Table 1.

Study characteristics

No.	Author	Year	Title	Geographical location	Study purpose	Primary health sector	Sample description	Sample BMI classification	Study design	Measures used	Main findings
1	Amy, N.K., Aalborg, A., Lyons, P., Keranen, L.	2006	Barriers to routine gynecological cancer screening for White and African-American obese women	California, USA	To investigate the factors that contribute to lower rates of gynecological cancer screening as related to women’s body size	Preventive cancer screening	Focus groups: n = 60 White and African American women 40–60 years old, n = 29 gynecological care providers (physician assistants, and nurse practitioners who provide gynecological care). Survey: n = 498 White and African American women 21–80 years, n = 129 health care providers	Women BMI: 25–35 kg/m2 (n = 131); >35–45 kg/m2 (n = 169); >45–55 kg/m2 (n = 121); >55 kg/m2 (n = 60)	Mixed methods	Focus group questions prompted discussions about perceptions and attitudes about gynecological cancer screening. Survey questions were based on focus group discussions. Women with obesity and health care providers were provided with different surveys.	Women reported weight-related barriers to health care access. These included disrespectful treatment, embarrassment at being weighed, negative attitudes, unsolicited advice about weight loss, and inappropriate medical equipment. With increases in BMI, a greater percentage of women reported delaying cancer screening tests.
2	Bottone, F.G., Musich, S., Wang, S.S., Hommer, C.E., Yeh, C.S., Hawkins, K.	2014	Obese older adults report high satisfaction and positive experiences with care	USA	To assess the impact of obesity on satisfaction and experiences with care in older adults	Did not exclusively examine one health sector (personal doctors and specialists)	N = 18,192 >65 years old with an AARP Medicare Supplement Insurance Plan insured by UnitedHealthcare Insurance Company in 10 states	Underweight (n = 516), normal (n = 7018), overweight (n = 6765) and obese (n = 3893)	Quantitative survey	Modified version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey mailed to the participants	Obesity was associated with higher patient satisfaction and better health care experiences. Patients with obesity had more doctor office visits about nutrition and exercise.
3	Brown, I., Thompson, J., Tod, A., Jones, G.	2006	Primary care support for tackling obesity: a qualitative study of the perceptions of obese patients	Sheffield, England	To explore obese person’s experiences and perceptions of support in primary care	General practice. Nurse practitioners or physicians	N = 28 (M = 10, F = 18) patients, >18 years from five general practice offices	Obese	Qualitative semi-structured interviews	Face-to-face 1-h interviews	Patients with obesity were ambivalent about accessing health services due to the lack of sensitive resources and ambiguous communication. Patients also perceived health professional ambivalence.
4	Buxton, B.K., Snethen, J.	2013	Obese women’s perceptions and experiences of healthcare and primary care providers: a phenomenological study	Pennsylvania, USA	To describe the experiences and perceptions of obese women with regard to stigma in health care	General practice. Nurse practitioners or physicians	N = 26 English-speaking women 27–66 years old	Obese	Phenomenological qualitative design using the Colaizzi method	Semi-structured, face-to-face 60–90 min interviews	All participants reported receiving some form of negative treatment from health care providers. Most participants did not report delaying or avoiding health care.
5	DeJoy, S.B., Bittner, K., Mandel, D.	2016	A qualitative study of the maternity care experiences of women with obesity: ‘more than just a number on the scale’	USA (13 different states)	To explore the experiences of women with obesity in the maternity care system in the United States	Maternity	N = 16 pregnant or recently postpartum women recruited from online communities for plus-size pregnant women	Obese	Qualitative interview	In-depth telephone interview ranging for 15 min–1 h	Most participants reported at least one stigmatizing maternity care experience. However, some participants did report being satisfied with the maternity services they received.
6	Drury, C.A.A., Louis, M.	2002	Exploring the association between body weight, stigma of obesity, and health care avoidance	Las Vegas, Nevada, USA	To explore the stigma of obesity and its effect on health care utilization	Did not exclusively examine one health sector (family practice, nurse practitioner, and gynecology)	N = 216 women from church sites 30–59 years old	Normal <27.5 kg/m2 (n = 137), mild obesity 27.5–30.0 kg/m2 (n = 19), moderate obesity >30–40 kg/m2 (n = 43), morbid obesity >40 kg/m2 (n = 11)	Quantitative survey	Questionnaire developed by Packer (1990) which included two questions from the Weight Locus of Control Scale modified by Packer, the Satisfaction with Medical Care Scale modified by Packer and the Rosenberg Self-Esteem Scale	Obesity stigma acts as a barrier to accessing health care. With increases in BMI, a greater number of participants delayed and/or avoided health care services.
7	Ferrante, J.M., Seaman, K., Bator, A., Ohman-Strickland, P., Gundersen, D., Clemow, L., Puhl, R.	2016	Impact of perceived weight stigma among underserved women on doctor-patient relationships	New Jersey, USA	To evaluate how perceptions of weight stigma among underserved women with obesity impacts doctor-patient relationships	General practice	N = 149 women 21–70 years old visiting physicians at four federally qualified health centers	Obese	Quantitative cross-sectional survey	The Stigma Situations in Health Care instrument and Consultation and Relational Empathy (CARE) measure	Increases in participant BMI classification was associated with increased likelihood of greater perceptions of weight stigma. With increases in stigma situations, there was a decrease in perceptions of physician empathy.
8	Forhan, M., Risdon, C., Solomon, P.	2013	Contributors to patient engagement in primary health care: perceptions of patients with obesity	Hamilton, Ontario, Canada	To identify issues associated with engagement in primary health care for patients with obesity	Family health team (family physicians, family medicine residents, and nurse practitioners)	N = 11(M = 2, F = 8) 19–64 years old registered with a primary care practice	Obese	Qualitative semi-structured interviews	Face-to-face and telephone interviews averaging 33 min	Feeling judged, lack of privacy, poor communication, and limited health provider knowledge about obesity were reported as barriers to primary health care engagement. Facilitators to engaging in primary health care included availability of resources, importance of relationship, and meaningful communication.
9	Gudzune, K.A., Bennett, W.L., Cooper, L.A., Bleich, S.N.	2014	Patients who feel judged about their weight have lower trust in their primary care providers	USA	To explore whether overweight and obese patients have less trust in their primary care providers (PCPs)	General practice	N = 600 (M = 312, F = 288) adults engaged in primary care in 2012	Overweight and obese	Quantitative cross-sectional survey	Survey questions assessed weight loss outcomes, doctor shopping behavior, and patient-provider relationship variables including duration, trust in PCP, and perceived weight judgment	21% of participants perceived weight related judgment from their PCPs. Participants who perceived judgment were less likely to trust their care provider.
10	Gudzune, K.A., Bennett, W.L., Cooper, L.A., Bleich, S.N.	2014	Perceived judgment about weight can negatively influence weight loss: a cross-sectional study of overweight and obese patients	USA	To examine the relationship between patient-perceived judgments about weight by primary care providers and self-reported weight loss	General practice	N = 600 (M = 312, F = 288) adults engaged in primary care in 2012	Overweight and obese	Quantitative cross-sectional survey	Survey questions assessed weight loss outcomes, doctor shopping behavior, and patient-provider relationship variables including duration, trust in PCP, and perceived weight judgment	Participants who perceived weight-related judgment from their primary care providers (21%) were more likely to attempt weight loss. However, perceptions of judgment were not associated with greater weight loss.
11	Gudzune, K.A., Bennett, W.L., Cooper, L.A., Clark, J.M., Bleich, S.N.	2014	Prior doctor shopping resulting from differential treatment correlated with differences in current patient-provider relationships	USA	To determine the prevalence of doctor shopping that is the result of differential treatment and to explore relationships between doctor shopping and current primary care relationships	General practice	N = 600 (M = 312, F = 288) adults engaged in primary care in 2012	Overweight and obese	Quantitative cross-sectional survey	Survey questions assessed weight loss outcomes, doctor shopping behavior, and patient-provider relationship variables including duration, trust in PCP, and perceived weight judgment	13% of participants reported previous doctor shopping behavior as a result of weight-based differential treatment. Doctor shopping behavior was associated with shorter durations of their current patient-provider relationships.
12	Gudzune, K.A., Beach, M.C., Roter, D.L., Cooper, L.A.	2013	Physicians build less rapport with obese patients	Baltimore, Maryland, USA	To describe the relationship between patient BMI and physician communication behaviors during a typical outpatient primary care visit	Routine follow-ups with primary care providers	N = 39 primary care physicians (PCPs) and N = 208 of their patients 18 years and older diagnosed with hypertension within 12 months of patient recruitment	Normal (n = 28), overweight (n = 60), and obese (n = 120)	Quantitative cross-sectional study	Audio-recorded outpatient encounters used to examine the frequency of communication behaviors in the patient-physician relationship	Primary care physicians engaged in less emotional rapport with patients with obesity or overweight, compared to normal weight patients.
13	Hansson, L.M., Rasmussen, F.	2014	Association between perceived health care stigmatization and BMI change	Sweden	To examine the association between experiences of health care stigmatization and BMI changes in men and women with normal weight and obesity	General practice	N = 2788 adults aged 25–64 years in 2008	Normal weight (n = 1064), moderate obesity (n = 1273), and severe obesity (n = 291) at the time of participation in the ULF survey	Quantitative survey	One question in the survey concerned perceived health care stigmatization. The Rosenberg’s Self-Esteem Scale and the Marlowe-Crowne social desirability scale	In the severe obesity group, health care stigmatization was associated with an increase in BMI by 1.5 kg/m2. With those classified as moderately obese, increases in BMI was associated with avoidance of health care and perceptions of insulting treatment.
14	Hilbert, A., Braehler, E., Haeuser, W., Zenger, M.	2014	Weight bias internalization, core self-evaluation, and health in overweight and obese persons	Germany	To examine a process model of self-stigma as well as the impact of core self-evaluation as a mediator between weight bias internalization, health outcomes, and health care utilization	Did not involve specific health care settings	N = 1158 (M = 629, F = 529) representative sample of German population 14–89 years old	Overweight (n = 931), obese (n = 227)	Quantitative survey	The Weight Bias Internalization Scale (WBIS), the Core Self-Evaluation Scale (CSES), the Patient health Questionnaire-2(PHQ-2), the Generalized Anxiety Disorder-2 (GAD-2), the Visual Analogue Scale (VAS) of health status, and the Health Care Utilization Questionnaire	In participants with overweight and obesity, lower core self-evaluation acts as a mediator in the relationship between weight bias internalization, health-related outcomes, and health care utilization.
15	Kaminsky, J., Gadaleta, D.	2002	A study of discrimination within the medical community as viewed by obese patients	Great Neck, New York, USA	To present the views and opinions of obesity surgery patients regarding care received before, during, and after weight loss surgery	Did not exclusively examine one health sector (primary care physicians and specialists)	N = 40 (M = 6, F = 34) obese adults 21–61 years old from four East Coast bariatric practices. Average preoperative weight of 145 kg	Obese	Quantitative survey	Survey assessing patient perceptions of physician and hospital staff attitudes, appropriateness of equipment, and level of care received from professional and non-professional medical personnel	17% of patients reported changing primary care physicians due to perceived physician indifference, lack of concern, or negative attitudes toward bariatric surgery.
16	Merill, E., Grassley, J.	2008	Women’s stories of their experiences as overweight patients	Texas, USA	To illuminate the meaning of women’s experiences as overweight patients in their encounters with health care services and health care providers	General practice and specialists	N = 8 women self-identified as being overweight patients. Ages 21–60 years old	Overweight and obese	Qualitative interviews. A hermeneutic phenomenological approach	In depth, face-to-face 50–90 min interviews. Participants were asked ‘Tell me a story, one you will never forget about going to your healthcare provider and your experience of being overweight’	Four major themes were identified: struggling to fit in, being dismissed, feeling not quite human, and refusing to give up.
17	Olson, C.L., Schumaker, H.D., Yawn, B.P.	1994	Overweight women delay medical care	La Crosse, Wisconsin, USA	To determine whether women delay or avoid health care because they are overweight	Community hospital	N = 310 female registered nurses (n = 225), licensed practical nurses (n = 26), nursing assistants (n = 13), health unit coordinators (n = 28), general psychiatric assistants (n = 1) and other (n = 17) 21–68 years old employed at St Francis Medical Center in July 1992	Underweight >20 kg/m2, normal weight 20–24.9 kg/m2, mild obesity 25–26.9 kg/m2 (n = 35), obese >27–34.9 kg/m2 (n = 75), very obese >35 kg/m2 (n = 11)	Quantitative survey	Visual analogue scale was used to assess perceptions of body weight. Survey questions assessed level of satisfaction with previous physician interactions concerning weight	BMI was positively associated with the delay of medical care. 12.7% of participants reported delaying or canceling a physician appointment due to weight concerns. Another small percentage (2.6) of participants reported keeping their appointments but refused to be weighed.
18	Pryor, W.	2002	The health care disadvantages of being obese	New South Wales, Australia	To describe the obese patients’ views about health care, myths and realities about obesity, and suggestions about how to improve health care for obese patients	General practice and specialists	A selection of messages posted by women with obesity on the Big Beautiful Women Down Under internet site	Obese	Informative bulletin	The Big Beautiful Women Down Under internet site	Health care professionals’ negative attitudes toward their patients with obesity are perceived by these patients. Inaccurate health professional assumptions about the eating habits and health behaviors of patients with obesity, inadequate equipment, and avoidance of general health care checkups were reported by women with obesity.
19	Puhl, R., Peterson, J.L., Luedicke, J.	2013	Motivating or stigmatizing? Public perceptions of weight-related language used by health providers	USA	To examine public preferences and perceptions of weight-based terminology	Routine checkup with a physician	N = 1064 (M = 417, F = 636) American adults 18–88 years old	Underweight (n = 47), normal (n = 351), overweight (n = 321), obese (n = 320)	Quantitative online survey	Likert scale (5 point) used to assess perceptions of 10 weight-related terms. Weight bias was assessed with the Fat Phobia Scale. Weight victimization was assessed with three forced choice questions (yes or no). Reactions to stigmatizing situations were assessed with a measure developed specifically for this study	Participants (19%) reported that they would avoid medical appointment if they felt stigmatized about their weight by their doctor. Participants (21%) also reported that they would seek a new doctor if they felt stigmatized about their weight by their doctor.
20	Russell, N., Carryer, J.	2013	Living large: the experiences of large-bodied women when accessing general practice services	New Zealand	To explore the experiences of large-bodied women (LBW) accessing general practice services	General practice	N = 8 self-identified LBW	Self-identified, large-bodied women (No BMI)	A qualitative descriptive inquiry that adopts a post-structural feminist lens during thematic analysis	Face-to-face interviews based on interview guide used in similar studies	Inappropriate humor, verbal insults, unmet health needs, and negative body language from health care providers were experiences of explicit negative weight bias reported by self-identified large bodied women.
21	Wadden, T.A., Anderson, D.A., Foster, G.D., Bennett, A., Steinberg, C., Sarwer, D.B.	2000	Obese women’s perceptions of their physicians’ weight management attitudes and practices	Philadelphia, Pennsylvania, USA	To examine obese women’s perceptions of their physicians’ weight management attitudes and practices	Weight management. (Physician, gynecologist, or nurse practitioner)	N = 259 women seeking treatment at one of three randomized control trials at the University of Pennsylvania with a history of weight loss and regain. Mean age of 44 ± 10 years	Obese	Quantitative questionnaire	A health care questionnaire developed by the authors measured patient satisfaction, frequency of physician discussions about weight, frequency of negative interactions with physicians about weight, and weight loss methods used by physicians. The Beck Depression inventory II was used to measure mood	Participants were less satisfied with the care they received for their obesity compared to the care they received for their general health. A small percentage of participants reported negative interactions with their physicians when weight management was discussed.