Jenny Setchell

Physiotherapists demonstrate weight stigma: a cross-sectional survey of Australian physiotherapists.

QUESTION Do physiotherapists demonstrate explicit and implicit weight stigma? DESIGN Cross-sectional survey with partial blinding of participants. PARTICIPANTS responded to the Anti-Fat Attitudes questionnaire and physiotherapy case studies with body mass index (BMI) manipulated (normal or overweight/obese). The Anti-Fat Attitudes questionnaire included 13 items scored on a Likert-type scale from 0 to 8. Any score greater than zero indicated explicit weight stigma. Implicit weight stigma was determined by comparing responses to case studies with people of different BMI categories (where responses were quantitative) and by thematic and count analysis for free-text responses. PARTICIPANTS Australian physiotherapists (n=265) recruited via industry networks. RESULTS The mean item score for the Anti-Fat Attitudes questionnaire was 3.2 (SD 1.1), which indicated explicit weight stigma. The Dislike (2.1, SD 1.2) subscale had a lower mean item score than the Fear (3.9, SD 1.8) and Willpower (4.9, SD 1.5) subscales. There was minimal indication from the case studies that people who are overweight receive different treatment from physiotherapists in clinical parameters such as length of treatment time (p=0.73) or amount of hands-on treatment (p=0.88). However, there were indications of implicit weight stigma in the way participants discussed weight in free-text responses about patient management. CONCLUSION Physiotherapists demonstrate weight stigma. This finding is likely to affect the way they communicate with patients about their weight, which may negatively impact their patients. It is recommended that physiotherapists reflect on their own attitudes towards people who are overweight and whether weight stigma influences treatment focus.

Objecting: multiplicity and the practice of physiotherapy

Drawing from Annemarie Mol’s conceptulisation of multiplicity, we explore how health care practices enact their object(s), using physiotherapy as our example. Our concern is particularly to mobilise ways of practicing or doing physiotherapy that are largely under-theorised, unexamined or marginalised. This approach explores those actions that reside in the interstitial spaces around, beneath and beyond the limits of established practices. Using Mol’s understanding of multiplicity as a theoretical and methodological driver, we argue that physiotherapy in practice often subverts the ubiquitous reductive discourses of biomedicine. Physiotherapy thus enacts multiple objects that it then works to suppress. We argue that highlighting multiplicities opens up physiotherapy as a space which can broaden the objects of practice and resist the kinds of closure that have become emblematic of contemporary physiotherapy practice. Using an exemplar from a rehabilitation setting, we explore how physiotherapists construct their object(s) and consider how multiplicity informs an otherwise physiotherapy that has broader implications for health care and rehabilitation.

Impact of Identity on Support for New Roles in Health Care A Language Inquiry of Doctors’ Commentary

Identity threat can be understood from a social identity perspective where people interrelate based on group memberships. Language use may indicate the presence of identity threat. We explored reactions of doctors to planned expanded roles for nurses to perform gastrointestinal endoscopy in Australia. Specialist doctors have traditionally performed endoscopic procedures, yet the level of doctor support for nurse endoscopy is relatively unknown. We present results of our valence and discourse analyses of text box responses in a national survey that explored doctors’ attitudes toward this role expansion. We found low levels of support for the role, and frequent expression of identity threat in three main areas: (1) framing nurses as incompetent, (2) use of contracted statements to evoke authority, and (3) emotive expression. Findings indicated that stakeholders should consider intergroup attitudes when facilitating changes in health professional scope of practice.

Addressing weight stigma in physiotherapy: Development of a theory-driven approach to (re)thinking weight-related interactions

ABSTRACT In this article, we propose a theory-driven approach to developing interventions for reducing weight stigma in physiotherapy and discuss the design and exploratory trial of such an intervention. Weight stigma has been identified in physiotherapists in empirical investigations. However, there has been little consideration of how this stigma might be addressed. We highlight Goffman’s work on stigma that provides social and embodied understandings of stigma. Goffman’s approach, however, is notably apolitical, ahistorical and lacks mechanisms for understanding power. We suggest that post-structuralist perspectives can provide insight into these areas. Drawing on these theories, we critically examine the literature on weight stigma reduction, finding that trials have largely been unsuccessful. We argue that this may be due to overly passive and simplistic intervention designs. As context-specific understandings are desirable, we examine the nature of physiotherapy to determine what might be relevant to (re)thinking weight in this profession. We then discuss the development of a multifactorial, active weight stigma intervention we trialed with eight physiotherapists. Supported by theory, the outcomes of the exploratory study suggest that physiotherapy-specific factors such as fostering professional reflexivity and improving understandings of stigma need to be incorporated into an active intervention that considers the complex determinants of weight stigma.

Researching stigma as an outsider: considerations for qualitative outsider research

ABSTRACT In this article, we discuss a number of important considerations that we have encountered in the process of researching health stigma topics as “outsiders”: researchers (personally) unfamiliar with the experience or topic under study. In particular, we discuss the importance of the following: a reflective stance, challenging negative representations, flexible and sensitive recruitment strategies, validating experiences of stigma, and participant control and power. We see these points as particularly important in the context of researching stigma as outsiders, where our privilege may contribute to unhelpful, narrow, de-politicized or overly simplistic representations of particular “groups” or experiences. We share these considerations in hope of assisting other researchers to reflect on, and articulate, how they negotiate their positionings within their research and the ways in which they shape and construct the research agenda and, by implication, the people or topics under examination.

Manipulating practices: A critical physiotherapy reader

Physiotherapy with horses and rider-patients builds on communication and interaction through groundwork and mounted work. This chapter discusses outdoor equine-facilitated physiotherapy on green care farms with three patients representing ideal types from the author’s clinical practice. The practice of co-creation and improvisation, i.e. devising, is used to discuss how the triad of physiotherapist, rider and horse, work together to support the rider’s step-by-step changes towards better health. Being with horses facilitates exploration of communicative strategies and embodied ways of being, whilst nature and physical activities add value to the therapeutic benefits. Horses represent risk and desire, as does the facing of bodily constraints or habits. Physiotherapy equinefacil itated phys iother apy 195 aims to facilitate a purposefully created change by playing with daring (out-of-the-ordinary experiences when usual boundaries are pushed) and compassion. Therapist, rider and horse face dares and desire together by experimenting, improvising, and testing new modes of co-being and becoming. The ideas and tools from applied drama (i.e. collaborative creation and contact improvisation) tune human and horse bodies to communication and action. Outdoor practice and devising equip physiotherapists with a larger toolbox for a playful practice.

Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey

BackgroundMost people experience low back pain (LBP), and it is often ongoing or recurrent. Contemporary research knowledge indicates individual’s pain beliefs have a strong effect on their pain experience and management. This study’s primary aim was to determine the discourses (patterns of thinking) underlying people’s beliefs about what causes their LBP to persist. The secondary aim was to investigate what they believed was the source of this thinking.MethodsWe used a primarily qualitative survey design: 130 participants answered questions about what caused their LBP to persist, and where they learned about these causes. We analysed responses about what caused their LBP using discourse analysis (primary aim), and mixed methods involving content analysis and descriptive statistics to analyse responses indicating where participants learnt these beliefs (secondary aim).ResultsWe found that individuals discussed persistent LBP as 1) due to the body being like a ‘broken machine’, 2) permanent/immutable, 3) complex, and 4) very negative. Most participants indicated that they learnt these beliefs from health professionals (116, 89%).ConclusionsWe concluded that despite continuing attempts to shift pain beliefs to more complex biopsychosocial factors, most people with LBP adhere to the traditional biomedical perspective of anatomical/biomechanical causes. Relatedly, they often see their condition as very negative. Contrary to current “best practice” guidelines for LBP management, a potential consequence of such beliefs is an avoidance of physical activities, which is likely to result in increased morbidity. That health professionals may be the most pervasive source of this thinking is a cause for concern. A small number of people attributed non-physical, unknown or complex causes to their persistent LBP – indicating that other options are possible.

Keep fit: marginal ideas in contemporary therapeutic exercise

Abstract Exercise has a long history as a therapeutic modality and has existed, in some form, in all cultures throughout recorded history. In recent years, therapeutic exercise has taken on new significance as a relatively low cost medical intervention designed to improve people’s health and well-being and reduce the downstream effects of comorbidity. Drawing our inspiration from Foucault and Deleuze, we argue that seeing therapeutic exercise as primarily ‘medical’ carries with it consequences – some recognised, others unseen – that are problematic and worthy of consideration. Our focus is on the acts of marginalisation, exile and exclusion implicit in the quotidian practice of therapeutic exercise, and how these acts mediate people’s daily lives. In the paper we explore how therapeutic exercise is being instrumentalised, normalised and constrained, arguing for much greater critical attention towards its putative ‘goodness’ and virtue as a health intervention.

Weight-related stigma and health policy

Although obesity has been shown to contribute to certain types of health problems, antifat stigma is also a threat to health. Antifat stigma adds both psychological and physiologic stress to people who are considered excessively fat, which some experts argue partially accounts for health disparities

General practitioners’ perspectives on a proposed new model of service delivery for primary care management of knee osteoarthritis: a qualitative study

BackgroundEffective management of people with knee osteoarthritis (OA) requires development of new models of care, and successful implementation relies on engagement of general practitioners (GPs). This study used a qualitative methodology to identify potential factors influencing GPs’ engagement with a proposed new model of service delivery to provide evidence-based care for patients with knee OA and achieve better patient outcomes.MethodsSemi-structured telephone interviews with 11 GPs were conducted. Based on a theoretical model of behaviour, interview questions were designed to elicit perspectives on a remotely-delivered (telephone-based) service to support behaviour change and self-management for patients with knee OA, with a focus on exercise and weight loss. Transcripts were analysed using an inductive thematic approach, and GPs’ opinions were organised using the APEASE (affordability, practicability, effectiveness, acceptability, safety/side effects and equity) criteria as themes.ResultsGPs expressed concerns about potential for confusion, incongruence of information and advice, disconnect with other schemes and initiatives, loss of control of patient care, lack of belief in the need and benefits of proposed service, resistance to change because of lack of familiarity with the procedures and the service, and reluctance to trust in the skills and abilities of the health professionals providing the care support. GPs also recognised the potential benefits of the extra support for patients, and improved access for remote patients to clinicians with specialist knowledge.ConclusionThe findings can be used to optimise implementation and engagement with a remotely-delivered ‘care support team’ model by GPs.