Layout 1 [Qualitative Research in Medicine & Healthcare 2019; 3:7832] [page 25] Introduction Weight-related stigma The public perception of individuals of higher weights is affected by media that propagate weight stigma.1 Weight discrimination in society often goes unchecked, and people of higher weight are subject to social blame based on com- mon assumptions of laziness, overeating and oversimplifi- cations of health status.1,2 The relationship between weight and health is often oversimplified and sensationalized.3 Rural, low-income women of higher weights occupy mul- tiple disadvantaged social locations that may influence their health.4 As these women may already be marginalized by sexism or classism, the added burden of weight-related stigma may exacerbate ongoing health issues and produce a multiply disadvantaged social status.5 Individuals experi- ence multiple, intersecting social locations at any one time that may accord them different disadvantages and advan- tages in particular contexts. In one of only few studies that examined weight from this intersectional perspective, Him- melstein et al. found that low income individuals experi- ence more weight-related stigmatization.5 Rural residents also must cope with added stereotyping of backwardness and unsophistication.6 Despite established research high- lighting the disproportionate disparities rural individuals face,7 women and weight-related stigma in rural and low- income environments are not studied often, in part, perhaps because these women are perceived as being less concerned with their bodies.8 Women experience harsher weight stigma in a variety of settings, and weight stigma in women is experienced at a lower weight compared to men.1 Evidence of stigma and its impact on psychological and behavioral responses should be viewed as a vital determinant of health that greatly influences health and health inequalities.9 Weight-related stigma and healthcare Weight-related stigma and stereotypes are widespread across society, including among healthcare professionals.2,10 Mounting evidence indicates that weight-related stereo- types negatively influence the quality of care higher weight individuals receive, worsening disparities and barriers to Experiences of weight-related stigma among low-income rural women of higher weights from the midwestern United States Katherine Hughes,1 Andrea E. Bombak,2 Samuel Ankomah1 1School of Health Sciences, Central Michigan University, Mount Pleasant, MI, USA; 2Department of Sociology, University of New Brunswick, NB, Canada ABSTRACT Weight-related stigma and stereotypes are widespread. Despite established research highlighting the disproportionate disparities rural individuals face, studies focusing on women in rural and low-income environments are underrepresented in the literature. The current study addressed these gaps in the literature using 25 in-depth interviews, which were analyzed using interpretive phenomeno- logical procedures. The research questions were: i) what are low income rural women of higher weights’ understandings and experiences of weight stigma in healthcare? and ii) to what extent do their experiences of stigma affect or do not affect their healthcare-related be- haviors? Sixteen women in the study experienced weight-related stigma in healthcare. Many delayed their care while others felt their care was essentially denied. Findings indicate that more can be done to address weight-related stigma. Correspondence: Katherine Hughes, School of Health Sciences, Central Michigan University, Mount Pleasant, MI 48859, USA. Tel.: +1.517.902.6262. E-mail: hughe1kl@cmich.edu Acknowledgments: the authors thank participants and community partnerships for recruitment opportunities. Key words: Weight; Stigma; Low-income; Rural; Women. Contributions: KH, AB completed research interviews; KH, SA data coding, worked with AB on data analysis. KH manuscript completion in consultation with AB. Conflict of interest: the authors declare no potential conflict of in- terest. Funding: the work was supported by a College of Health Profes- sions Early Career Grant, Central Michigan University. Received for publication: 17 September 2018. Revision received: 18 February 2019. Accepted for publication: 18 February 2019. This work is licensed under a Creative Commons Attribution Non- Commercial 4.0 License (CC BY-NC 4.0). ©Copyright K. Hughes et al., 2019 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2019; 3:25-31 doi:10.4081/qrmh.2019.7832 Qualitative Research in Medicine & Healthcare 2019; volume 3:25-31 No n- co mm er cia l u se on ly care.2 Consequences of weight stigma include avoidance of medical care, poorer quality of care, medication non-ad- herence, disordered eating, reduced weight loss, inactivity, psychosocial stress, provider distrust, and poorer mental health.2,10 In their review on the effects of weight stigma on health, Phelan et al.2 reviewed numerous studies that indi- cate that those who experience weight-related stereotyping in healthcare settings delay care and avoid providers due to the stress caused by their negative treatment. In a review of reports on weight-related stigma, Flint11 suggests that the breakdown of the patient-practitioner re- lationship, which can involve the use of alarmist terms to describe excess fatness, has contributed to patients avoid- ing and even cancelling appointments. In a study that helps elucidate why women of higher weights are less likely to seek care than thinner counterparts, Mensinger et al.12 found that women of higher weight experience in- ternalized weight-related stigma that contributes to body guilt and shame. This guilt and shame leads to increased healthcare-related stress causing healthcare avoidance. The evidence that individuals of higher weight may fail to report health concerns and delay/avoid needed health- care emphasizes the paramount importance of understand- ing the experiences of stigma in those disproportionately affected by additional barriers and disadvantages,4 which has not been a focus of weight-stigma research. Despite the potentially highly salient effect of weight-related stigma, we know little about these factors in low-income and rural locales whose residents may experience com- pounding disparities and barriers to receiving healthcare. The inadvertent or deliberate stigmatization of women of higher weights and the barriers it creates should be ex- plored in order to better understand how to promote health at every size. The current exploratory study helps to elu- cidate the role of weight stigma in terms of healthcare be- haviors and beliefs of rural women of higher weights. Research objective In the current study, we seek to address the above- mentioned gaps in the literature using 25 in-depth inter- views, conducted in the rural Midwest of the United States of America, and analyzed using interpretive phenomeno- logical analysis. We address the following questions: i) what are low income rural women of higher weights’ un- derstandings and experiences of weight stigma in health- care? and ii) to what extent do their experiences of stigma affect or do not affect their healthcare-related behaviors? Materials and Methods Study design This study employed in-depth interviewing and Inter- pretive Phenomenological Analysis (IPA) practices. IPA equips researchers with the skills necessary to understand the experiences of individuals by capturing their narra- tives and providing transparent, comprehensive, and or- ganized interpretations or sense making.13,14 Just as indi- viduals are conducting sense making of their own lived experiences, IPA requires the researcher to make sense of the participant’s experience. This two-way relationship is the process of a double hermeneutic, enabling interpreta- tions to be made by the researcher based on participants’ narratives related to the phenomenon of interest. Analysis in IPA is based on ideography; the event of interest in each individual case is identified and all interviews are exam- ined to identify patterns, themes, and divergence across all individuals.13,14 IPA is not a prescriptive approach – it provides freedom and flexibility, but it also requires cross- checking at multiple points during data collection and analysis.15 Given that IPA focuses on participants’ lived experience and sensemaking practices, it provides an ap- propriate means to understand how individuals make sense of their weight stigma experiences.16 Participant selection We recruited individuals from flyers, listservs, and snowballing at community groups and sites serving low- income families (food pantries, clinics, college campus, and community centers). The inclusion criteria for this study included self-identifying as female, currently or have ever been considered obese (Body Mass Index≥30), less than twice the poverty guidelines set forth by the De- partment of Health and Human Service or enrolled in an income-based social assistance program, and living in a rural Michigan area defined by the US Census Bureau urban-rural classification system. We excluded individu- als from the study if they were non-English speaking. In- dividuals interested in participating were contacted via email or phone to schedule an interview. We recruited twenty-five participants, which is considered the upper limit for phenomenological studies.17 Participants were given $50 to reimburse their time and travel. Setting Data collection was conducted at public places of the participants’ choosing. The majority of interviews took place at McDonalds fast food locations, as that is one of few pub- lic meeting places in rural areas that is accessible and con- venient. A total of 25 women (age: 22-90, M=40.5, SD=19.87) participated. Participants self-identified as White (83.33%), Black (8.33%), Latin American (4.17%), and American Indian (4.17%). Most of the participants had com- pleted secondary school (20.83%) or some university (20.83%). Most of the participants were not working in the labor force (a caregiver who does not work by preference/on leave/unemployed) (45.83%) or were retired (25%). Data collection Data was collected during face-to-face interviews, using semi-structured interview guides (Table 1). Smith [page 26] [Qualitative Research in Medicine & Healthcare 2019; 3:7832] Article No n- co mm er cia l u se on ly and Osborn suggest the utilization of semi-structured in- terviews in IPA to allow flexibility in obtaining partici- pants’ unique stories and for rapport building.16 We audio-recorded interviews, which were then transcribed by a third party. We recorded fieldnotes after each inter- view to depict the interactions during the interview, to elaborate on emotions expressed, and to capture visual or verbal cues that were not captured by the recording.18 On average, interviews lasted 46 minutes, ranging from 20- 84 minutes (Median: 42 minutes, Mode: 60 minutes). KH was the interviewer and was trained by AB, who has ex- tensive experience conducting qualitative interviews. KH had previous contact with some participants through re- cruitment at a community food distribution site. Data analysis Prior to the first interview, AB deductively began de- veloping the initial code list by mapping the field19 and con- sidering relevant prior studies and theory that may prove pertinent to the present study. The first interviews then in- formed the code list; new fields were added from relevant themes arising in the interviews. All three authors were re- sponsible for coding the interviews using NVivo 11 soft- ware; coders met weekly to discuss patterns and allow for investigator triangulation. Coding was done using a step- wise approach, informed by IPA procedures.16 Each line of the interviews was read and re-read to identify words or phrases that match with the field; text that converged and diverged from the existing code were included. Each inter- view was summarized by the interview’s initial coder and a subsequent coder. Separate codes were then combined to identify patterns with similar meaning; these patterns in meaning were identified as emergent themes. We then looked at all across interviews using coding tables as a way of detecting patterns among participants. We used these coding tables to reaffirm and refine the themes that emerged and to detect patterns within emergent themes. Results Below, we examine the two main themes we identified by using quotations from our interviews with participants. Their experiences with weight-related stigma will be de- scribed first and then, we will move to analyze how par- ticipants were affected by weight-related stigma in a healthcare setting. The subheadings represent sub-themes within each of the three main themes; quotes that support each category and exceptional disconfirming quotes will be included. Weight-centrism in healthcare Sixteen participants described feelings of judgment or assumptions by healthcare professionals (mostly physi- cians) that were solely related to weight. Most participants felt physicians made judgments about their health without taking into consideration context, background, or their personal history. One participant mentioned that she be- lieves physicians are unequipped and ill trained to work with patients of higher weights. This notion was shared by participants who describe nurses speaking about pa- tients of higher weights in a demeaning way and physi- cians who give recommendations that the women in this study felt were unachievable given the presence of a con- flicting injury or illness. The sense that physicians reduce complicated lifeways is described by Naomi: Dealing with medicine…the doctor looks at you and already they can tell that they’ve analyzed you…by see- ing…one thing and that’s not always the case. The situation that Naomi described was a very com- mon occurrence for the women in this study. For example, Taylor shared a similar experience of assumptions based only on weight by healthcare professionals. Taylor who has chronic health issues and sports-related injuries de- scribes her experiences in healthcare: I have a really [bad] knee from playing softball in high school, and they automatically say that it’s just because of your weight. Or…I have a pinched nerve in my back from work, and it’s like, “Well, you need to lose weight.” Which, I’ve done…and those problems don’t go away with losing weight…they’re a chronic issue…they just auto- matically assume everything wrong with you is because of your weight. Participants also described hearing statements made by physicians that led them to believe they were being [Qualitative Research in Medicine & Healthcare 2019; 3:7832] [page 27] Article Table 1. Sample of semi-structured interview guide. Question 1 How do you think society treats women of higher weights? In what ways do you think society has or has not treated you differently due to your size? Question 2 How do you think healthcare providers treat women of higher weights? How do you think those experiences are related (or not related) to your size? Question 3 How do you think those experiences of being judged (or not judged) for size has affected women’s health? Lifestyle? Willingness to go to the doctor? How do you think experiences of being judged (or not judged) for size has affected your health? Lifestyle? Willingness to see healthcare providers? No n- co mm er cia l u se on ly judged because of their weight. Statements made by physicians to the participants concerning their weight fol- lowed the same general pattern. For example, Contessa shared a statement made to her by a physician that encom- passes what many of the participants expressed: [We] wouldn’t have to be seeing you for this issue if you’d lose some weight...we wouldn’t have to do this test, ya know. Wouldn’t cost as much for your medical care if you could just lose some pounds. Weight-centrism present in the physician-patient re- lationship was described by many women. While varia- tions in its manifestation were present, it can be summarized as physicians indiscriminately attributing all their health conditions or illnesses only to their current weight. Weight-centrism may have seemed especially egregious for women in this study who were living in rel- atively isolated locales on limited budgets. These individ- uals were already coping with barriers to healthfulness and class-based stereotypes. As described by Lucy: I’m retired and older and having to live on a fixed in- come…if you use a Bridge Card people [act] like it’s com- ing out of their pocket…I can’t afford to buy food, but the government’s helping me pay for it so people think, well, I pay taxes so into government programs, you know, so it’s coming out of my pocket. Why are you so fat and why are you so lazy… Therefore, in addition to reinforcing simplistic confla- tions of health and weight status, weight-centrism dis- missed the health-damaging inequities participants encountered in their everyday lives. Effects of weight-related stigma Every participant mentioned the effects of weight-re- lated stigma that they had experienced. Most expressed that the situation elicited an emotional response (e.g. cut down, depressed, hopeless, confused, and angry); with respect to experiences in healthcare, some went further, describing consequent feelings of evasiveness toward seeking care (Avoidance of care), and/or feeling like they were denied care to which they were entitled (Denial of care). Avoidance of care Participants described a variety of situations that would cause them to avoid healthcare. For some partici- pants, avoidance was due to the seeming futility of speak- ing to physicians. Naomi describes her reaction to the way she is treated in healthcare: They’re going to say, if you’re overweight, “You’re overweight, you need to lose weight”...it kind of hurts hearing that over and over and over again to the point where you get discouraged to go to the doctor anymore. For participants like Naomi, a visit to the physician was unnecessary. The outcome of the visit was a foregone conclusion (being told to lose weight) and would simply produce emotional hurt. Taylor similarly describes one of her experiences dur- ing pregnancy that led her to cease care unless she was very sick: Then going to the OB when you’re heavy versus if you’re not heavy, there’s…a huge difference. They…auto- matically assume you eat trash all day, or you’re already gonna have gestational diabetes, or your baby’s gonna be huge and they just wanna automatically schedule you for a C-section (laughs)... Having their lives reduced to weight-based stereotypes and encountering persistent negativity concerning their size motivated some women to forgo medical treatment. Impor- tantly, knowledge, which was used to counter-productively reinforce to Taylor the risks associated with her pregnancy, was viewed as insufficient preparation for physicians in treating those with higher weight. As emphasized by Mia in explaining why she delays healthcare treatment: I think healthcare professionals get to a point where they see their daily routine as a job…if the healthcare workers aren’t overweight, they still have the same atti- tudes that people on the street have. Just because you have a degree in medicine doesn’t make you any nicer. While some participants delayed or avoided care be- cause they expected to encounter weight-centric treat- ment, others described more material reasons for avoiding care. Bette, who has had both positive and negative expe- riences with physicians, explains what makes her unwill- ing to go see a physician: Mainly just the…cost…I do have Medicare…but the copays are still high…Medicare is like over a hundred- dollars a month...that they take out of my…disability… Thus, participants experienced multiple barriers to seeking respectful, effective healthcare. For some, given the likelihood of encountering reductionist commentary on their size, the outcome of compounding material and social inequities was to avoid healthcare. Denial of care Other participants described what can be interpreted as a form of denial of care. This manifested most often because of weightcentrist ideals held by physicians pre- venting any course of action being taken during the ap- pointment. Participants were persistently told to lose weight, eat healthy, and exercise leaving them feeling like the condition or illness for which they sought medical care for was not being addressed. For example, Jen (whose husband had only one episode of high blood sugar and eats a healthy diet) summarized her frustration with healthcare professionals: They just like, “Oh, you have type 2 diabetes.” It’s just their go-to. They don’t wanna look…intensively…They don’t wanna look into what’s actually causing that. Because of the frequent elision of higher weight status with diabetes, Jen’s husband was essentially denied care for his true issue. Rogue had a similar experience with a physician saying: I went to see a doctor about potentially rheumatoid [page 28] [Qualitative Research in Medicine & Healthcare 2019; 3:7832] Article No n- co mm er cia l u se on ly arthritis...this gentleman…never saw me before, and he saw me for less than 10 minutes, I timed it. And he had just looked at my hands and said, “This isn’t inflamma- tion, it’s just because you’re overweight.” and walked out the door …I think it’s easier for health professionals to call me out on not exercising as much, or that’s where they go straight to. I mean they’re not entirely wrong, but I wonder if it’s just because of the way I look that they, they go quickly to that. Rogue, again, felt that her actual concern (rheumatoid arthritis) were easy to dismiss for physicians because of assumptions linked to higher weight status. Some participants recounted experiences of family members and friends that influenced their own health- seeking behavior. Abbie describes the experience her fa- ther had with healthcare professionals in trying to address high blood sugar levels. The problem persisted despite her father following medical advice: My father just died...He said, “I will not go to the healthcare system because…they told him the same thing, Lose weight. Your sugar’s not gonna come down until you lose weight.” Well, he lost weight, sugar was still acting up…It kind of has affected me as far as like healthcare be- cause it makes me not even want to go to the doctor…I just want to be healthier, you know, but you’re not giving me advice really, you’re just telling me what I already know. Abbie mirrors what many of the participants ex- pressed, seeking care becomes a chore where many felt they needed to defend themselves, speak up, or fight to be believed when wanting to address their concerns per- taining to health and their bodies. Even when they advo- cated for themselves during appointments they felt their summons for help went unanswered. As Tamara states: They treat me like I’m no good, you know…To set you aside and just blow you off instead of helping when you ask for help. Thus, when participants did seek out care (which might involve considerable effort and resources), they were likely to encounter reductionist solutions based on assumptions concerning the link between health and weight. This denial of the care they actually sought could produce an unwillingness to engage further with health- care providers. Discussion Low income, rural women of higher weight experi- ence weight-related stigma. Research suggests that stigma may affect quality of care and health-seeking behaviors. The current study adds to the body of literature regarding experiences of weight-related stigma, providing insights from low-income rural women of higher weights who are sometimes perceived as indifferent to societal body stan- dards.8 While there are few studies that examine stigma, well-being, and health-seeking behaviors among low-in- come and rural women, each theme can be compared with similar studies. Women who reported experiencing stigma in Himmelstein et al.’s4 survey had higher BMI’s and a lower average income than those who did not report ex- periencing stigma. Most participants mentioned stigma- tizing interactions with their physicians. Weight-related stereotypes held by physicians have been abundantly measured and affirmed. Comparable to the studies re- viewed by Phelan et al.,2 participants in this study de- scribed feeling like they received lower quality care due to their weight. A previous study done by Bombak et al.20 found that women classified as overweight or obese felt their reproductive care needs were denied based on their weight. The women in the current study described similar refusal of needed care by healthcare professionals who held weight-centrist ideals. Importantly, some participants stated they had neutral or positive interactions with health- care professionals. All three participants who relayed pos- itive experiences (characterized as timely and attentive) had the same family physicians since childhood. Participants in the present study described similar rea- soning leading to avoiding or delaying healthcare as iden- tified by other researchers. These reasons included: not having a good rapport with healthcare staff and not re- ceiving treatment on the basis of weight,11 a lack of com- munication and hurtful words to describe body fat,21 a perceived lack of resources, and prior negative experi- ences.22 The avoidance of care for women of higher weights due to stigmatizing experiences has been estab- lished; however, how these encounter constitute a form of implicit (or explicit) denial of care through the dismissal of patients’ concerns remains under-explored. This research adds to the literature tasked with under- standing stigma of underrepresented groups, but it is critical that more research is conducted that will aid in countering the deeply held assumptions regarding individuals of higher weights. More research must also be conducted that con- siders intersectional forms of marginalization.4 Participants in the present study were also coping with material and so- cial disadvantage produced through living on lower in- comes and in rural locations. Discrimination based on socioeconomic status is present in healthcare contexts.23 Rural spaces and lifestyles are depicted as backward and unsophisticated6,24 and class-based assumptions tend to dis- miss material barriers to well-being as forms of igno- rance.25 More research will not only guide more respectful medical messaging, but it may help develop messaging that improves patients’ self-image. Strengths and limitations Our findings help to articulate the experiences of those who frequently experience stigma and disadvantage and can be used to guide medical interactions and messaging that is more respectful for women at every size. For ex- ample, findings highlight potential disparaging messaging in healthcare and other sectors and should act as a catalyst to change the discourse surrounding the care of women [Qualitative Research in Medicine & Healthcare 2019; 3:7832] [page 29] Article No n- co mm er cia l u se on ly of higher weights. The avoidance and denial of care sub- themes can help inform dialogue related to perceived care for low-income rural women of higher weights. To enhance rigor, we created audit trails in the form of NVivo memos and employed investigator triangulation throughout analysis.26-28 Professional transcription and re- flexive fieldnotes, including a final reflexive summary con- sulted after the interview, added to the rigor of the study.26,27 Due to the nature of this study, the focus was on women, but the experiences of rural and low-income men would further add to the body of literature dealing with weight-related stigma. The sample was highly educated and mostly White. Studies on weight bias in general should aim for greater diversity and considerations of in- tersectionality.4 The small scale, qualitative nature of the study prohibits generalization, but similar themes have been identified elsewhere, suggesting transferability of findings. KH, the main interviewer, is a slim female from a different class background, which may have affected rapport with participants. Conclusions In this interpretive phenomenological exploration of low income, rural women’s experiences with weight stigma, all participants described experiencing some form of weight-related stigma. Many had experiences that fell into all the categories explicated in the results section: weight-centric ideals from healthcare professionals, and more than half revealed that the stigmatization from healthcare professionals produced evasion from seeking care or feeling like they were denied care. Weight-cen- trism during previous medical encounters contributed to the women in this study deciding that it was futile for someone with their body to seek care. As some of the women did not seek care until they were very ill or never sought care at all, this indicates weight stigma is a critical concern. Action needs to be taken across sectors to reduce barriers to medical care for rural residents, low-income individuals, and women of higher weights. A weight-neu- tral approach should be adopted for health communica- tion.29 This approach maintains a holistic approach to health; an endorsement of sound research and prevention; and advocates for improved access to healthcare, re- sources for health promotion, social justice and stigma re- duction.29 Such an approach would help alleviate the intersecting forms of disadvantages that kept participants marginalized within the healthcare system. Given the ef- fects of weight-centrism on participants’ health-seeking behaviors, public health policy and practice should pro- mote non-stigmatizing messages that seek to promote healthy behavior without mention of body weight or size30 and that resist the common, damaging stereotyping of higher weight persons as ignorant, lazy, and over-indul- gent,3,25 particularly among low-income, rural residents coping with similar classist assumptions.6,24 The findings from the current study point to the urgency of making public health messages more respectful by keeping weight out of health-related communications and pushing to eliminate intersections stigmas in every interaction and touch-point with the public. References 1. Puhl R, Heuer C. The stigma of obesity: A review and up- date. Obesity 2009;17:941-64. 2. Phelan S, Burgess D, Yeazel M, et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev 2015;16:319-26. 3. Gard M, Wright J. 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