understanding weight stigma. For instance, the Weight gain, Obesity, Maternal-child Biobehavioral pathways, and Stigma (WOMBS) framework was made to guide hypothesis generation to test mechanisms through which PPP stigma confers maternal-child health risk (Incollingo Rodriguez & Nagpal, 2021). However, there remains a gap regarding a conceptual model to help translate evidence into action to combat weight stigma among PPP women. Therefore, we strive to contribute to theoretical advancements by developing a novel conceptual model to guide intervention. This model draws on and integrates multiple perspectives including social and psychological factors. We draw from and synthesise across multiple disciplines that pertain to PPP women including social stigma theories, feminist theories, and linguistic theories. Also, concepts related to stigma formation, types of stigma, and interrelationships between manifestation of stigma types are incorporated. Language theories help us to uncover the discursive practices that perpetuate weight stigma while feminist theories highlight the gendered aspects and intersections with other types of stigmatisation. Social stigma theory, on the other hand, emphasises the importance of social interaction and social processes in the formation and perpetuation of weight stigma (Goffman, 1963; Halliday, 1978; Osmond & Thorne, 1993).

2. Method to inform conceptual model development

A conceptual model is a visual representation showing the potential connections between different concepts that are believed to be relevant to a specific public health problem (Earp & Ennett, 1991). A research-oriented conceptual model summarises what a team has prioritised and chosen to study and is intentionally focused in scope compared to a framework (Brady et al., 2020). According to Brady et al. (2020), conceptual models that are based on socioecological frameworks and prioritise health equity and social justice principles can offer better guidance for prevention and intervention strategies (Brady et al., 2020). Our conceptual model aligns with this because it is based on theories and frameworks where the central focus is a socioecological approach and incorporates equity and justice lenses as discussed in feminist and language theories or communication models. Based on evidence-based paradigms for conceptual model development, we are guided by the three steps described by Brady et al. for developing a conceptual model: (1) identifying resources for idea generation; (2) considering risk and protective factors; and (3) selecting factors to be included in the conceptual model (see Figure 1) (Brady et al., 2020).

Figure 1. Diagrammatic presentation of the SWIPE conceptual model development based on Brady et al., 2020.

First, we conducted a search of databases for peer-reviewed articles and books published in English on OVID Medline, Embase, PsycINFO, Pubmed, ProQuest, and Google Scholar using the terms ‘Weight stigma’ OR ‘Weight bias’ AND ‘model’, OR ‘framework’ OR ‘theory’ AND preconception OR pregnan* OR postpartum OR postnatal’. We supplemented our search by adding well-known or seminal theories, models, and frameworks from the broader literature as well as drawing upon the literature from foundational research groups in the field (Step 1). The goal was not to conduct a systematic and complete review of the literature, but to synthesise across a wide range of useful theories/models/frameworks to enhance our knowledge and understanding of weight stigma.

Following the literature review we conducted in step one, we were able to synthesise and present evidence from the general stigma literature, theories, or concepts that may inform weight stigma from multiple disciplines (Step 2). The conceptual models and frameworks that are designed to enhance the understanding of weight stigma among PPP women were also discussed by the authors to facilitate decision making about which one(s) would inform our new model. Finally, we narrowed down and selected the concepts that can be included in our new conceptual model that would be used as a weight stigma intervention guiding tool (Step 3). The guideline by Brady et al. (2020) also suggests the consideration of three important factors that can enhance the usefulness of the conceptual model. These are ‘mechanistic factors’, ‘upstream factors’ and ‘effect modifiers’ (Brady et al., 2020). Mechanistic factors encompass biological, psychological, and social processes that elucidate the links between the outcome of interest and associated factors. Effect modifiers are elements that can impact the effectiveness of intervention practices or policies in particular communities. Upstream factors pertain to societal and structural practices that have connections to health outcomes (Brady et al., 2020). Accordingly, we discussed for potential inclusion in the model, a list of concepts relating to these factors, along with their potential relationships with other factors and with weight stigma (Figure 1). We also agreed on and applied definitions of the PPP periods to align with those presented in the reviewed articles. Specifically, preconception women refer to non-pregnant women or women with or without the intention to conceive or who are in the inter-conception period (Hill et al., 2020); pregnant women refer to women during the period of pregnancy; postpartum women refer to women within one year following childbirth (Endres et al., 2015).

3. Theories, models, and frameworks to inform weight stigma for PPP women

Below, we discuss key pertinent theoretical orientations including social stigma, linguistic and feminist theories, and socioecological models and frameworks identified during our literature search. Following, we propose a new comprehensive conceptual model that synthesises across these theories to help guide intervention efforts to mitigate weight stigma in the PPP periods.

3.1. What is stigma and how does it develop?

3.1.1. Social stigma

Stigma is generally defined by Erving Goffman (1963) to be an ‘attribute that is severely discrediting’. A discredited characteristic could be obvious, like one's skin tone or size, or it could be concealed yet still be revealed to be discreditable, like a criminal past or mental health issues (Goffman, 1963). According to Goffman, stigma complicates regular social interactions; the stigmatised person may be reserved from engaging with those without stigma, and those who do not share that stigma may ridicule, overcompensate for, or try to disregard stigmatised individuals (Goffman, 1963). Goffman also mentioned three categories of individuals concerning stigma as ‘the stigmatised’, ‘the normals’, and ‘the wise’, referring to those with stigma, those without stigma, and those accepted by the stigmatised people as accepting and understanding, respectively (Goffman, 1963). Goffman emphasised stigma as the phenomena between an individual and a social situation with a specific set of expectations; this concept gets backing from other scholars that stigma occurs in social interactions and is contextual (Crocker et al., 1998).

The consequences of stigma were also the part of Goffman’s theory of social stigma mentioning that the stigmatised are devalued, disregarded, and even encounter discrimination in housing and employment realms (Goffman, 1963). This is well captured by researchers in the field where women living with overweight or obesity reported experiencing stigmatisation and humiliation in societal domains including at health facilities, employment discrimination at workplace settings, and via interpersonal relationships (Obara-Gołębiowska, 2016; Sercekus et al., 2024). This stigmatisation is frequently due to pervasive misconceptions that people with obesity are unmotivated, lacking in self-control, and careless (Puhl & Brownell, 2001; Puhl & Brownell, 2003). These stereotypes are rarely challenged, making people living with overweight or obesity susceptible to biased treatment, social injustice, and diminished quality of life due to significant disadvantages and bias (Puhl & Heuer, 2009).

3.1.2. How does stigma develop?

Labelling theory constructs stigma as a sequential process occurring by the convergence of four interrelated components (Link, 1989; Link & Phelan, 2001). In the first part, individuals identify and label people’s distinctions. In the second, prevailing cultural ideas associate labelled individuals with undesirable traits and unfavourable stereotypes. In the third, labelled individuals are grouped into different categories to achieve some level of ‘us’ versus ‘them’ separation. At last, the labelled individuals face status loss and prejudice that results in unfair outcomes (Link, 1989; Link & Phelan, 2001).

We hypothesise that the stigma formation steps are applicable to describe how stigma is formed towards PPP women living in larger bodies. Accordingly, first, people distinguish and label women living in larger bodies. Then, the prevailing societal norms of thin ideals link women in larger bodies to negative stereotypes. Thirdly, women in larger bodies are grouped into different categories to achieve some level of ‘us’ versus ‘them’ separation. Consequently, women living in larger bodies face stigma and discrimination affecting their social relationships, healthcare seeking, and employment opportunities (Hill & Incollingo Rodriguez, 2020; Obara-Gołębiowska, 2016; Sercekus et al., 2024).

On the other hand, Tomiyama (2014) theorised the cyclic nature of weight stigma formation in the Cyclic Obesity/Weight-Based Stigma (COBWEBS) model. The COBWEBS model posits that weight stigma is a stressor that will provoke physiological, behavioural, and emotional reactions that eventually lead to weight gain or difficulty in losing weight, hence exposing people to further weight stigma (Tomiyama, 2014). Grounded in the same logic model, the Weight gain, Obesity, Maternal-child Biobehavioral pathways, and Stigma (WOMBS) Framework brought an intergenerational lens resting on the known interconnectedness between maternal and child obesity. The framework posits how experiences of weight stigmatisation in the mother engage physiological and behavioural mechanisms to promote obesity in the child (Incollingo Rodriguez & Nagpal, 2021). For instance, hypothesised in this framework, weight stigma may cause prenatal complications by altering health behaviours and physiology, leading to increased maternal weight gain and subsequently increasing the risk of childhood obesity (Incollingo Rodriguez & Nagpal, 2021).

3.2. Feminism theories informing stigma: postmodern feminism theory

Feminist theory analyses women's subordination to find ways to change it (Osmond & Thorne, 1993). Postmodern feminism is applicable to inform weight stigma among women particularly as it emphasises how societal discourse shapes societal assumptions about how women should be treated (Ebert, 1991). It is documented that weight stigma is three times more prevalent among women compared to men with similar levels of weight (Puhl et al., 2008). This discrepancy is believed to result from society’s thinness norms, expectations for women to be thin, fit, and perfect as well as cultural-specific issues of social inequality (Faucher & Mirabito, 2020; Krems & Neuberg, 2022; Puhl et al., 2008). The physical appearance of women is a topic of constant criticism, evaluation, and judgment from others (Chrisler & Johnston-Robledo, 2018). Women are constantly being told how their bodies should appear, behave, and perform from a variety of sources, including the healthcare system, the media, and society more broadly (Chrisler & Johnston-Robledo, 2018).

On a similar note, Wooley et al. (1979) contend that fat is a feminist issue given that women are generally allowed to deviate from aesthetic ideals much less than men. As a result, more women end up feeling unsatisfied with their bodies and devote themselves to various ‘corrective’ behaviours, such as restrictive dieting. It is also observed that women pay a ‘price’ for having aberrant bodies in the form of discrimination in addition to the impact on their psychological and emotional health (Fikkan & Rothblum, 2012; Wooley et al., 1979).

3.3. Language theories and communication models informing stigma

3.3.1. Social semiotics

Social semiotics is a theoretical framework that explores how meaning is created (Halliday, 1978). According to this theory, when we listen, read, speak, or write, we are drawing on systems of culturally constructed meaning from which we simultaneously make our choices (Halliday, 1978). In the context of weight stigma, social semiotics can help explain how societal body meanings and interpretations surrounding weight contribute to the stigmatisation of individuals living in larger bodies (Goffman, 1963; Halliday, 1978). Body weight is linked with societal and cultural meanings that presume evaluative qualities of one's identity; it can be a challenging and sensitive subject to communicate about (Goffman, 1963; Halliday, 1978; Swami, 2015). People's self-perceptions, attitudes, and behaviours can be impacted by how they are spoken about their body weight (Watts & Cranney, 2010).

One of the social domains in which weight stigma is perpetuated is social media (Puhl, 2022). The communication in social media directly shames and stigmatises individuals living in larger bodies using negative language and blaming individuals for a lack of self-control or purposefully aiming derogatory humour at individuals based on their body size. Also, the proliferation of information and images promoting unrealistic thinness ideals fuelled by the anonymity of social media are additional communication content cues for perpetuating weight stigma (Wanniarachchi et al., 2020).

We hypothesise that social semiotics can be used to explain how weight stigma in PPP women is learned and reinforced in society as a process of meaning-making across all socioecological layers. For instance, the societal thinness norms, stereotypes about women in larger bodies, and forcing women to bounce back to pre-pregnancy body weight (Hill & Incollingo Rodriguez, 2020; Incollingo Rodriguez et al., 2020) all set a tone of how people should understand women’s body weight and then reinforce weight stigma in society. Furthermore, the lack of representation of women with obesity in the media and the causal attribution of obesity to poor diet and physical activity practices, even by healthcare professionals (Incollingo Rodriguez et al., 2020; Nippert et al., 2021), all contribute to societal meaning-making regarding obesity, and about women with obesity, which then lead to weight stigma.

3.3.2. Model of stigma communication

The Model of stigma communication alludes to the messages that are disseminated throughout communities to help their members identify those who are stigmatised and respond accordingly (Smith, 2007). It illustrates that stigma messages are characterised by signals that lead to the formation of stereotypes, and stigmatising attitudes. When people come across such stigmatising messages, they tend to share them with their group members because stigma-related messages provide in-group solidarity and distinction from others (Smith, 2007). This is true in the case of media as well, where the frequent stigmatisation of individuals living with obesity in the media leads to the audiences misjudging the degree that others share negative attitudes towards people living with obesity and ultimately reflects prejudiced stereotypes (Puhl & Brownell, 2003). Stigmatising messages, therefore, inform and enable social categorisation, labelling, rejection, and discrimination of the stigmatised people (Link & Phelan, 2001).

Public health messages and campaigns frequently contribute to weight stigma (Hunger et al., 2020). For instance, Turner et al. (2020) reported that nearly half (44%) of campaigns targeting obesity in the United States include stigmatising content (Turner et al., 2020). This phenomenon is driven by assumptions about the connection between weight and health, the perception of weight as largely within individual control, and the belief that stigmatisation can effectively motivate positive behavioural changes (Hunger et al., 2020). Nevertheless, evidence consistently indicates that experiencing weight stigma increases the probability of engaging in unhealthy eating habits and reducing levels of physical activity (Puhl & Heuer, 2010).

Likewise, it has been well articulated in the weight stigma literature that communication, either verbal or nonverbal, is one of the important ways people use to perpetuate stigma towards people living with obesity and this is true for PPP women as well (Puhl & Heuer, 2009). For instance, the use of pejorative language, and framing the women responsible for their larger bodies, a rare portrayal of women with obesity, and negative headlines in the media were commonly reported, making PPP women feel humiliated, stigmatised, and discriminated against (Hill & Incollingo Rodriguez, 2020; Incollingo Rodriguez et al., 2020; Nippert et al., 2021; Sercekus et al., 2024).

3.4. Systems approaches and the socioecological model

The Socioecological Model (SEM) is a beneficial framework unfolding a systems approach on a range of societal levels. This model recognises and articulates the relationship between the individual and their environment (Bronfenbrenner, 1977; Bronfenbrenner, 1992). Systems theories assist in identifying several levels of influence and interacting components that can alter or adapt in reactions to one another or external factors (Bagnall et al., 2019). The socioecological model is a type of systems approach (Bronfenbrenner, 1977; Bronfenbrenner, 1992). The first theory proposed by Bronfenbrenner used nesting circles, which put the individual at the centre surrounded by several systems (Bronfenbrenner, 1992). These systems encompass relationships within the immediate environment, organisations with which an individual directly interacts, community contexts, societal values, and policy frameworks (Bronfenbrenner, 1986; Bronfenbrenner, 1992).

The socioecological model is useful to show the big picture of weight stigma. For instance, the Health Stigma and Discrimination Framework describes the stigmatisation process across the socioecological layers (Stangl et al., 2019). According to this framework, the stigmatisation process can be divided into several constituent domains, such as drivers and facilitators, stigma ‘marking’, and stigma manifestations. It also highlights the impact of weight stigma on the affected populations as well as on organisations and institutions, which in turn have an impact on health and society (Stangl et al., 2019). This is endorsed by a recent review highlighting that PPP women experience weight-based stigmatisation across all the socioecological layers (Hill & Incollingo Rodriguez, 2020).

Additionally, according to a survey conducted with pregnant and postpartum women living with obesity, it was found that women face weight stigmatisation from multiple sources such as family and friends, at the workplace, at church, from healthcare providers, media, strangers, and society in general (Incollingo Rodriguez et al., 2020; Puhl & Heuer, 2009). Therefore, consideration of systems approaches and socioecological perspectives would be helpful in designing an effective multipronged intervention strategy that is applicable to tackle weight stigma across each socioecological layer.

4. The stigma of weight in the PPP experience (SWIPE) conceptual model

The SWIPE conceptual model was developed to guide interventions that help to mitigate weight stigma among PPP women using an evidence-based paradigm for conceptual model development as a guide (Brady et al., 2020). It draws from and synthesises across multiple disciplines that acknowledge the complexity and multifaceted nature of weight stigma. The conceptual model represents the processes, the psychological aspects, and the social factors underlying weight-based stigmatisation among PPP women across socioecological layers (Figure 2). Informed by the theories, frameworks, and models discussed above, the SWIPE conceptual model synthesises linguistic and feminist theories to emphasise the importance of language, meaning-making, and gender in the formation and perpetuation of weight stigma. The model also highlights social stigma as a core and a catalyst for other types of stigma (Hebl & Dovidio, 2005). Additionally, predictors and moderators of weight stigma, stigma formation steps, and types of stigma are represented (Figure 2). The socioecological layers across which stigma forms overlay the entire framework. Below, we unpack the components of the model and explain their importance in the PPP context.

Figure 2. The SWIPE conceptual model demonstrates the factors and steps that lead to weight stigmatisation, and types of stigma, which lead to its impact on PPP women across socioecological layers. The arrows between the panels indicate the relationship between each concept.

4.1. Predictors of weight stigma

The model proposes that the predictors of weight stigma (Figure 2; first panel) include causal attribution of obesity, societal norms, and lack of knowledge. Lack of knowledge relates to a lack of awareness of stigmatising behaviour and/or a lack of understanding of how to provide care for women in larger bodies. These predictors play a role in the formation of weight stigma (Hill & Incollingo Rodriguez, 2020; Low et al., 2003; Stangl et al., 2019).

Causal attribution of obesity, (i.e., others attributing women’s weight to their character by presuming individuals have self-control over their weight (Puhl & Brownell, 2003)) often results in blaming women for their weight, which then leads to stigmatisation (Furber & McGowan, 2011). Societal norms, on the other hand, are socially constructed and shared beliefs that a person should act in a certain way (Link & Phelan, 2001; Low et al., 2003; Rimal & Lapinski, 2015). Societal norms towards PPP women often manifest in common ways. These include expecting women to meet societal thinness ideals before being ‘worthy’ of becoming pregnant, making negative remarks about gestational weight gain, and pressuring women to bounce back to pre-pregnancy body weight. These societal norms shape people's interpretations and evaluations of body weight and lead to the development of weight stigma (Low et al., 2003; Stangl et al., 2019).

Lack of awareness of stigmatising behaviour can be seen in the case of implicit weight bias or the absence of an accommodating environment where, in both cases, the stigmatiser unconsciously practices a stigmatising behaviour (Hill & Incollingo Rodriguez, 2020; Sabin et al., 2012; Stangl et al., 2019). For instance, PPP women may encounter subtle stigmatising behaviours through nonverbal expressions (e.g., lack of eye contact) or they may feel compelled to conform to an environment that does not accommodate their specific needs (DeJoy et al., 2016; LaMarre et al., 2020; Sercekus et al., 2024; Tomiyama et al., 2018). Furthermore, healthcare professionals report low confidence and poor knowledge of how to comfortably provide treatment for larger-bodied women, which impacts the quality of care and the doctor-patient relationship (Christenson et al., 2018; Furness et al., 2011).

4.2. Moderators of weight stigma

The second panel in the model refers to factors that moderate the relationship between the predictors and stigma formation. Evidence indicates that demographic characteristics such as race and socioeconomic status, body mass index (BMI) or adiposity, and weight self-perception may influence the degree to which PPP women experience weight stigma (DeJoy & Bittner, 2015; Hill & Incollingo Rodriguez, 2020; Himmelstein et al., 2015; Incollingo Rodriguez & Nagpal, 2021). For instance, women with an elevated BMI would experience more weight stigma compared to those with a lower BMI. Also, whether PPP women would perceive weight stigma depends on how they perceive their weight (Himmelstein et al., 2015; Incollingo Rodriguez & Nagpal, 2021). An individual’s (e.g., general public) self-perceived weight also moderates the perpetuation of weight stigma toward PPP women (Elran-Barak & Bar-Anan, 2018). This means individuals tend to exhibit stigmatising behaviours towards people with larger bodies when they perceive themselves as thin or not living with obesity compared to those who perceive themselves as larger-bodied (Elran-Barak & Bar-Anan, 2018; Tajfel & Turner, 1986).

4.3. Stigma formation

The process of stigma formation is depicted in the model (Figure 2; third panel) drawing from modified labelling theory, the conceptualisation of stigma, and definitions of a social stigma (Goffman, 1963; Link, 1989; Link & Phelan, 2001). Stigmatisation is a consecutive process. It begins with labelling PPP women at a higher risk of infertility or pregnancy-related complications due to their body size (Furber & McGowan, 2011; Link & Phelan, 2001). This labelling leads to stereotyping of PPP women which includes forming (incorrect) assumptions about lack of control with eating, excessive gestational weight gain, and mother blame discourse (Furber & McGowan, 2011; Jarvie, 2017; Link, 1989). Next, the categorisation of ‘us’ versus ‘them’ occurs which results in a sense of isolation from general society. Preconception, pregnant and postpartum women often experience this in the form of receiving unwelcome stares from the public or social exclusion (Furber & McGowan, 2011; Obara-Gołębiowska, 2016). This categorisation is also evident in the media by either lack of or inappropriate portrayal of PPP women living with obesity (Heslehurst et al., 2022; Link, 1989).

The final step in stigma formation includes status loss, stigma, and discrimination (Goffman, 1963; Link, 1989; Link & Phelan, 2001). Preconception, pregnant, and postpartum women often experience status loss in the form of denial of their individual needs and by a disproportionate emphasis on fetal well-being rather than considering the health of both the mother and fetus (Bombak et al., 2016; Furber & McGowan, 2011; LaMarre et al., 2020). Moreover, discrimination against women based on their body size is often experienced in the form of receiving sub optimal care observed at health facilities or evident via limited employment and educational opportunities (Link, 1989; Obara-Gołębiowska, 2016). These steps of stigma formation help to envision and thereby more fully understand several important issues and processes in the concept of stigma and thus represent a potential point of intervention (Link & Phelan, 2001).

4.4. Types or manifestations of stigma

The model also dictates the types or manifestations of stigma (Figure 2; Right-hand panel) based on Pryor and Reeder’s (2011) conceptual model of the manifestation of HIV- related stigma (Pryor & Reeder, 2011). Pryor and Reeder’s (2011) conceptual model illustrates four interconnected and dynamic types of stigma (Pryor & Reeder, 2011); and we hypothesise that this concept can be applicable to describe the manifestations of weight stigma among PPP women. Once stigma is formed, it can be expressed in various forms across each socioecological layer (e.g., intrapersonal, interpersonal, community, organisational, and policy). These four interrelated manifestations of stigma include social or public stigma, self-stigma or internalised stigma, stigma by association, and structural stigma (Bos et al., 2013; Pryor & Reeder, 2011). To effectively address stigma, it's important to have a comprehensive understanding of its various forms and how they relate to one another. This knowledge can inform a coordinated, multi-layered intervention strategy (Heijnders & Van Der Meij, 2006). Preconception, pregnant, and postpartum women have reported experiencing all four types of stigma, despite the limited research focused on this period (Hill & Incollingo Rodriguez, 2020).

Social stigma represents social and psychological reactions to women living in larger bodies and might lead to internalised or self-stigma (Bos et al., 2013; Pryor & Reeder, 2011). The pervasiveness of ‘fatphobia’ in society, societal pressure to maintain a thin figure (such as ‘shedding the baby weight’), and treatment of PPP women as ‘’less than’’ are all examples of a social stigma (Hill & Incollingo Rodriguez, 2020; Incollingo Rodriguez et al., 2020). Internalised stigma, on the other hand, constitutes both the apprehension of being stigmatised and the potential internalisation of the stereotypes associated with living with overweight or obesity as a woman (Bos et al., 2013).

The third type of stigma, which is stigma by association, is analogous to Goffman’s courtesy stigma (Goffman, 1963; Pryor & Reeder, 2011). It involves both the psychological and social reactions towards individuals related to stigmatised people (e.g., family and friends) as well as responses of individuals to being linked to a stigmatised person (Hebl & Mannix, 2003). Even though stigma by association has been studied in mental health related areas (Yin et al., 2020), further research is needed to explore the experiences of stigma toward family and its consequences concerning PPP women.

Structural stigma includes the perpetuation and legitimisation of weight stigma by societal institutions like healthcare, media, workplace, and ideological systems (Pryor & Reeder, 2011). It also includes the lack of legal accountability of the perpetrators and the lack of legislation to prevent weight stigma (Pryor & Reeder, 2011). Structural stigma in the context of PPP needs further investigation, albeit women claim policy and structural factors as common sources of weight stigmatisation (Hill & Incollingo Rodriguez, 2020; Incollingo Rodriguez et al., 2020; Incollingo Rodriguez et al., 2020). Examples of this in PPP women include inadequate services and facilities for women in larger bodies at health facilities, gymnasiums, and workplaces (Faucher & Mirabito, 2020; Holton et al., 2017; Myre et al., 2021; Obara-Gołębiowska, 2016).

The four types of stigma are associated, interconnected, reinforce each other, and may be manifested in more than one socioecological layer (Hill, 2021; Pryor & Reeder, 2011). However, social stigma is believed to be the basis of other forms of stigma, as it is created and perpetuated through social interactions (Bos et al., 2013; Goffman, 1963; Hill, 2021; Pryor & Reeder, 2011). In addition, social stigma occurs at multiple socioecological layers and it reinforces the other forms of stigmatisation (Hill, 2021; Pryor & Reeder, 2011). Furthermore, empirical research on the interrelationships of different types of stigma and the efficiency of focusing interventions on social stigma is needed (Bos et al., 2013). Finally, the model acknowledges that weight stigma enacted against PPP women from various sources impacts the health of the mother and her children. For instance, it may lead to poor birth outcomes, poor maternal and child health, increased risk of childhood obesity, and, the intergenerational perpetuation of weight stigma (DeJoy & Bittner, 2015; Hill & Incollingo Rodriguez, 2020; Incollingo Rodriguez & Nagpal, 2021).

5. Discussion

The SWIPE conceptual model aims to inform interventions to reduce and ultimately eliminate weight stigma for PPP women. It brings a novel approach to guide intervention development that targets weight stigma perpetuated towards PPP women by synthesising evidence and concepts from multiple disciplines and by taking multiple psychological and sociological factors into consideration. To date, weight stigma reduction interventions are mainly concentrated in healthcare settings or targeting healthcare professionals or students (Kaufmann & Bridgeman, 2021; Lee et al., 2014; Talumaa et al., 2022). However, weight stigma is reported to be pervasive across all socioecological layers (Puhl & Brownell, 2001). Also, to our knowledge, there are no interventions that are specifically designed to reduce weight stigma towards PPP women (Kaufmann & Bridgeman, 2021; Lee et al., 2014; Talumaa et al., 2022). Due to the role of weight stigma in undermining physical and psychological health, understanding and addressing weight stigma is essential for promoting better health outcomes and improving the well-being of the large-bodied PPP women who are affected by it and their children.

The complexity and pervasiveness of weight stigma require a strategic and efficient guide to target multiple levels of influence and that is exactly what is highlighted by the SWIPE conceptual model. For instance, SWIPE will help to guide the development of interventions that target the predictor level such as demographic factors, beliefs, and attitude-related attributes. Simultaneously, interventions that prevent the formation of weight stigma or that target stigma at either intrapersonal, interpersonal, organisational, broader societal, or policy levels can be designed.

The SWIPE model is specifically tailored for women considering the societal norms and expectations regarding body image, particularly during significant life stages such as preconception, pregnancy, and postpartum, which often exert unique pressures on women. Our model also acknowledges and addresses the gender-specific aspect of weight stigma and guides the design of more targeted and effective interventions to alleviate its impact on women’s psychological and physical well-being. Generally, the SWIPE model recognises the diverse experiences of PPP women across each socioecological layer and this would be helpful to inform more nuanced interventions that align with their specific needs. It is possible, however, that this model may have applicability to other populations, albeit further exploration and testing of this is necessary.

One of the common intervention areas reported in the weight stigma prevention literature is to increase awareness of people about the controllability of obesity. However, studies reported mixed evidence of these interventions’ effectiveness in reducing weight stigma (Daníelsdóttir et al., 2010). According to SWIPE, ‘predictors’ which included controllability (causal attribution) of obesity, lack of knowledge, and societal norms are a relevant area for weight stigma intervention. If we applied the SWIPE model to guide these interventions, our focus should also include targeting societal norms, such as thin body ideals and societal discourse about women's body weight. This helps to concurrently target social stigma which is one of the manifestations of weight stigma. Additionally, we should emphasise creating awareness of weight stigma and its impacts on stigmatised individuals to achieve better outcomes. Doing so will help to target the weight stigma formation steps and social stigma, concurrently.

The same applies to interventions designed to reduce weight stigma in healthcare settings. A recent review by Talumaa and colleagues (Talumaa et al., 2022) identified several weight stigma interventions in health care and among them are increasing education and targeting beliefs about causal attribution of obesity. According to the SWIPE model, the following additional factors would be considered when designing those interventions. Firstly, interventions that target the weight stigma norms within the health facility (for instance, overmedicalisation of obesity) would be relevant. Secondly, interventions that equip the professionals (e.g., communication skills) and improve their interaction with people living with obesity should be designed. Thirdly, strategies that target the structural stigma would be relevant in a healthcare context. This could be done by focusing on structural factors such as creating an inclusive healthcare environment and inclusive policies. Consideration of these factors could contribute to improved attitudes and mitigating of negative stereotypes towards people with obesity.

Additionally, one of the limitations reported by many existing interventions for reducing weight stigma is that the effect of the interventions diminishes over time, and individuals tend to go back to their prior level of attitude or bias towards people with overweight or obesity (Kaufmann & Bridgeman, 2021; Lee et al., 2014; Talumaa et al., 2022). Researchers therefore recommended that a combination of the intervention strategies may be helpful (Kaufmann & Bridgeman, 2021; Lee et al., 2014; Talumaa et al., 2022). We hypothesise that our model addresses this goal by guiding the development of complex interventions across socioecological layers with the potential for lasting effects that influence policy reforms, structural changes in institutions, and societal norms.

Furthermore, we believe that the SWIPE model is poised to make a significant contribution to the elimination of weight stigma among PPP women. Its strength lies in its integration of a socioecological perspective, health equity, and social justice principles, and relevant concepts from multiple disciplines. These are characteristics highlighted to be relevant and impactful when developing a conceptual model (Brady et al., 2020). The SWIPE conceptual model is intended to supplement rather than replace current frameworks, models, or theories in informing stigma reduction interventions. Prospectively, researchers can use this conceptual model to further explore and intervene to address weight stigma among PPP women. In doing so, they consider the importance of gender as well as social meaning-making, which involves how individuals derive meaning within a social context (Halliday, 1978; Osmond & Thorne, 1993). This is important in weight stigma because it gives an insight on how weight stigmatisation practices towards women are learned and reinforced in society. Also, in the future, researchers can build on and update the SWIPE model iteratively as the evidence base grows regarding weight stigma reduction interventions in the preconception, pregnancy, and postpartum periods.

Given the evidence highlighting the role of weight stigma in poorer health behaviours, there may also be scope for future research to explore the application of SWIPE to interventions to improve diet and physical activity behaviours in PPP women. However, we wish to highlight that interventions focusing on weight gain restriction or weight loss would not be considered in alignment with stigma reduction or weight-inclusive approaches to health (Hunger et al., 2020).

Furthermore, it may be appropriate for the SWIPE conceptual model to be used as a framework to support systematic reviews of evidence, such as in framework synthesis. To make the method explicit, the ‘best fit’ framework synthesis process could be used as an example (Booth & Carroll, 2015). For example, in framework synthesis, data extraction and coding of weight stigma interventions across any of the PPP periods could be conducted, and mapped against the constructs of SWIPE. If new concepts are identified, these may be evaluated for addition to and further improvement of the model in the future.

A limitation of this conceptual model was that we only included articles that were published in English due to resource constraints. This leads to a risk of missing information on unknown intersectional factors. However, the SWIPE conceptual model takes intersectional factors into consideration as ‘moderators’ of weight stigma.

6. Conclusion

There remain gaps in our understanding of weight stigma across the reproductive life period, the influence of social stigma among PPP women, and its relationship with other stigma types. Also, weight stigma towards PPP women across socioecological layers outside healthcare is an emerging area of inquiry. The SWIPE model responds to these gaps and provides a new way to conceptualise and address weight stigma across socioecological layers by recognising theoretical and scientific foundations not previously considered. Theoretical perspectives from multiple disciplines including language theories and feminist theories have informed key aspects of the model. The importance of social interaction, societal norms, social aspects of people’s interpretation of circumstances, and social assignment of gendered roles are elucidated. It is crucial to consider a systematic and integrated approach that synthesises across multiple disciplines and is underpinned by a socioecological viewpoint when approaching weight stigma among PPP. Such an approach will help overcome current issues with addressing weight stigma for women due to the complexity and pervasiveness of weight stigma across each socioecological layer. Furthermore, our model has the potential to contribute new knowledge that may weaken the cycle of weight stigma across the reproductive life phase with far reaching implications for physical and psychological health. Interventions based on evidence and comprehensive conceptual models may help to successfully reduce and eventually eradicate all forms of weight stigma. This eradication will both directly and indirectly improve psychological wellbeing, ensure equitable access to care, and encourage healthier behaviours – all of which contribute to improvement in the overall physical and mental health outcomes of PPP women and their children.

Acknowledgments

We would like to acknowledge all the researchers whose work served as stepping stones for the development of this conceptual model.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by an Australian Research Council Discovery Project (DP220101107); and Monash University MGS and MITS scholarships. BH is funded by an Australian Research Council Discovery Early Career Researcher Award (DE230100704).