A Web-Based Training Approach to Impacting Providers’ Attitudes Toward Obesity Care

Obesity bias is on the rise in the United States. Nearly one-third of the adult population is affected by obesity. Unfortunately, this population often experiences attitudes of bias in a multitude of settings, particularly in health care. Health care providers who have bias against individuals with obesity can hinder efforts in fighting the obesity epidemic. Providers can implement a variety of strategies to help reduce weight stigma and improve their own attitudes. One way of helping providers is through continued education. Web-based training is one method to assist providers in professional development. This pilot study focused on helping providers to identify personal bias towards obese patients through an online self-paced educational tool, raise awareness of weight bias, and support evidence-based solutions. This study used a pre-test/post-test design to measure changes in attitudes toward obese patient care using the Attitude Toward Obese Patient (ATOP) survey (Allison, Basile & Yuker, 1991).

Providers including physicians, nurse practitioners and physician assistants completed the pre- and post-survey. Participants completed an online eight-week educational tool. Results indicated that while there was no statistical significance, the educational intervention impacted female providers more than male providers. Web-based training activities are helpful and demonstrated increased self-obesity stigma awareness among providers.

Introduction

Obesity is a significant health problem in the United States. According to the Centers for Disease Control and Prevention (CDC, 2018) about 93.3 million American adults are impacted by obesity. Obesity prevalence for adults 20 to 39 years was reported at 35.7%, 40 to 59 years at 42.8%, and 60 and older at 41% (CDC, 2018). The CDC (2017) identified adults as overweight or obese when their weight is greater than what is considered as a healthy weight for an individual’s height. Adults with a body mass index (BMI) of 30.0 or higher fall within the obese range. Obesity can also be divided into subcategories. Class one obesity is defined as an adult with a BMI between 30 to 34. Adults with class two obesity have a BMI of 35 to less than 40, and those with class three obesity have a BMI of 40 or greater. Those who are class three have “severe” or “extreme” obesity (CDC, 2017).

Obesity is also one of the most significant drivers of preventable chronic diseases and healthcare costs in the U.S. Obesity-related healthcare cost in the U.S. is over $150 billion annually (Smigelski-Theiss, Gampong, & Kurasaki, 2017). Medical expenses are far greater for those impacted by obesity. For example, an obese adult patient will pay more than $1,400 on average for care compared to those patients with normal weight (CDC, 2018). Obesity is associated with severe health risks, and there is a strong correlation between obesity, morbidity, and mortality. Health care institutions and providers need to promote and implement public health programs that focus on reducing and/or preventing obesity. Despite increased attention on the obesity epidemic, little has been done to address the bias and discrimination that people with obesity face every day (The Rudd Centre for Food Policy and Obesity, 2017).

Technology is one potential solution to this growing obesity epidemic. There is a growing interest in how health care providers can use online educational programs to gain clinical knowledge and how this online learning approach can benefit patients (Walsh, 2018). Continuing education for health care providers using web-based or online approaches has become increasingly prevalent over the past few years. Several known benefits to web-based or online training include convenience, ease of access, reduced travel costs, better instructor availability, customization for the busy learner, and the ability to modify training to fit different learning styles (Gance-Cleveland, Aldrich, Dandreaux, Oetzel, & Schmiege, 2015; MacNeill, Telner, Sparaggis-Agaliotis, & Hanna, 2014).

Purpose

The purpose of this pilot study was to raise obesity stigma awareness and help healthcare providers improve the care of adult obese patients through the use of a web-based training tool. Studies have shown that providers’ attitudes may reinforce the notion of bias, which in turn may negatively impact how care is delivered (Flint, 2015; Fruh, et al., 2016; FitzGerald & Hurst, 2017; Gudzune, Bennett, Cooper, & Bleich, 2014; Phelan, et al., 2015). Providers should implement strategies that motivate all patients to participate in health care, and one strategy is being conscious of the existence of obesity biases when dealing with obese patients. This study focused on helping providers identify personal bias toward obese patients through an online self-paced education module.

Background and Significance

According to the CDC (2018), obesity increases health care costs, preventable deaths, and chronic diseases such as high blood pressure, high cholesterol, type 2 diabetes, heart disease, stroke, sleep apnea and respiratory problems. Therefore, it is crucial for primary care providers to evaluate obesity, as it is associated with higher mortality and co-morbid conditions. The rise in obesity has corresponded with increased stigmatization against individuals living with obesity. As the rate of obesity rises in the U.S., so does weight discrimination. Widespread stereotypes characterize people with obesity as lazy, less competent, lacking in self-discipline, non-compliant, sloppy, and worthless (Jackson, 2016). Weight discrimination increased by 66% over the past decade, making it comparable to rates of racial discrimination (World Health Organization (WHO), 2016). Patients who experience obesity bias from providers may cancel or delay appointments and avoid preventative healthcare and screenings (Gudzune, et al., 2014).  Preventing or delaying care in obese patients can further complicate co-morbidities and result in poor health outcomes (Phelan, et al., 2015). Obesity stigmas may cause individuals in this group to develop unhealthy lifestyles and to develop stress-induced illnesses (DeJoy & Bittner, 2014). Patients who feel stigmatized because of weight have lower trust in primary care providers (Gudzune, et al., 2014). 

Providers who view obesity as a self-afflicting problem may have no empathy for such patients which may affect the quality of care provided (Phelan, et al., 2015). Providers’ negative attitudes toward obese patients may hinder the quality of care and lead to lost opportunities to encourage the patient’s weight management efforts, and the patient-provider relationship may be adversely affected. Providers represent the most common workforce within the healthcare system; therefore, to provide optimal care, they must reflect upon their preconceived attitudes toward obese patients (Wakefield & Feo, 2017). Recognizing that obesity is a complex medical condition that has psychosocial and physiological implications for obese patients can help providers to deliver optimal care to those patients struggling with obesity (Smigelski-Theiss et al., 2017). Providers can coach the obese patient to lose weight and live a healthy life. It is important that healthcare organizations provide educational training opportunities on diversity and sensitive communication skills. Using online or web-based educational tools to highlight research findings and patient experiences can be a convenient method for providers to overcome bias when dealing with obese patients (Kahan, Sederstrom, & VanDyke, 2016).

Literature Review

Online Learning

Online continuing education training examples found in the literature are labeled by several different terms including, but not limited to, web-based training, e-learning, internet-based training, online learning, or computer-assisted learning (Lawn, Xhi, & Morello, 2017). Literature reviewed by Gance-Cleveland, et al. (2015) found that after participants used a web-based training program, overall satisfaction was reported, and the participants were committed to practice change, which directly related to behavioral changes. However, Malan, Mash, and Everett-Murphy (2016) found only short-term effects of behavioral, practice changes in health care providers when an online training program to counsel on risk factors for non-communicable diseases in South Africa was implemented. The literature suggested that providers’ negative attitude toward obese patients can be a deterrent to providing quality care to obese patients, and as a result, obese patients may delay or avoid seeking health care in fear of being judged. Some health care providers believe that obese patients are personally responsible for their weight. This was found to have an impact on the quality of care providers delivered to obese patients (Phelan, et al., 2015). Gudzune, et al. (2014) found that weight bias can impair patient-centered communication.  Phelan, et al. (2015) concluded that poor provider-patient communication could lead to patients mistrusting the provider and non-adherence to treatment.

Provider Attitudes and Obesity Bias Impact on Patients

Much of the literature suggests that providers’ negative attitudes toward obese patients can have a negative impact on the quality of care. There was a general theme throughout the literature, linking healthcare providers as biased against obese patients. The themes that emerged as affecting attitudes toward obesity and patient biases include provider bias, implicit bias and effect on health care, obesity bias impact on patients, and impact of education on attitudes (DeJoy & Bittner, 2014; Ferrante, et al., 2016; FitzGerald & Hurst, 2017; Flint, 2015; Fruh, et al., 2016; Gudzune, et al., 2014; Jackson, 2016; Kahan, et al., 2016; Lee, Ata, & Brannick, 2014; Phelan, et al., 2015; Sabin, Riskind, & Nosek, 2015; Smigelski-Thesis et al., 2017; Ward-Smith & Peterson, 2015). Despite the rising epidemic of obesity in the U.S., weight management is not adequately addressed in primary care. A plethora of evidence demonstrates that many providers voluntarily or involuntarily have perceptions that obese patients lack the motivation to make changes, have deficient knowledge on how to lose weight, show insufficiency in self-control, are non-compliant with treatment, lack will-power, and are naturally unorganized, dishonest, and/or unsuccessful (Flint, 2015; Fruh, et al., 2016; Smigelski-Theiss, et al., 2017; Ward-Smith & Peterson, 2015). Smigelski-Theiss, et al. (2017) found that providers with higher weight bias expressed greater frustration when dealing with obese patients.

Patients who are stigmatized may avoid or delay seeking healthcare services because of embarrassment about being weighed or instructed to lose weight (Phelan, et al., 2015). Patients who feel judged because of weight have lower trust in primary care providers (Gudzune, et al., 2014). Avoiding or delaying care in obese patients increases vulnerability to co-morbid diseases such as diabetes, hypertension and hyperlipidemia. These health co-morbidities further result in poor health outcomes. Health care providers must understand that when obese patients are reluctant to seek medical help, they are not only missing education on weight management but also on other health problems (Fruh, et al., 2016). Judgmental attitudes by providers may further aggravate the patient-provider relationship, potentially leading to obese patients feeling more shame and embarrassment and resulting in less reporting of health concerns and the avoidance and cancellation of health appointments (Flint, 2015). Biases may weaken the patient-provider relationship and reduce opportunities to encourage the client’s weight management efforts (Fruh, et al., 2016; Gudzune, et al., 2014). There is a known correlation between obesity and an increase in morbidity and mortality (National Institutes of Health [NIH], 2014). Embarrassing obese patients in the belief that it will motivate weight loss has proved to have the opposite effect (Phelan, et al., 2015).

Impact of Education on Attitudes

Attitudes are complex mental processes that can be influenced by formal and informal education and training. Health care providers’ attitudes can have a negative or positive impact on the care of obese patients. Health care providers should be encouraged through educational training to develop attitudes that promote healthy outcomes for patients. Sensitivity training can be used as a tool to help increase provider self-awareness of bias toward obese patients (The Rudd Center for Food Policy and Obesity, 2017). To provide excellent and efficient care to obese patients, providers must overcome personal biases and focus on empowering patients. Through self-awareness training, providers’ attitudes towards obesity can be improved. Several studies support that educational interventions aimed at reducing obesity bias among health care personnel have a significant positive impact on reducing obesity stereotypes (Jackson, 2016; Kushner, Zeiss, Feinglass, & Yelen, 2014; Phelen, et al., 2015). Increasing self-awareness is an essential first step in improving attitudes and reducing bias (Lee, et al., 2014).

Given the amount of data supporting the existence of providers’ bias toward obese patient care, most educational institutions are encouraging training for all disciplines to provide awareness of weight-biased discrimination and to promote fair treatment for obese patients (Flint, 2015). Wakefield and Feo (2017) found that having an awareness of one’s belief systems to identify and overcome bias is an essential step to ensuring these beliefs do not adversely affect patient care. The Institute of Medicine supports the expansion of the role of health care providers in obesity prevention (Pool, et al., 2014). Healthcare providers must implement strategies that accelerate progress toward obesity prevention in all age groups and help obese patients reach healthy goals.

Theoretical Model

Pender’s health promotion model (HPM) can guide providers to work collaboratively with their patients to assist them to adopt healthy behaviors to achieve healthy outcomes. According to Pender, Murdaugh, and Parsons (2011), the HPM was designed to support nurses to understand the main determinants of health behaviors as a basis for counseling to promote healthy lifestyles. The sub-concepts of personal factors, perceived benefits of action, and perceived self-efficacy of Pender’s HPM were used within this study.

Personal factors categorized as biological, psychological and socio-cultural are predictive of a given behavior and shaped by the nature of the target behavior being considered. Recognizing that weight bias exists in a broader context of other social stigmas can help providers to implement strategies to reduce this form of bias in health care settings (Ferrante, et al., 2016; Flint, 2015; Phelan, et al., 2015; The Rudd Center for Food Policy and Obesity, 2017).

Perceived benefits of action involve providers working with obese patients to employ a variety of strategies to help reduce weight stigma and improve attitudes. According to The Rudd Center for Food Policy and Obesity (2017), healthcare providers can make a difference by becoming aware of personal biases. Training providers on sensitivity toward obese patients may help providers view all patients holistically.

Perceived self-efficacy is the judgment of personal capability to organize and execute a health-promoting behavior. This sub-concept influences perceived barriers and motivates action to overcome obstacles. Health care providers’ attitudes can affect actions in the delivery of care to patients either negatively or positively (Ward-Smith & Peterson, 2015). A change in attitude helps the health care provider to view the person holistically rather than focusing on the obesity.

Methods

Study Design
This pilot study used a pre-test/post-test research design aimed to evaluate how an online eight-week web-based educational tool impacted providers’ attitudes toward obese patient care. Institutional Review Board (IRB) approval was granted by the educational institution located in a southeastern state prior to the study beginning. Furthermore, permission to conduct the study was also granted from the rural community hospital located in a Midwestern state.

Sample
A convenience sample of 50 healthcare providers including physicians, nurse practitioners, and physician assistants at a community hospital in rural Indiana were invited to participate in the pilot study via email. A total of 22 providers consented to participate in the pilot study. The inclusion criteria for provider participation included the ability to read and speak English, working as a full-time provider with prescriptive authority, and seeing outpatient patients with chronic or acute health conditions. 

Procedures
The informed consent and pre-intervention Attitudes Toward Obese Patients (ATOP) survey were sent via Survey Monkey© link through the secured hospital email system. For privacy and information protection, participants were advised to use a unique identifier code. The unique identifier was used to link the pre-survey and post-survey results. No monetary compensation was provided to participants.

The intervention for this pilot study was a web-based educational intervention created by the Rudd Center for Food Policy and Obesity, Preventing Weight Bias: Helping without Harming in Clinical Practice (http://biastoolkit.uconnruddcenter.org). The intervention was designed by the Rudd Center to help providers implement solutions and resources to improve delivery of care for overweight and obese patients and to increase awareness of weight bias among health care providers. The Rudd Center has created these modules to be readily available to any provider interested in using the information. The modules within the intervention ranged from simple strategies to improve communications between providers and patients to profound ones focused on self-examination of personal biases.

The intervention consisted of eight online self-paced modules, but only the first four modules were used in this study. The researchers chose to only use the first four modules for the intervention because the remaining four modules focused on specific populations of patients, i.e. pediatrics, that were not applicable to the practice setting. The four modules used within this study were not modified from the original modules created by The Rudd Center. The use of informational technology (IT) assistance, or an IT support person, was not needed to implement this intervention in this particular setting. Figure 1 describes the four self-paced online modules (The Rudd Centre for Food Policy and Obesity, 2017). Providers were allowed eight weeks and estimated that each module would require 30 minutes of time to complete the four self-paced online modules.

Figure 1: The four self-paced online modules (The Rudd Centre for Food Policy and Obesity, 2017).

Instrument
Demographic data were collected from the participants. Demographic questions included age, gender, race/ethnicity, and years of practice experience. The ATOP survey was used to assess attitudes toward obese patient care pre- and post-intervention (see Figure 2). The survey consisted of 20 Likert-type items with a Cronbach alpha range of 0.80 to 0.84. The survey has a scoring system ranging from -3 = I strongly disagree, -2 = I moderately disagree, -1 = I slightly disagree, +1 = I slightly agree, +2 = I moderately agree, +3 = I strongly agree. Higher numbers indicate more positive attitudes and lower numbers indicate less positive attitudes.

The ATOP scale has been used in several studies to measure providers’ attitude toward obesity. Dedeli, Bursalioglu, and Deveci (2014) used the ATOP survey to measure the attitudes about obese persons in Turkish speaking countries and used exploratory factor and confirmatory factor analysis to establish validity and reliability. A Cronbach alpha result of 0.86 supported internal consistency. Tsai, Luck, Jerreries, and Wilkes (2017) used the Mandarin version of the ATOP scale to measure the attitudes of nursing students toward childhood obesity in Taiwan. This study established that the Mandarin version of this scale was reliable and valid. Both the attitude and belief scales were found to have internal consistency and reliability. The reliability for the 13 items on the attitude subscale was 0.76, and the six-item beliefs subscale was 0.75.

Figure 2: Attitudes toward Obese Person Scale (ATOP) (Allison, et al., 1991).

Results

Data were compiled into a dataset and analyzed using IBM SPSS version 22. Table 1 displays the frequencies describing the samples of participants who completed the pre-ATOP only, and those that completed the study. Twelve completed pre-ATOP and only 10 participants completed both the pre- and post-ATOP surveys. A comparison of the demographics for participants completing the pre-ATOP only and those completing the pre- and post-ATOP surveys are shown in Table 1. Overall, there were more females who participated in the study than males, and most of the participants were Caucasians and 45 years of age and older.

Table 1: Frequencies of Variables describing the Samples

Mean (M), standard deviation (SD), and range were calculated for the pre-ATOP total score for those who completed the study, and those who did not. Those completing the pre-ATOP only (n = 12) had a mean score that was 11 points higher (M = 143) than those who completed the study (M = 132), suggesting that those who completed the study had a lower attitude toward obese people. M, SD, and range for pre- and post-ATOP total scores was calculated for the 10 participants who completed the study. The score improved post-intervention by 5.0, showing improvement in provider attitudes toward obese patient care. 

An independent samples t-test was conducted comparing the pre-ATOP total score for those who completed and those who did not complete the study. Results are shown in Table 2.

Table 2: Independent Samples t-test of pre-ATOP total scores and samples (n=10)

While this result did not meet the level of significance (p = 0.05), the result was clinically significant. A paired samples t-test was conducted to compare pre- and post-ATOP total scores for those who completed the study to examine whether the educational intervention had an impact on providers’ attitudes toward obese patients. As shown in Table 3, while this was not statistically significant (p = 0.181), it is clinically significant.     

Table 3: Paired samples t-test of Pre and Post-ATOP total scores (n=10)

Independent samples t-tests were also conducted to examine the impact of gender on pre- and post-ATOP total scores among those who completed the study. In the pre-ATOP, the M score for males was 138 compared to 130 for females, indicating that male providers had a more favorable attitude toward obese people. In post-ATOP male providers had a M score of 137 and female providers had a M score of 139, an improvement of 9.0 points. Even though the p-value was not significant in either t-test, the clinical trend indicates that the educational intervention impacted female providers more than male providers.

Table 4 displays the result of a one-way ANOVA comparing pre- and post-ATOP total scores and “how you view weight” was conducted to examine for differences. While neither ANOVA was statistically significant, it did show clinical significance, especially for those who were not happy with their weight. In the pre-ATOP, providers who were not happy with their weight were identified (M = 127), and on the post-ATOP, whether or not provider weight satisfaction increased (M = 137). While neither of the ANOVAs were significant, it did show that for those providers not happy with their weight, the post-ATOP total score increased by 10 points, demonstrating that provider weight bias was reduced following the educational intervention. 

Table 4: ANOVA of Pre- and Post-ATOP total scores and views of weight (n=10)

Limitations

One limitation of this study was that the sample size was too small to be generalized to a larger group. In addition, the study was limited to a small rural hospital. A limited time frame for implementation of the modules was an issue, as well. Findings of this study cannot be generalized and cannot be interpreted without bias.

The recruitment and retention of participants was a challenge. While 22 providers completed the pre-survey, only 10 finished the post-survey. Giving incentives for participating in the research could have encouraged better participation. The busy schedules of participants might have prevented completion of the modules and the post-survey. Those who completed the survey may have filled the questionnaire casually, which might have affected the results. 

Findings and Recommendations

Healthcare providers are influential sources in the healthcare industry and must provide the utmost in quality health care to all patients (Phelan, et al., 2015). The providers’ negative attitude toward obese patients, coupled with the fragmentation of preventive care in such patients, cumulate into exacerbation of co-morbid disease. Negative attitudes toward obesity by health care providers can be a barrier to obesity management. An example can be seen when a patient who has obesity delays or cancels an appointment to avoid provider stigma. To fight obesity bias, healthcare providers must acknowledge that obesity bias is a stumbling block to obese patient care. Overcoming one’s own bias toward obese patients can be the starting point in delivering adequate care to obese patients.

When providing care for obese patients, healthcare providers must develop a trusting relationship with open communication to assist these patients to meet healthy goals. Obese patients need numerous provider visits to ensure they are meeting weight loss goals. Medication management may also be needed in addition to lifestyle modification. Exercise, diet planning, referral to dieticians, and behavioral medicine intervention should be discussed with obese patients (Fitzpatrick, et al., 2016; Hensley, 2018). A multidisciplinary team approach can help obese patients address the multiple components that contribute to obesity (Kahan, 2018). While new information may be delivered at each visit, all previous information should be reinforced.  To ensure that obese patients return for follow-up visits, health care providers must put aside any bias related to this population and encourage these patients as steps are made toward healthy goals. This patient population deserves healthcare providers who will provide competent and supportive care to improve obese patient outcomes, particularly those related to co-morbidities such as diabetes, hypertension, and dyslipidemia; certain types of cancer; and cardiovascular disease (Fitzpatrick, et al., 2016).

Healthcare providers should implement strategies that embrace all patients with no prejudice and strive to guide them to meet their health goals. There is an increasing amount of interest in online learning for providers and how knowledge gained from an online training program can benefit quality of patient care (Walsh, 2018). Numerous online continuing education offerings are available for healthcare providers who wish to learn about obese patient care. Many of these offerings recommend providing culturally sensitive care to obese patients.  As the population of obese patients continues to expand, health care providers must become better able to provide quality patient care. Obese care training offered on an annual basis may decease bias and aid in providing culturally sensitive care to obese patients.

The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.