Obesity, stigma, and responsibility in health care: A synthesis of qualitative studies

Figures & data

Table I. Features of the 13 primary studies included in the analysis.

Source paper (N=13)	Country	Study design	Analysis method	Sample origins	Participants (N)	Age range (years)	First author's background
Brown et al. (2006)	UK	Individual interviews	Generic^a	Obese patients, primary care	28	19–77	Nurse
Brown and Thompson (2007)	UK	Individual interviews	Generic	Nurses, primary care	15	28–57	Nurse
Diaz et al. (2007)	USA	Focus groups	Not specified	Obese adult Latinos	21	22–81	Unknown
Epstein and Ogden (2005)	UK	Individual interviews	Intepretative phenomenological analysis	GP primary care	21	30–60 +	GP
Mercer and Tessier (2001)	UK	Individual interviews	Generic	GPs and practice nurses	10 + 10	<55	Unknown
Merrill and Grassley (2008)	USA	Individual interviews	Phenomenological approach	Obese patients, primary care	8	20–61	Nurse
Reed (2003)	USA	Single case autobiography	Narrative	Obese adult	1	Unknown	Patient
Robbins (2007)	USA	Single case history	Narrative	Nurse encountering obese woman giving birth	1	Unknown	Nurse
Rogge et al. (2004)	USA	Individual interviews	Phenomenology	Obese patients and family, employed in healthcare	18	24–57	Nurse
Thomas et al. (2008)	Australia	Individual interviews	Constant comparative method	Obese adults, recruited from newspaper	76	16–72	Unknown
Wear et al. (2006)	USA	Focus groups	Generic	Medical students	58	Unknown	Unknown
Whitfield and Grassley (2008)	USA	Individual interviews	Hermeneutic phenomenology	Nurses	12	20–59	Nurse
Wright (1998)	UK	Individual interviews	Generic	Nurses	10	Unknown	Nurse

GP, general practitioner.

^aThe term “generic” has been used when several different references to analysis method, or when procedures for analysis were described step by step in a more general sense.

Table II. Example of grid for reciprocal translation: content issues from the primary articles about life style advice perceived as humiliating.

Brown et al. (2006)	Rogge et al. (2004)	Merrill and Grassley (2008)	Wright (1998)	Brown and Thompson (2007)	Thomas et al. (2008)	Reed (2003)	Diaz et al. (2007)	Epstein and Ogden (2005)	Our translation	Stigma pattern
(1) Your weight is a problem. (2) Minimal support was offered along with practical advice	It ought to be easy to lose 20 pounds before the operation	Well, you just have to stop eating	Fat is unhealthy and poses serious risks, go home and lose weight before surgery			Just drink more water and push yourself away from the table			Well, you just have to stop eating	Apparently proper advice, probably well-intended—yet perceived as patronizingwell-intended—yet perceived as patronizing
(1) Strong sense of personal responsibility. (2) Imagine the worst must be thought about them	(1) Obese people agree with the construction of obesity as their own fault. (2) Assume obesity is due to overindulgence and eating out. (3) The doctor will not be thrilled to hear that I have gained	Persistence of trying to control or lose weight		The importance of personal lifestyles	All participants had attempted to lose weight numerous times in their lives		Familiarity with weight loss methods and failed weight loss attempts	(1) A problem that had been caused and should be managed by the patients themselves, (2) Patients can be in denial, reluctant to accept responsibility, want the doctor to take ownership	The personal responsibility of obesity
They are putting everything down to your weight		Having their weight addressed instead of the health problem							Attributing any problem to body weight

Table III. Synthesis (second- and third-order analysis).

Themes	Second-order analysis		Third-order analysis
Lifestyle advice experienced as humiliating	Well, you just have to stop eating The personal responsibility of obesity Attributing any problem to body weight	Apparently appropriate advice, perhaps well intended—yet perceived as patronizing	Responsibility and blame: Providers think patients do not recognize the nature of the problem Patients express a strong sense of personal responsibility
Segregation due to weight norms	Why bother me with your extra kilos? Struggling to fit in—you do not belong here	Abnormal bodies cannot be incorporated in the medical systems—exclusion consequently happens	Stigma—internalized contempt: Subtle derogatory comments from providers Vulnerability and experience creating negative expectations in patients
Derogatory comments	Disdain for the unattractive obese body Bad people who deserve reprimands	Customary standards for interpersonal respect are legitimately surpassed—contempt as if deserved