Attitudes toward and beliefs about obese persons across Hong Kong and Taiwan: wording effects and measurement invariance

Assessing Weight Stigma: Validating Attitudes and Beliefs Questionnaires Among Future Healthcare Professionals

Background This study aimed to establish the reliability and validity of the Anti-Fat Attitudes (AFA) questionnaire and the Beliefs About Obese Persons (BAOP) scale. Methodology A convenience sample of 257 students from three distinct sections of the University of Medicine and Pharmacy "Grigore T. Popa" Iasi (Medical Faculty, Nutrition and Dietetics, and Nursing) participated in an observational study. Construction validity was tested with exploratory factor analysis. The students completed a form containing sociodemographic data, the AFA questionnaire, and the BAOP scale. Weight and height were self-reported and used to determine the body mass index. Results The value of the Cronbach alpha coefficient for the AFA questionnaire indicated adequate internal consistency (0.862). The exploratory factor analysis identified the following three factors corresponding to the original questionnaire: Dislike, Fear of Fat, and Willpower. We validated a single-factor structure of the BAOP scale, which had adequate internal consistency (0.781). There were statistically significant differences (AFA: p = 0.02; BAOP: p = 0.03) between the scores of the students from Nutrition and Dietetics, Nursing, and General Medicine. Conclusions This study demonstrated that the AFA questionnaire and the BAOP scale could be used to evaluate weight stigma in healthcare students, providing a useful tool to assess the effects of weight stigma awareness interventions in this population.

Does Terminology Matter When Measuring Stigmatizing Attitudes About Weight? Validation of a Brief, Modified Attitudes Toward Obese Persons Scale

Objective Commonly used terms like "obese person" have been identified as stigmatizing by those with lived experience. Thus, this study sought to revise a commonly used measure of weight stigmatizing attitudes, the Attitudes Toward Obese Persons (ATOP) scale. Methods The original terminology in the 20-item ATOP (e.g., "obese") was compared to a modified version using neutral terms (e.g., "higher weight"). Participants ( N  = 832) were randomized to either receive the original or modified ATOP. Results There was a statistically significant difference, with a low effect size ( d =-0.26), between the scores of participants who received the original ATOP ( M  = 69.25) and the modified ATOP ( M  = 72.85), t (414) = -2.27, p  = .024. Through principal component analysis, the modified ATOP was found to be best used as a brief, 8-item unidimensional measure. In a second sample, confirmatory factor analysis verified the fit of the brief, 8-item factor structure. Conclusions Findings suggest a modified, brief version of the ATOP (ATOP-Heigher Weight; ATOP-HW) with neutral language is suitable for assessing negative attitudes about higher-weight people. The ATOP-HW may slightly underestimate weight stigma compared to the original ATOP. Further examination of the terminology used in weight stigma measures is needed to determine how to best assess weight stigma without reinforcing stigmatizing attitudes. The findings of the present study suggest that the use of neutral terms in measures of anti-fat bias is a promising solution that warrants further investigation.

Does Terminology Matter When Measuring Stigmatizing Attitudes About Weight? Validation of a Brief, Modified Attitudes Toward Obese Persons Scale

Objective Commonly used terms like "obese person" have been identified as stigmatizing by those with lived experience. Thus, this study sought to revise a commonly used measure of weight stigmatizing attitudes, the Attitudes Toward Obese Persons (ATOP) scale. Methods The original terminology in the 20-item ATOP (e.g., "obese") was compared to a modified version using neutral terms (e.g., "higher weight"). Participants ( N  = 832) were randomized to either receive the original or modified ATOP. Results There was a statistically significant difference, with a low effect size ( d =-0.26), between the scores of participants who received the original ATOP ( M  = 69.25) and the modified ATOP ( M  = 72.85), t (414) = -2.27, p  = .024. Through principal component analysis, the modified ATOP was found to be best used as a brief, 8-item unidimensional measure. In a second sample, confirmatory factor analysis verified the fit of the brief, 8-item factor structure. Conclusions Findings suggest a modified, brief version of the ATOP (ATOP-Heigher Weight; ATOP-HW) with neutral language is suitable for assessing negative attitudes about higher-weight people. The ATOP-HW may slightly underestimate weight stigma compared to the original ATOP. Further examination of the terminology used in weight stigma measures is needed to determine how to best assess weight stigma without reinforcing stigmatizing attitudes. The findings of the present study suggest that the use of neutral terms in measures of anti-fat bias is a promising solution that warrants further investigation.

Body shaming and internalized weight bias as potential precursors of eating disorders in adolescents

Introduction

Body shaming (BS) is a growing phenomenon within the school context, especially among adolescents. Recently, it has been described as an unrepeated act in which a person expresses unsolicited, mostly negative comments about an individual's body. The targeted person perceives these comments as negative, offensive or body shame-inducing. Empirical evidence also suggests that body weight is the most common reason that youths are teased and bullied. Indeed, weight stigma, described as bias or discriminatory behaviors, attitudes, feelings, and thinking about individuals, because of their weight, can lead to weight-based discrimination and victimization. Preliminary evidence suggests that BS and weight stigma have negative effects on psychological health both in the short and long term. In the delicate stage of adolescence development and pubertal maturation, BS experiences can be highly prevalent and it can lead to adverse outcomes such as eating disorders (ED). However, prevalence data in the Italian context are still lacking.

Methods

The study aims to estimate weight-related BS perceived by different sources (i.e., peers and family members) and their associations with public and internalized weight bias, body mass index (BMI), body dissatisfaction, and ED symptoms. A sample of 919 high school students (Mage = 15.97, SD = 1.58; 57.1% boys) completed a battery of self-report questionnaires assessing these variables.

Results

One in four students reported experiences of weight-related BS by peers or family members. A total of 37% reported having at least one BS experience in a lifetime. Higher scores of ED symptoms, body dissatisfaction, and weight bias were reported by adolescents who experienced BS, especially females. Among overweight participants, results showed that internalized weight bias partially mediated the relationship between BS by family members and ED symptoms and fully mediated the relationship between BS by peers and ED symptoms, after controlling for age, sex and BMI.

Discussion

These findings, despite their cross-sectional nature, add an important contribution to the creation of quantitative empirical evidence on the phenomenon of BS. Its role in explaining eating disorders, both alone and with the mediation of internalized weight stigma has been first proved and needs to be confirmed by longitudinal results.

Improving emotional and psychosexual well-being screening in women living with polycystic ovary syndrome: experiences from the United Kingdom and India

With increasing evidence of emotional well-being disorders associated with polycystic ovary syndrome (PCOS), effective screening processes are of utmost importance. We studied the impact of using questionnaires to screen for emotional and psychosexual well-being across different models of care for PCOS. We analysed the data from the surveys to assess the difference in the prevalence of emotional and psychosexual ill-being across ethnicity and region. In this prospective cohort study, we invited all women attending consultations for PCOS in Birmingham, UK, and Bengaluru and Navi Mumbai, India. Those who consented to participate in the study were invited to complete a pre-clinic survey about socio-demographic data, Hospital Anxiety and Depression Scale (HADS), Body Image Concern Inventory (BICI), Beliefs about Obese Person scale (BAOP), and Female Sexual Function Index score (FSFI) and a post-clinic survey on clinic experience, lifestyle advice, and specialist referral. A total of 115 women were included in this study. The rate of questionnaire completion was 98.3% (113/115), 97.4% (112/115), 93.04% (107/115), and 84.3% (97/115) for HADS, BICI, BAOP, and FSFI, respectively. In the post-clinic survey, 28.8% reported they were screened for anxiety, 27.1% for depression, and 45.8% for body image concerns. The prevalence of anxiety, depression, and body dysmorphic disorder through pre-clinic survey was 56.5% (50.0% UK vs 59.5% India, P = 0.483), 16.5% (13.9% UK vs 17.7% India, P = 0.529), and 29.6% (36.1% UK vs 26.6% India, P = 0.208), respectively. Surveys with validated questionnaires can improve screening for emotional and psychosexual well-being associated with PCOS which may be missed by ad hoc screening during consultations.

Emotional and psychosexual well-being is influenced by ethnicity and birthplace in women and individuals with polycystic ovary syndrome in the UK and India

OBJECTIVE

To assess the association of ethnicity and birthplace on emotional and psychosexual well-being in women with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional study.

SETTING

Community recruitment via social media campaigns.

POPULATION

Women with PCOS completing an online questionnaire in September-October 2020 (UK) and May-June 2021 (India).

METHODS

The survey has five components, with a baseline information and sociodemographic section followed by four validated questionnaires: Hospital Anxiety and Depression Scale (HADS); Body Image Concern Inventory (BICI); Beliefs About Obese Persons Scale (BAOP); and Female Sexual Function Index (FSFI).

MAIN OUTCOME MEASURES

We used adjusted linear and logistic regression models, adjusting for age, education, marital status and parity, to evaluate the impact of ethnicity and birthplace on questionnaire scores and outcomes (anxiety and/or depression, HADS ≥ 11; body dysmorphic disorder (BDD), BICI ≥ 72).

RESULTS

A total of 1008 women with PCOS were included. Women of non-white ethnicity (613/1008) reported higher rates of depression (OR 1.96, 95% CI 1.41-2.73) and lower BDD (OR 0.57, 95% CI 0.41-0.79) than white women (395/1008). Women born in India (453/1008) had higher anxiety (OR 1.57, 95% CI 1.00-2.46) and depression (OR 2.20, 95% CI 1.52-3.18) but lower BDD rates (OR 0.42, 95% CI 0.29-0.61) than women born in the UK (437/1008). All sexual domains, excluding desire, scored lower for non-white women and women born in India.

CONCLUSIONS

Non-white women and women born in India reported higher emotional and sexual dysfunction, whereas white women and women born in the UK reported higher body image concerns and weight stigma. Ethnicity and birthplace need to be considered for tailored, multidisciplinary care.

Reliable Knowledge about Obesity Risk, Rather Than Personality, Is Associated with Positive Beliefs towards Obese People: Investigating Attitudes and Beliefs about Obesity, and Validating the Polish Versions of ATOP, BAOP and ORK-10 Scales

Obesity has reached epidemic proportions. With the increase in the number of obese people, we have also witnessed a rise in the stigmatisation of this population. The aim of our study was to: (I) validate Polish versions of the attitude toward obese people (ATOP) scale, the beliefs about obese persons (BAOP) scale, and translate the obesity risk knowledge scale (ORK-10); (II) analyse the relationship between personality and the knowledge about obesity, as well as attitudes and beliefs towards obese people.

METHODS

The translation procedure was based on the principles of intercultural validation scales. The study was conducted on a group of 306 individuals, including 189 females and 117 males.

RESULTS

The original three-factor structure of the ATOP scale was confirmed in the Polish version. Factor analysis confirmed the one-factor structure of the BAOP scale in the Polish version. A very strong correlation was found between ATOP/BAOP and ORK-10. The correlation of personality with ATOP/BAOP scales was at a low level. Regression analysis indicated that knowledge of obesity risk predicted ATOP and BAOP by more than 58% and 50%, in turn, personality only 20% and 3.7%, respectively.

CONCLUSION

The polish versions of ATOP, BAOP and ORK-10 scales are fully useful measurement tools. The knowledge about obesity risk is associated with beliefs and attitudes about obese people.

A validation study of the Italian version of the Attitudes Toward Obese Persons (I-ATOP) questionnaire

OBJECTIVES

Weight bias is defined as negative attitudes towards, and beliefs about, others because of their weight. Like other forms of stigma, weight stigma has a harmful impact on health, including depressive symptoms, disordered eating, body image disturbances and poor quality of life. Several instruments measuring weight-related attitudes have been developed, such as the Attitudes Toward Obese Persons (ATOP). The purpose of this study was to test the psychometric properties of the Italian version of the ATOP (I-ATOP).

METHODS

The ATOP was adapted into Italian following the back-translation procedure. A total of 800 participants (M_age=31.40; 54.9% females) completed the I-ATOP alongside the Weight Bias Internalization Scale (WBIS). Exploratory factor analysis (EFA) was conducted on half of the sample, while the remaining half was selected to cross-validate the resulting solution via confirmatory factor analysis (CFA). Factorial invariance tests across gender were computed using multi-group CFA.

RESULTS

EFA suggested a one-factor structure with four items excluded due to their low standardised loadings. The trimmed model was cross-validated showing an acceptable fit to the data: MLRχ2 = 159.467 (df=81); RMSEA= 0.049; CFI= 0.939; TLI= 0.910; SRMR= 0.046. An omega coefficient of 0.818 confirmed the strong reliability of the I-ATOP. Convergent validity was demonstrated by a significant and moderate correlation with the WBIS. Configural, metric, and scalar invariance across gender were established.

CONCLUSIONS

I-ATOP demonstrated to be a valid and reliable instrument useful for both clinical and research practices, as well as to support the development of educational and therapeutic actions able to reduce the stigma among the general public.

The mediation effect of perceived weight stigma in association between weight status and eating disturbances among university students: is there any gender difference?

BACKGROUND

The study aimed to examine the association between perceived weight stigma (PWS), weight status, and eating disturbances. We hypothesized that PWS would partially mediate the association between weight status and eating disturbances among university students.

METHODS

The study involved 705 undergraduate students (379 females and 326 males) recruited from Hong Kong and Taiwan Universities (399 Hong Kong; 306 Taiwan participants). Our sample was from one Hong Kong university (located in Kowloon) and five Taiwan universities (three located in Southern Taiwan, one located in Central Taiwan, and one located in North Taiwan). Participants' mean age was 20.27 years (SD = 1.79). All participants completed a demographic information sheet, the Three-Factor Eating Questionnaire-18 (TFEQ-R18), and the PWS questionnaire. PROCESS macro models were used to analyze potential mediations.

RESULTS

We found a significantly higher PWS scores in a high weight group for females and males. There was a significant difference between weight status and eating disturbances. Moreover, PWS partially mediated the association between weight status and eating disturbances for both genders.

CONCLUSIONS

PWS is associated with weight status and eating disturbances, making it an important target for health improvement among young adults. Further studies are needed to corroborate such associations in participants from other societies and cultures.

Psychological Distress and Protective Behaviors During the COVID-19 Pandemic Among Different Populations: Hong Kong General Population, Taiwan Healthcare Workers, and Taiwan Outpatients

PURPOSE

The novel coronavirus disease 2019 (COVID-19) caused psychological distress and changed human living styles. However, rare studies have examined the psychological distress and protective behaviors across different populations. Therefore, the present study aimed to assess psychological distress, protective behaviors, and potential predictors of psychological distress and protective behaviors across the Hong Kong general population, Taiwan healthcare workers, and Taiwan outpatients.

METHODS

A cross-sectional design was used to recruit participants from Hong Kong and Taiwan. Telephone interviews were carried out for Hong Kong participants (n = 1,067; 30.2% male participants); online surveys were used for Taiwan healthcare workers (n = 500; 8.0% male participants) and Taiwan outpatients (n = 192; 32.8% male participants). All the participants completed questions on psychological distress and protective behaviors. Multiple linear regressions and multivariable logistic regressions were employed to explore the potential predictors of psychological distress and protective behaviors, respectively.

RESULTS

Hong Kong participants had significantly lower levels of psychological distress than Taiwan participants [mean (SD) = 0.16 (0.39) vs. 0.47 (0.59) in healthcare workers and 0.46 (0.65) in outpatients; p < 0.001]. Hong Kong participants (51.7%) and Taiwan outpatients had more people showing fear of COVID-19 (52.0%) than Taiwan healthcare providers (40.8%; p < 0.001). Moreover, Hong Kong participants engaged the most in protective behaviors, followed by Taiwan healthcare providers and Taiwan outpatients (p < 0.001). Moreover, being a female, fear of COVID-19 and worry about personal savings were associated with protective behaviors in general.

CONCLUSIONS

Despite the greater COVID-19 severity and fear of COVID-19 in Hong Kong, the general population in Hong Kong experienced less psychosocial distress with higher compliance to protective behaviors than the other groups in Taiwan.

Perceptions and Attitudes Toward Obesity and its Management in Migrants and Rural Residents in China: a Cross-sectional Pilot Study

BACKGROUND

The incidence of overweight and obesity in rural-to-urban migrants and rural residents is increasing rapidly. This study aims to explore the perceptions and attitudes toward obesity and its management among rural-urban migrants and rural residents who are left in rural regions, China.

METHODS

We performed a cross-sectional survey investigating migrants and rural residents aged 18-45 in China from October to November 2020. We created a questionnaire. Two hundred five questionnaires were completed.

RESULTS

Finally, 184 were included, of which 102 were migrants and 82 were non-migrants. More respondents were male (62%). There was no significant difference in BMI between the two groups. The migrants had good knowledge about obesity as a disease (75.5%) and agreed that obesity seriously threatens health (93.1%). It is worth noting that more non-migrant group believed that obesity was due to a lack of willpower (87.3% vs. 54.9%, p = 0.000) than the migrant group. More than half in both groups believed that obesity was caused by a bad lifestyle (69.6%) or addiction to food (58.7%). Half of the participants believed that biological factors caused obesity. Most participants in both groups still believed weight loss modalities were limited to exercise and diet while having extremely poor acceptance of pharmacotherapy and bariatric surgery.

CONCLUSIONS

This study found that the migrants and rural residents had a good understanding of obesity as a disease, and better among migrants than rural residents. However, they showed significant uncertainty and misconceptions about the efficacy and safety of pharmacotherapy and bariatric surgery.

Factor Structure and Measurement Invariance of the Attitudes Toward Persons with Obesity (ATOP) Scale in a Preoperative and Postoperative Bariatric Surgery Sample

BACKGROUND

The Attitudes Toward Persons with Obesity (ATOP) scale is widely used to assess stigmatization toward persons with obesity. The measure has previously been suggested to assess three facets-self-esteem, personality, and social difficulties-however, psychometric support for this has been inconsistent and warrants further study if the measure intends to be scored this way.

OBJECTIVES

Explore and confirm the factor structure of the ATOP in people assessed prior to bariatric surgery and reassessed 1 year postoperatively SETTING: Midwestern hospital in the USA.

MATERIALS AND METHODS

Three-hundred sixteen people who were seeking bariatric surgery were assessed preoperatively, and 161 of those people were reassessed 1 year after surgery with a battery of measures including the ATOP. Exploratory factor analysis (EFA) was performed on ATOP data from a random split-half of people before surgery, and confirmatory factor analysis (CFA) was performed on the second randomly selected half. With the postoperative sample, a CFA was performed, testing the best-fitting model from the preoperative CFA findings.

RESULTS

The EFA suggested a two-factor structure interpreted as self-esteem and personality/social difficulties. This structure was supported by CFA performed on the second randomly selected half of people at preoperative assessment and by CFA performed on people 1 year following surgery. Tests of measurement invariance suggested that the two-factor structure was similar at both time points.

CONCLUSIONS

Only two factors for the ATOP were empirically supported in the current sample (self-esteem and personality/social difficulties), which is slightly different from the three factors that were originally proposed when the measure was developed. This factor structure is supported both prior to bariatric surgery and 1 year after bariatric surgery.

Adapting the Motors of Influenza Vaccination Acceptance Scale into the Motors of COVID-19 Vaccination Acceptance Scale: Psychometric evaluation among mainland Chinese university students

BACKGROUND

COVID-19 continues to ravage the world with economies and life significantly and negatively affected. Fortunately, there has been significant progress in the production of vaccines to stem the infection. However, with controversies and myths surrounding vaccinations, it is timely to examine individuals' willingness to vaccinate. The present study adapted the Motors of Influenza Vaccination Acceptance Scale (MoVac-Flu Scale) into the Motors of COVID-19 Vaccination Acceptance Scale (MoVac-COVID19S) for validation and assessed the acceptance of COVID-19 vaccination utilizing the cognitive model of empowerment (CME).

METHODS

A total of 3145 university students (mean age = 20.80 years; SD = 2.09) were recruited for the present study between January 5 and 16, 2021. Two MoVac-COVID19S scales (9-item and 12-item) were adapted from the MoVac-Flu Scale, an instrument developed using CME. Psychometric tests were conducted to ascertain reliability and validity properties.

RESULTS

The findings indicated that the MoVac-COVID19S had high internal consistency in both the 9-item version (ω = 0.921) and 12-item version (ω = 0.898). The factor structure of the MoVac-COVID19S (9-item and 12-item versions) corresponded well with CME theory. All the fit indices were satisfactory (comparative fit index = 0.984, Tucker-Lewis index = 0.971, root mean square error of approximation = 0.088, standardized root mean square residual = 0.058) but the 9-item MoVac-COVID had better fit indices than the 12-item MoVac-COVID due to the negative wording effects existing in the 12-item MoVac-COVID19S. The scale had satisfactory known-group validity in both 9-item and 12-item versions.

CONCLUSIONS

The MoVac-COVID19S has promising psychometric properties based on internal consistency, factor structure, and known-group validity.

Multidimensional Structure or Wording Effect? Reexamination of the Factor Structure of the Chinese General Self-Efficacy Scale

Despite overwhelming evidence supporting the unidimensional structure of the General Self-Efficacy Scale (GSES) across various language adaptations, a multifactor structure has frequently been identified for the Chinese version (GSES-C), leading some researchers to conclude that the GSES-C is multidimensional. However, the multifactor structure might derive from common method bias, such as wording effects. To test this postulation, a sample of 1,515 college students completed the GSES-C, then 507 of the sample additionally completed 3 other criteria scales. The research approach included logistic-semantic analysis, exploratory factor analysis, and confirmatory factor analysis of single-factor and bifactor models. The study yielded 3 main findings: (a) There were 2 common wording factors underlying the GSES-C: "uncertain situation wording" and "hypothetical wording." (b) Although the 1-factor model of the GSES-C did not fit the data, unidimensionality was supported when the 2 wording factors were controlled for in a bifactor model, indicating that the wording effects emerged. (c) The correlation coefficients between the general factor and external positive constructs were substantially underestimated if the wording effects were not controlled. The reasons for and the meanings of the wording effects underlying the GSES-C are also discussed.

Perceptions of nursing students about individuals with obesity problems: Belief, attitude, phobia

PURPOSE

This study aimed to determine the beliefs, attitudes, and phobias of nursing students about obese individuals.

DESIGN AND METHOD

This descriptive and cross-sectional study involved 658 students from the nursing department of a Turkish university. Data collection tools were the Fat Phobia Scale (FPS), Turkish Attitudes toward the Obese Persons Scale (T-ATOP), and Turkish Beliefs about Obese Persons Scale (T-BAOP).

FINDINGS

Students had moderate levels of fat phobia and attitudes towards obese individuals and they believed obesity is controlled by individuals.

PRACTICAL IMPLICATIONS

Fat phobic attitudes of nursing students should be prevented and positive beliefs and attitudes should be developed.

Psychological Pathway from Obesity-Related Stigma to Depression via Internalized Stigma and Self-Esteem among Adolescents in Taiwan

The objective of this research was to examine the pathway from public stigma, to perceived stigma, to depression in adolescents via internalized stigma. Adolescents in grade 7 through 9 from a junior high school in Changhua County in Taiwan completed self-administered surveys from March to July in 2018. Adolescents were asked questions regarding depressive symptoms, obesity-related perceived stigma, and internalized stigma. Structural equation modeling was used to fit the pathway model. The pathway was first analyzed with the full sample and then stratified by actual and perceived weight status. Our final analytic sample consisted of 464 adolescents. The pathway model suggested an acceptable model fit. Perceived weight stigma (PWS) was significantly associated with internalized stigma regardless of actual or self-perceived weight status. Internalized stigma was significantly associated with anxiety for both actual (β = 0.186) and self-perceived nonoverweight (non-OW) participants (β = 0.170) but not for overweight (OW) participants (neither actual nor self-perceived). For OW adolescents, perceived weight stigma was associated with anxiety. However, the internalization process did not exist. It may be that the influence of perceived weight stigma is larger than internalized stigma on anxiety. It may also be that the level of internalization was not yet high enough to result in anxiety.