Occupational Therapy in Health Care, 25(1):77–90, 2011

C 2011 by Informa Healthcare USA, Inc.
Available online at http://informahealthcare.com/othc
DOI: 10.3109/07380577.2010.533252

Prejudicial Attitudes Toward Clients Who Are

Obese: Measuring Implicit Attitudes of
Occupational Therapy Students
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

Kerryellen Vroman & Sabrina Cote

Department of Occupational Therapy, University of New Hampshire, Durham,

New Hampshire, USA

ABSTRACT. Stigmatizing attitudes can undermine the quality of health care. This
study examines the attitudes and beliefs of 189 occupational therapy students toward
clients who are obese. Results indicate that the occupational therapy students were more
likely to make negative evaluations of clients who were obese. The univariate between-
subjects analysis of the Attitudes Toward Obesity—Prejudicial Evaluation and Social
For personal use only.

Interaction Scale scores found that the difference between the means for overweight
and average-weight clients for Social Distance and Judgment were statistically signifi-
cant (t(187) = 2.06, p = .04; t(187) = −2.008, p = .04). There was also a statistically signif-
icant difference between the Social Distance score means for female and male clients
(t(187) = −2.12, p = .03). The explicit measures, the Attitudes Toward Obese Persons
and the Beliefs About Obese Persons scores, showed that many students in the sample
had stereotypical beliefs and, to a lesser extent, had negative attitudes about obesity.
These results add support to the inclusion in occupational therapy curricula content
that specifically addresses the awareness of stigmatizing stereotypes and attitudes to-
ward clients who are obese.

KEYWORDS Obesity, discrimination, attitudes, education

INTRODUCTION
This study investigates whether occupational therapy students have prejudicial at-
titudes and stereotypical beliefs toward persons who are obese. Previous studies
report that nurses and physicians show prejudicial attitudes and hold stereotypi-
cal beliefs about obesity (Brown, 2006; Foster et al., 2003) and view patients who
are obese as socially and physically unattractive and noncompliant and that their
hygiene is poor. They also find the experience of caring for people who are obese
to be difficult, exhausting, stressful, and time-consuming (Brown, 2006; Epstein &
Ogden, 2005; Mercer & Tessier, 2001; Teachman & Brownell, 2001). Maroney and
Golub (1992) report that one third of nurses in their study responded that if given

Address correspondence to: Dr. Kerryellen Vroman, Department of Occupational Therapy, University of
New Hampshire, Library Way, Durham, New Hampshire 03824, USA (E-mail: kgn3@unh.edu).

77
 78 Vroman and Cote

a choice, they would prefer not to care for adult patients who were obese. The pos-
sible consequence of these attitudes is a lack of comfort and trust between health
care practitioners and patients. For example, physicians even minimally annoyed
by a patient’s excess weight are more likely to rush the appointment, give biased
care, or end the appointment prematurely before fully helping the patient (Hebl,
Xu, & Mason, 2003).
Although there have been articles published on the topic of obesity in the oc-
cupational therapy literature, including a position paper by the American Occu-
pational Therapy Association (Calderaro-Munguba, Valdes, & Silva, 2008; Clark,
Reingold, & Salles-Jordan, 2007; Mosely, Jedlicka, Lequieu, & Taylor, 2008),
there is no research examining occupational therapy practitioners’ attitudes toward
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

clients who are obese. While there are a few studies of prejudicial attitudes among
allied health professions (i.e., dieticians, physical therapists, dental hygienists, and
exercise science; Chambliss, Finley, & Blair, 2004; McArthur & Ross, 1997; Sack,
Radler, Mairella, Touger-Decker, & Khan, 2009), these studies examined attitudes
using direct measure methods. Direct measures are vulnerable to social desirability
bias and therefore may actually underestimate prejudicial attitudes of obesity. For
that reason, it is conceivable that occupational therapy practitioners may also have
prejudicial attitudes and stereotypical beliefs about obesity. Since prejudicial atti-
tudes effect the quality of care a client receives, a critical examination to determine
whether a significant number of occupational therapy practitioners have negative
For personal use only.

attitudes toward people is warranted.

Measurement of Attitudes
Attitudes are cognitive and emotionally based judgments that can predispose an
individual to behave in stereotypical ways in relation to others of particular identi-
fied groups (White & Olsen, 1998). Identifying prejudicial attitudes and beliefs can
increase self-awareness and enhance health care providers’ understanding of how
to reduce stigmatization and discrimination of marginalized individuals.
The two methods used to measure attitude are direct and indirect, also referred
to as explicit and implicit measures. Although direct methods, such as surveys
and social scales that examine cognitive and affective components of attitudes, are
used widely, there is a risk of underreporting prejudicial attitudes. Since people are
aware that their attitudes are being measured, they have a tendency (i.e., social de-
sirability bias) to respond in a way as to present themselves favorably and more con-
sistent with socially accepted norms (Paulhus, 1991). Furthermore, the wording of
direct measures can be more easily manipulated, which undermines validity (Wang,
Brownell, & Wadden, 2004). Because of the inclusive philosophy and ethical prin-
ciples of health care professions, it is conceivable that they feel more pressure to
report attitudes and beliefs that are consistent with those of their profession. This
would heighten their vulnerability to social desirability.
The alternative approach for measuring prejudicial attitudes is the use of indi-
rect measures, which include observation, implicit association tests (IATs), projec-
tive techniques, and error-choice measures. With indirect measures, respondents are
not informed about the purpose of the measure or, in some situations, the reason
they are being observed. Thus, indirect measures have been shown to be more ef-
fective in predicting discriminatory behaviors than self-reported direct measures of
 Obesity and Prejudicial Attitudes 79

attitudes (Fisher, 1993; Wang et al., 2004). Additionally, when these measures are
performance based, they are considered more accurate (Carr & Friedman, 2005;
Puhl & Heuer, 2009).
One of most common type of indirect measures of attitudes is an IAT of attitudes,
which examines the relative strength of automatic associations between concepts
(Grewald & Nosek, 2001). Teachman and Brownell (2001), using an IAT of obe-
sity among 84 mostly male health care professionals (72% physicians) who treated
clients for obesity, found both significant stereotypical and antifat attitudes. Their
results supported the value of using an indirect measure to avoid the social desir-
ability issues with direct measures but acknowledged that a weakness of IATs is that
the measure does not define the direction of the association (e.g., negative views of
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

obesity or positive views of thinness).

An indirect measure of stereotypical beliefs and stigmatizing attitudes that is spe-
cific to a person’s health condition is the model used in the Prejudicial Evaluation
and Social Interaction Scale (PESIS). This scale is a measure of interpersonal judg-
ments and willingness to interact socially with individuals diagnosed with AIDS
(Kelly, Lawrence, Smith, Hood, & Cook, 1987). The PESIS presents a case sce-
nario of an individual who in one version of the case study has AIDS and in the
other does not; all other characteristics remain the same. The scale is designed to
implicitly explore interpersonal judgments of stereotypical attitudes and beliefs re-
lated to individuals with AIDS.
For personal use only.

In 2008, O’Brien and colleagues used a similar model to examine discrimination

against job candidates. They attached photos to the portfolios of job candidates who
were either obese or of normal weight to assess implicit and explicit attitudes among
university students as participants. Similarly, the Attitudes to Obesity—Prejudicial
Evaluation and Social Interaction Scale (AO-PESIS) was developed on the ba-
sis of the conceptual model of the PESIS to investigate attitudes toward obesity
(Vroman, 2006). The AO-PESIS scenarios kept the characteristics of a client the
same except for weight by attaching single image of a female or male who was
either average weight or obese. As with the PESIS, the AO-PESIS implicitly mea-
sures interpersonal judgment of stereotypes about obesity. The items reflect exist-
ing stereotypes and prejudicial attitudes toward people who are obese that have
been documented in the literature, such as “people who are obese lack self-control.”
The social interaction items of the AO-PESIS reflect subjective social evaluations
about persons who are obese that are negative. Social interaction items are intended
to measure the social distance, which is the self-reported level of comfort and/or
willingness to engage in interpersonal relationships with a person (e.g., friendship,
dating, or employing), of a particular group (e.g., race), or a given condition (e.g.,
AIDS) (Coker, 2005; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). So-
cial distance defines both emotional and physical distance, and the measures often
ask questions about whether one wants this person as one’s neighbor or friend or
would one employ this person.
Given the findings of previous research in prejudicial attitudes and stereotypi-
cal beliefs among other health care providers (e.g., nurses, dieticians, and doctors),
it is important to determine how pervasive such attitudes and beliefs are in the
profession of occupational therapy. This study was designed to explore prejudicial
attitudes and stereotypical beliefs related to obesity among occupational therapy
 80 Vroman and Cote

students. Using both direct and indirect measures, we hypothesized that occupa-
tional therapy students would express prejudicial attitudes toward clients who are
obese with the negative attitudes being strong on social interaction measures. We
also believed the students would exhibit negative attitudes and stereotypical beliefs
on direct measures that were consistent with existing negative societal attitudes to-
ward people who are obese and that the students’ body mass index (BMI) would
correlate positively with attitudes and beliefs.

METHODS
This quasi-experimental study was approved by the Institutional Review Board
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

(IRB) for the protection of human subjects at two of the three participating uni-
versities, and the existing IRB approval was accepted by the third university. The
surveys were administered at the three sites, and the data analyzed were an aggre-
gate of these sites (i.e., participants were not identified by university).

Participants
One hundred eighty-nine occupational therapy students (122 undergraduates and
67 graduates; 181 female and 8 male) were recruited from three New England uni-
versities. Two of the programs were 5-year masters programs, and the third was a
For personal use only.

postbaccalaureate graduate program. The students were selected as participants in

this study for two reasons. First, the assumption was made that occupational ther-
apy students’ attitudes were likely to correlate with those of occupational therapy
practitioners. Second, the study was piloting a new instrument specifically designed
to measure attitudes within a health care context in order to examine the psycho-
metric properties of the instrument prior to using it with a sample of occupational
therapy practitioners.
Eight male and 181 female participants whose ages ranged from 20 to 52 years
(mean of 24 years) volunteered for the study. Participants’ BMI, a reliable mea-
sure calculated using height and weight, identified a range from 17.5 to 35.7, with a
mean of 23.7 (SD = 3.7). The BMI for normal weight is 18.5–24.9; scores between
25 and 29.9 indicate a person is overweight with obesity classified by a score of 30
or greater (U.S. Department of Health and Human Services—National Heart and
Lung Institute, 2010). Ten percent of the participants’ BMI scores placed them in
the overweight category, 8% were obese, and slightly more than 3% were under-
weight.

Instruments
The Attitudes Toward Obesity—Prejudicial Evaluation and Social Interaction Scale
This is an indirect 22-item measure developed specifically to measure prejudicial
attitudes among health care practitioners in the context of health care (Vroman,
2006). The items are rated on 10-point Likert scale from 1 (strongly disagree) to
10 (strongly agree). Because social desirability bias can influence a participant’s
response to trend toward the more socially acceptable responses, the measure has
a 10-point scale that excludes a neutral position (Garland, 1991).
 Obesity and Prejudicial Attitudes 81
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

FIGURE 1. Female client’s digitally altered image and average-weight image.

For personal use only.

The AO-PESIS items are preceded by a 150-word case scenario of an inpatient

client admitted following cardiac arrest. A cardiac health condition was selected
because of the risk of coronary disease associated with obesity. In the scenario, the
client is medically stable and has been referred to the occupational therapy prac-
titioner (i.e., the participant). There are both female and male versions of the case
scenario. In the AO-PESIS, each case scenario is accompanied by either a photo
of a middle-aged white female or a male of average weight or the female or the
male client whose photos had been digitally altered to make them appear morbidly
obese (see Figure 1). In all four versions of the measure, the case scenario and client
characteristics are constant with the exception of body weight.
Attitudes Toward Obese Persons and Beliefs About Obese Persons. These are
self-reported direct measures of attitudes and beliefs about people who are obese
(Allison, Basile, & Yuker, 1991; Yuker, Allison, & Faith, 1995). These measures
ask participants to agree or disagree with statements about obesity and people who
are obese on a scale from −3 (strongly disagree) to +3 (strongly agree). For exam-
ple, “Obesity is usually caused by over eating” is on the believe scale, and “Obese
people are as happy as non-obese people” is on the attitude scale. The Attitudes
Toward Obese Persons (ATOP) scale has demonstrated high internal consistency
and moderate reliability with an alpha coefficient range of .80– .84, and the Beliefs
About Obese Persons (BAOP) has an alpha coefficient of .65– .82 (Allison et al.,
1991). In this study, the ATOP and BAOP demonstrated good internal consistency
and reliability with alpha coefficients of .815 and .762, respectively.
 82 Vroman and Cote

TABLE 1. Factor Analysis AO-PESIS

Loading

Factor 2
Factor 1 Social Factor 3
Items Judgmenta Distanceb Motivationc

I would find . . . easy to work with. .66

I would chose . . . as patient. .64
It would easy to be empathetic toward . . .. .56
I believe . . . is motivated as any client or patient. .54
. . . chance of recovery is as good as anyone with her .54
condition.
I would be happy to have . . . as patient. .53
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

. . . deserves sympathy and understanding. .30

I would . . . chose as friend. .85
I would . . . chose as colleague. .73
I would . . . initiate a conversation with in social setting. .50
I would . . . would trust. .48
. . . is likely to be motivated to work toward recovery. .75
. . . is likely to change lifestyle to improve health. .55
I expect . . . will work hard to get . . . health back. .53

Note: All items assessed on a 10-point Likert scale ranging from 1 (strongly disagree) to 10 (strongly agree).
a
28.2% of variance
b
9.9% of variance
c
7.8% of variance.
For personal use only.

Procedure
All participants signed a letter of consent prior to the study, and they received
a written debriefing upon completion of the study. The surveys were completed
anonymously, and code numbers were assigned to match the two sections. The AO-
PESIS was completed first. To blind participants for the purpose of the study, they
were told the survey was an examination of practitioners’ clinical reasoning pro-
cesses during the period between receiving a referral, reviewing a chart, and seeing
the client for the first time. Following completion of the AO-PESIS, a demographic
survey including participants’ height and weight to determine body mass and their
age, sex, ethnicity, work experience, and level of education was administered as well
as the direct ATOP and BAOP. Participants were given debriefing information at
the end of the session.

RESULTS

Prejudicial Evaluation and Social Interaction Attitudes Toward Obesity

Using the statistical package SPSS version 16, principal axis factor extraction with
Varimax orthogonal rotation was used with the AO-PESIS data for data reduction.
This procedure yielded three factors with eigenvalues greater than one that concep-
tually represented the following: Social Distance (attributions of social exclusion),
Judgment (evaluations and perceptions of a client), and Motivation (the partici-
pants’ appraisal of client’s motivation toward recovery and engagement in therapy;
see Table 1). Judgment accounted for 28.1% of the variance, Social Distance 9.9%,
and Motivation 7.8%; collectively, these factors accounted for 45.9%. Reliability
 Obesity and Prejudicial Attitudes 83

TABLE 2. Significant Correlations Between Antifat Measures: ATOP, BAOP, and AO-PESIS
Scales

AO-PESIS AO-PESIS AO-PESIS Social

BAOP Motivation Judgment Distance

ATOP .506∗ .201∗

BAOP
AO-PESIS Motivation .565∗ .286∗
AO-PESIS Judgment .430∗
∗
Correlation is significant at the .01 level.
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

analysis found that the factors have good internal consistency (i.e., Cronbach alpha
coefficients were between .70 and .89). The simpler option of averaging individual
factor items to create scales was chosen, which were then used in the subsequent
analysis. The rationale for creating scales is that scores computed from the factor
items usually correlate highly with the unit-weighted raw score and produce equiv-
alent results (Warner, 2008).

Correlations Between Scales and Measures

The AO-PESIS scales (Social Distance, Judgment, and Motivation) were signifi-
cantly correlated (see Table 2). The Judgment scale was highly correlated with Mo-
For personal use only.

tivation and moderately correlated with the Social Distance scale, and there was a
small correlation between Motivation and Social Distance scales. The direct mea-
sures (ATOP and BAOP) were significantly correlated with each other, and the
ATOP was significantly correlated with the Judgment scale. Since both the ATOP
and BAOP measure prejudicial attitudes about obesity, this relationship may be
used to infer construct validity of the Judgment scale of the AO-PESIS. There were
no significant relationships between the participants’ own weight (i.e., BMI) and
any of the AO-PESIS scales or the ATOP and BAOP.
A multivariate analysis of variance (MANOVA; 2 × 2) was used to assess inter-
actions among the independent variables and main effects. The interaction between
clients’ sex and weight was not significant. However, there was a statistically signif-
icant overall main effect for clients’ weight (F(3,183) = 5.199, p = .002) but not a
significant effect for clients’ sex (F(3,183) = 1.524, p = .21).

Univariate Between-Subjects Analysis of AO-PESIS Scales

Univariate tests (independent t-tests) were performed to describe the nature of the
difference between the group means for each of the dependent variables (Judg-
ments, Motivation, and Social Distance) of the client who was overweight and the
clients who were of average weight. The results of these independent t-tests showed
that participants rated clients who were obese significantly more negatively (M =
7.14, SD = 1.19) than clients who were average weight (M = 7.49, SD = 1.17) with
respect to their Judgment of client’s attributes (t(187) = −2.008, p = .04). This Judg-
ment scale included ratings on items such as deserving of empathy and compas-
sion, their willingness to treat the client, and the client’s potential for recovery.
The participants also rated the clients who were obese (M = 6.34, SD = 1.41) and
clients who were average weight (M = 5.90, SD = 1.17) significantly differently
 84 Vroman and Cote

(t(187) = 2.06, p = .04) on the Social Distance scale, which included ratings on items
such as whether they would choose the client as a friend or trust the client. The
participants rated the clients who were average weight more negatively on the So-
cial Distance scale than clients who were obese, which implies they would be more
likely to choose to interact socially with clients who were obese. On the third scale,
Motivation, there was no statistically significant difference between the means for
the two groups of clients (t(187) = −1.85, p = .06). The participants did not view the
clients who were obese as less motivated or committed to working toward recovery
than were the average-weight clients.

Analysis of Attitudes and Beliefs Toward Obese Persons

Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

Attitudes and beliefs evaluated directly using the ATOP and BAOP scales (higher
scores indicating less prejudicial attitudes and beliefs) showed that many students
in the sample had prejudicial attitudes and stereotypical beliefs about obesity. Un-
dergraduate students’ ATOP scores ranged from 36 to 106 with a mean of 72.8 (SD
= 15.4) with the maximum possible score of 120. Graduate students scores ranged
from 44 to 100 with a mean of 73.3 (SD = 13.9). Approximately 16% of the students
scored below 60. The BAOP scores of the undergraduates ranged from 6 to 36 with
a mean of 19.5 (SD = 6.9) with the maximum possible score being 48. Graduate
BAOP scores ranged from 6 to 43 with a mean of 20 (SD = 7.9). Thus, graduate and
undergraduate students did not differ significantly on the direct measures of antifat
For personal use only.

attitudes and beliefs.

DISCUSSION
Obesity is associated with the stigmatizing attributes that Goffman (1963) in his
seminal work identified as “abominations of the body” and “blemishes of individ-
ual character” (Carr & Friedman, 2005). However, it is consequences of stigma, the
discrimination that results in loss of status, psychological and emotional pain, and
cost to physical well-being, that are most significant for individuals who are obese.
(Link & Phelan, 2001). The results of this study indicate that occupational ther-
apy students hold both prejudicial attitudes and stereotypical beliefs about obesity.
When unaware that their attitude toward an obese client was being measured, the
participants’ scores were significantly different between the clients who were obese
and those who were average weight in relation to Judgment and Social Distance.
Furthermore, on direct measure (ATOP and BAOP) scores of their attitudes and
stereotypical beliefs, the participants demonstrated prejudicial attitudes even when
they were aware that their attitudes about obesity were being examined.

Indirect Measures
The participants’ judgments (negative appraisal) of clients who were obese are a
concern since this scale reflects the professional values of client-centered and equi-
table care. The items include “the client being easy to work with,” being “deserving
of sympathy and understanding,” and being “easy to be empathetic toward.” The
Judgment scale also indicated whether a therapist would choose the person as a
client given a choice and his/her expectation that the client who is obese would
be less motivated than other clients. The implications of significant differences
 Obesity and Prejudicial Attitudes 85

between the means for clients who were obese and those of average weight on this
scale are that participants are likely to relate less therapeutically with the client who
is obese. From the present study, we cannot determine how or if negative judgments
about clients who are obese would be translated into discriminatory behavior in the
clinical setting, as there are insufficient data that prejudicial attitudes are directly
related to acts of discrimination (O’Brien et al., 2008). However, we may hypothe-
size their attitudes may influence their work with a client who is obese as reported
in other samples of health care professionals (Puhl & Heuer, 2009).
Social desirability bias may have influenced the significant difference seen in the
AO-PESIS Social Distance scale, as the results were inconsistent with the other
scales. Participants favored the client who was obese in their ratings of the Social
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

Distance scale and expressed a significant social preference toward the clients who
were obese compared with the average-weight clients. According to the results on
this scale, participants would prefer and feel more comfortable socializing or having
personal contact with the client who was obese. This seems to contradict the prej-
udicial attitudes they demonstrated on direct measures (ATOP and BAOP) and
the prejudicial attitudes toward clients who are obese on the AO-PESIS Judgment
scale. Measures of social distance are used to investigate social rejection associ-
ated with characteristics of stigma (e.g., race; Link et al., 1999). In this study, typical
items of Social Distance scales were used, including choosing the person as a friend
or work colleague or trusting this person. A possible explanation for the direction
For personal use only.

of the Social Distance scores favoring the client who was obese may be an artifact of
social desirability bias (Paulhus, 1991). Namely, the participants were aware of the
clients’ obesity and that it would be socially inappropriate to discriminate based on
a client’s weight. Therefore, they compensated for their negative attitudes, and the
outcome was a more favorable response for the clients who were obese instead of
findings of prejudices or no significant difference between the two types of clients.

Direct Measures
The majority of the participants’ BAOP scores (i.e., 73% scored at or below 21.5,
which is the midpoint of the measure of a maximum possible score of 43) indicated
they held stereotypical beliefs that were similar to those expressed by other sam-
ples of undergraduate and graduate students in other studies (Yuker et al., 1995).
The implication of this finding is that health professions may globally attribute the
stereotypes associated with obesity to other domains of the clients’ occupational
performance.
The ATOP measure scores were slightly more positive than comparable college
samples (Yuker et al., 1995). However, many participants held strong prejudicial
attitudes toward persons who were obese, as indicated by the range of the scores.
These attitudes could adversely influence the quality of their relationships and ther-
apy with clients who are obese.

Prejudicial Attitudes and Stereotypical Beliefs Impact on Practice

Obesity is a pervasive, complex, and multifaceted health and social problem. Mod-
ifying prejudicial attitudes is particularly challenging since obesity is associated
with two types of stigma. Goffman (1963) in his seminal work described these
as stigma associated with bodily abomination, a physical characteristic that is a
 86 Vroman and Cote

visible and esthetically unpleasing, and blemishes of individual character, which im-
plies moral failure and infers blame and puts personal responsibility upon the indi-
vidual (Crocker, Cornwell, & Major, 1993; Goffman, 1963). Clients who have been
misunderstood or who have experienced discrimination because of their weight of-
ten internalize the stigmatizing attitudes and become sensitive to their weight being
a salient characteristic by which they will be judged (Carr & Friedman, 2005). At
the same time, they are self-critical and have low self-esteem (Brown et al., 2006;
Kaminsky & Gadalet, 2002). Because of past experiences, clients who are obese
may approach each new relationship with a health care provider tentatively. Their
vulnerability, accentuated by their illness experience and the uncertainty of the ex-
pectations of the provider, will be made more challenging if they do not feel sup-
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

ported by or at ease with their practitioner.

From an occupational therapy practitioner perspective, personal attitudes and
beliefs (conscious or unconscious) act as filters through which the evaluations of
clients are made. This data inform their clinical reasoning and mediate the ther-
apeutic relationship. Hiller (1982) suggested that being overweight or obese may
have a more significant effect because it may act as a “master status” (p. 112).
Namely, that obesity becomes a primary characteristic upon which other assump-
tions about a person are based. Hence, if a practitioner has prejudicial attitudes
about obesity, it may act as a global prejudice and influence his/her ability to see the
individual’s unique qualities, dispositions, and concerns. Instead, these dimensions
For personal use only.

of the person are skewed relative to the practitioners’ attitudes and stereotypical
beliefs.
Thus, the stigma affects both the clients’ and the practitioners’ behaviors and the
therapeutic relationships. Jussim, Palumbo, Chatman, Madon, and Smith (2000)
suggest it may become a self-fulfilling prophecy. The client who is obese receives
differential treatment because the practitioners’ beliefs result in reducing their ex-
pectations, being less positive about the client’s prognoses, providing less than op-
timal interventions, and spending less time with him or her. In turn, Shapiro King,
and Quiñones (2007) found that an individual who is obese responds by adjusting
and lowering his/her expectations for himself or herself accordingly. The result is an
iterative process that continues to confirm the therapist’s prejudicial attitudes and
beliefs, and the negative experience reinforces the client’s negative self-evaluation.

Implications for Occupational Therapy Education

The American Occupational Therapy Association (2005) Code of Ethics states that
“occupational therapy personnel shall provide services in a fair and equitable man-
ner” (p. 1085). In its commitment to nondiscrimination and inclusion, the Amer-
ican Occupational Therapy Association advocates that practitioners must “avoid
differentiating between people because of biases or prejudices” [. . . and that this
. . .] “ is best served when the inherent worth of every individual is recognized and
valued” (American Occupational Therapy Association, 2009). To achieve this out-
come, occupational therapy education curricula should and does include reducing
stigmatization and discrimination among its objectives.
Occupational therapy faculties address cultural sensitivity, develop cultural
competency, and promote tolerance. Prejudicial attitudes and stereotypical be-
liefs about obesity need to be included in this aspect of curriculum. Stigmatizing
 Obesity and Prejudicial Attitudes 87

attitudes about obesity are pervasive and complex; modifying them is challenging.
Psychologically and socially targeted interventions that combine multiple attitude-
changing strategies are likely to be more effective (Puhl, Schwatz, & Brownell,
2005). These strategies include accurate information about attitudes toward per-
sons who are obese and collective peer group condemnation of prejudicial attitudes.
These can be achieved using trained peer leaders or role modeling by occupational
therapy fieldwork supervisors and professors who express positive attributes and
nonstereotypical beliefs about people who are obese.
There are also examples of effective educational programming that have ad-
dressed prejudicial attitudes related to obesity that can be used as a model for occu-
pational therapy education. Occupational therapy educators might look at strate-
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

gies developed by Weise, Wilson, Jones, and Neises (1992) who demonstrated that
an intensive educational program on obesity and empathy resulted in significant
improvement in students’ explicit attitudes and beliefs. Similarly, there are existing
pedagogical models in occupational therapy education that are employed to teach
the tenets of client-centeredness, as well as content and experiential learning, de-
veloped for cultural sensitivity programs that could be modified to address obesity.
This would include education about the etiology of obesity and the challenges of the
behavioral changes necessary to reduce weight. It is essential that obesity stigma-
reducing interventions are part of occupational therapy students’ education before
they enter the profession.
For personal use only.

STUDY LIMITATIONS
The majority of the participants sampled were white and drawn from one allied
health care profession. Therefore, replication of this study using a more diverse
sample is desirable, especially as ethnic and cultural differences in attitudes toward
obesity have been reported in other studies (Davidson & Knafl, 2006). Although
the AO-PESIS demonstrated sound psychometric properties, all the items loaded
on three factors. Conceptually, it would be preferable if the items loaded on more
factors that represented different dimensions of stigmatization.

FUTURE DIRECTIONS AND CONCLUSION

This study found that participants who were occupational therapy students differ-
entiated between clients who were obese and average-weight clients on indirect
measures of judgment and social distance and showed prejudicial attitudes and
stereotypical beliefs about obese people on direct measures. Research has shown
students’ attitudes positively correlate with those of practitioners of the same pro-
fession (Chambliss et al., 2004; Weise et al., 1992); therefore, we can suggest that
entry-level occupational therapy practitioners may have prejudicial attitudes and
stereotypical beliefs about obesity. Currently, this study is being replicated with
practitioners, and because of the influence of social desirability biases, this and other
future studies would benefit from the inclusion of a measure to control for this po-
tential bias. Future research needs to examine prejudicial attitudes and stereotyp-
ical beliefs among other allied health professions, including occupational therapy,
 88 Vroman and Cote

with the goal of developing educational materials that would target stigmatizing
attitudes toward client/patients who are obese.

ACKNOWLEDGMENTS
The data collection was partially funded by the University of New Hampshire
Undergraduate Research Opportunity Program. Thanks are expressed to the stu-
dents and faculty in the participating occupational therapy programs, Dr. Rebecca
Warner for her expert advice in the analysis process, and Elizabeth Crepeau for
her useful feedback on this article. A special thanks to my friend and colleague
who agreed to be digitally altered for this study.
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

Declaration of interest: The authors report no conflicts of interest. The authors

alone are responsible for the content and writing of this article.

ABOUT THE AUTHORS

Kerryellen Vroman, PhD, OTR/L, and Sabrina Cote, MS, OTR/L, are affiliated
with the Department of Occupational Therapy, University of New Hampshire,
Durham, New Hampshire, USA.
For personal use only.

REFERENCES
Allison, D., Basile, V., & Yuker, H. E. (1991). The measurement of attitudes toward and beliefs
about obese persons. International Journal of Eating Disorders, 10, 599–607.
American Occupational Therapy Association. (2005). Occupational therapy code of ethics.
American Journal of Occupational Therapy, 59, 1085–1086.
American Occupational Therapy Association. (2009). Occupational therapy’s commitment
to nondiscrimination and inclusion. Retrieved from http://www.aota.org/Practitioners/
Official/Position/38198.aspx
Brown, I. (2006). Nurses’ attitudes towards adult patients who are obese: Literature review. Jour-
nal of Advance Nursing, 53, 221–232.
Brown, I., Thompson, J., Tod, A., & Jones, G. (2006). Primary care support for tackling obesity: a
qualitative study of the perceptions of obese patients. British Journal of General Practice, 56,
666–672.
Calderaro-Munguba, M., Valdes, M. T., & Silva, C. (2008). The application of an occupational
therapy nutrition education programme for children who are obese. Occupational Therapy
International, 15, 56–70. doi: 10.1002/oti.244
Carr, D., & Friedman, M. (2005). Is obesity stigmatizing? Body weight, perceived discrimination,
and psychological well-being in the United States. Journal of Health and Social Behavior, 46,
244–259.
Chambliss, H. O., Finley, C., & Blair, S. (2004). Attitudes toward obese individuals among exer-
cise science students. Medicine and Science in Sports and Exercise, 36, 468–474.
Clark, F., Reingold, F. S., & Salles-Jordan, K. (2007). Obesity and occupational therapy. American
Journal of Occupational Therapy, 61, 701–703.
Coker, E. M. (2005). Selfhood and social distance: Toward a cultural understanding of psychiatric
stigma in Egypt. Social Science and Medicine, 61, 920–930.
Crocker, J., Cornwell, B., & Major, B. (1993). The stigma of overweight: Affective consequences
of attributional ambiguity. Journal of Personality and Social Psychology, 64, 60–70.
Davidson, M., & Knafl, K. A. (2006). Dimensional analysis of the concept of obesity. Journal of
Advance Nursing, 54, 342–350.
 Obesity and Prejudicial Attitudes 89

Epstein, L., & Ogden, J. (2005). A qualitative study of GPs’ views of treating obesity. British
Journal of General Practice, 55, 750–754.
Fisher, R. J. (1993). Social desirability bias and the validity of indirect questioning. Journal of
Consumer Research, 20, 303–315.
Foster, G., Wadden, T., Markis, A., Davidson, D., Sanderson, R., Allison, D., et al. (2003). Primary
care physicians’ attitudes about obesity and treatment. Obesity Research, 11, 1168–1177.
Garland, R. (1991). The mid-point on a rating scale: Is it desirable? Marketing Bulletin, 2, 66–70.
Goffman, I. (1963). Stigma: Notes on the management of spoiled identity. New York: Simon &
Schuster.
Grewald, A. G., & Nosek, B. A. (2001). Health of the implicit association test at age 3. Zeitschrift
fur Experiementelle Psychologie, 48, 85–93.
Hebl, M., Xu, J., & Mason, M. (2003). Weighing the care: Patients’ perceptions of physician care
as a function of gender and weight. International Journal of Obesity and Related Metabolic
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

Disorders: Journal of the International Association for the Study of Obesity, 27, 269–275.
Hiller, D. A. (1982). Overweight as master status: A replication. The Journal of Psychology, 110,
107–113.
Jussim, L., Palumbo, P., Chatman, C., Madon, S., & Smith, A. (2000). Stigma and self-fulfilling
prophecies. In T. F. Heatherton, R. E. Kleck, M. R. Hebl & J. G. Hull (Eds.), The social psy-
chology of stigma (pp. 374–418). New York: The Guilford Press.
Kaminsky, J., & Gadaleta, D. (2002). A study of discrimination within the medical community as
viewed by obese patients. Obesity Surgery, 12, 14–18.
Kelly, J. A., Lawrence, J. S. S., Smith, S., Hood, H. V., & Cook, D. J. (1987). Stigmatization of
AIDS patients by physicians. American Journal of Public Health, 77, 789–791.
Link, B., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27,
363–385.
For personal use only.

Link, B., Phelan, J. C., Bresnahan, M., Stueve, A., & Pescosolido, B. A. (1999). Public concep-
tions of mental illness: Labels, causes, dangerousness, and social distance. American Journal
of Public Health, 89, 1328–1333.
Maroney, D., & Golub, S. (1992). Nurses’ attitudes towards persons and certain ethnic groups.
Perceptual and Motor Skills, 75, 387–391.
McArthur, L. H., & Ross, J. K. (1997). Attitudes of registered dietitians towards personal over-
weight and overweight clients. Journal of the American Dietetic Association, 97, 63–66.
McCaughey, T. L., & Strohmer, D. C. (2005). Prototypes as an indirect measure of attitudes to-
wards disability groups. Rehabilitation Counseling Bulletin, 48, 89–99.
Mercer, S., & Tessier, S. (2001). A qualitative study of general practitioners’ and practice nurses’
attitudes to obesity management in primary care. Health Bulletin, 59, 248–253.
Mosely, L., Jedlicka, J., Lequieu, E., & Taylor, F. (2008). Obesity and occupational therapy prac-
tice: Present and potential practice trends. OT Practice, 13, 8–14.
O’Brien, K., Latner, J., Halberstadt, J., John, A., Hunter, J., Jeremy Anderson, J., et al. (2008).
Do antifat attitudes predict antifat behaviors? Obesity, 16, 87–92.
Paulhus, D. L. (1991). Measure and control of response bias. In J. P. Robinson, P. R. Shaver &
L. S. Wrightman (Eds.), Measures of personality and social psychological attitudes (pp. 17–59).
New York: Academic Press.
Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: A review and update. Obesity, 17,
941–961. doi: 10.1038/oby.2008.636
Puhl, R. M., Schwartz, M. B., & Brownell, K. D. (2005). Impact of perceived consensus on stereo-
types about obese people: A new approach for reducing bias. Health Psychology, 24, 517–525.
Sack, S., Radler, D. R., Mairella, K. K., Touger-Decker, R., & Khan, H. (2009). Physical thera-
pists’ attitudes, knowledege, and practice approaches regarding people who are obese. Physi-
cal Therapy, 89, 804–815.
Shapiro, J., King, E., & Quiñones, M. (2007). Expectations of obese trainees: How stigmatized
trainee characteristics influence training effectiveness. The Journal of Applied Psychology, 92,
239–249.
Teachman, B. A., & Brownell, K. D. (2001). Implicit anti-fat bias among health professionals: Is
anyone immune? International Journal of Obesity, 25, 1525–1531.
 90 Vroman and Cote

U.S. Department of Health and Human Services—National Heart and Lung Institute. (2010).
Calculate your body mass index. Retrieved from http://www.nhlbisupport.com/bmi/ Retrieved
June 10th 2010
Vroman, K. (2006). An assessment of occupational therapy students’ attitudes towards clients who
are obese. Paper presented at the 14th World Federation of Occupational Therapy Congress,
Action, Local and Global, Sydney, Australia.
Wang, S. S., Brownell, K. D., & Wadden, T. A. (2004). The influence of the stigma of obesity on
overweight individuals. International Journal of Obesity, 28, 1333–1337.
Warner, R. M. (2008). Applied statistical analysis: From bivariate through multivariate techniques.
Los Angeles: Sage Publications.
Weise, H., Wilson, J. F., Jones, R., & Neises, M. (1992). Obesity stigma reduction in medical stu-
dents. International Journal of Obesity and Related Metabolic Disorders, 16, 859–868.
White, M. J., & Olsen, R. S. (1998). Attitudes towards people with disabilities: A comparison of
Occup Ther Health Downloaded from informahealthcare.com by University of Montreal on 12/08/14

rehabilitation nurses, occupational therapists, and physical therapists. Rehabilitation Nursing,

23, 126–130.
Yuker, H., Allison, D., & Faith, M. (1995). Methods for measuring attitudes and beliefs about
obese people. In D. Allison (Ed.), The handbook of assessment methods for eating behaviors
and weight related problems: Measures, theory, and research (pp. 81–118). Thousand Oaks, CA:
Sage Publications.

Received: 02/06/2010
Revised: 10/13/2010
Accepted: 10/15/2010
For personal use only.