The physiotherapy profession increasingly considers weight management to be part of its scope of practice. Ostensibly this may seem like a good idea: popular media and biomedical discourses highlight a global “obesity epidemic”, and physiotherapists, considered “experts in movement”, may be well placed to help address obesity by encouraging activity. On the other hand, an excessive focus on weight can have negative consequences. A large body of research now highlights negative attitudes towards those who are overweight (weight stigma) among health professionals, including doctors, nurses, dieticians, psychologists and exercise scientists. Yet, despite the size and impact of the profession, there has been little work exploring weight stigma in the context of physiotherapy.
My aims are two-fold. First, I investigate weight-related interactions in physiotherapy, and second, I investigate how weight might be (re)thought in this context. The first three thesis chapters provide a theoretical exploration of concepts relevant to weight in physiotherapy. In the introductory chapter I argue that it is helpful to draw from scholarship in critical psychology and the emerging field of critical physiotherapy. In Chapter 2 I consider traditional social psychological theories that provide a social and embodied understanding of weight stigma. However, I outline how these theories are notably apolitical, acultural, ahistorical and lack mechanisms for understanding power in stigma. To address this issue, I introduce post-structuralist perspectives (particularly those of Michel Foucault) that are often used in critical social science. Using a post-structural psychological lens, I critically examine the literature on weight and its associated stigma. As context specific understandings are desirable, I use Chapter 3 to examine the nature of the physiotherapy profession, to determine what might be relevant to “thinking weight” and considerations of stigma. Here I look in depth at this profession, discussing where power, the body, reflexivity and the profession’s ontological underpinnings might be relevant to weight-related physiotherapy interactions.
In Chapter 4 I outline the empirical approaches I took to further address the aims of the thesis, and discuss their underlying assumptions. Following this, in Chapters 5 to 7 I present three empirical studies, each of which is published in peer-reviewed journals (or under review). In a previous study (described in Chapter 3) I tested weight stigma in physiotherapists using attitude tests in an online survey. I found that participating physiotherapists held explicit and implicit weight stigmatising attitudes similar to those in related professions. Building on this earlier work, I conducted an inductive thematic analysis of interviews with patients who had experienced weight-related interactions with physiotherapists (described in Chapter 5). Participants spoke of perceiving weight stigma in a number of elements of physiotherapy interactions, elements of the physiotherapy environment and in the way that physiotherapy presents itself to the world. Following this largely inductive study, I designed a further study (described in Chapter 6) to delve deeper into why physiotherapists might hold these attitudes and why patients perceived weight stigma in physiotherapy contexts. I facilitated focus groups of physiotherapists that I analysed using discourse analysis to identify participants’ ways of thinking and talking about weight (their weight discourses). Seen through the lens of Foucault’s theories of discourses as constitutive of reality, this study provided insight into what types of practices are likely in physiotherapy interactions. Findings suggested that physiotherapists require more nuanced understandings of: how patients who are overweight might feel in a physical therapy setting; the complexity of weight’s determinants; and possible disadvantages of introducing weight management discussions with patients.
Drawing on the results of these studies and the theory outlined in Chapters 2 and 3, I devised a final study (described in Chapter 7) to develop a process for rethinking weight in physiotherapy, including an exploratory intervention trial. This study highlighted that: there is no simple singular cause of weight stigma; approaches to reducing weight stigma need to be complex, involved and delivered over time; a flexible process is desirable to cater to individuals’ different contexts; reflexivity should be prioritised as a component of rethinking; and the specific context of the physiotherapy profession should be considered.
In Chapter 8 I draw together the theoretical and empirical work of this thesis to demonstrate that physiotherapy, a body-focused profession associated with mainstream healthcare and the fitness industry, is likely to be an environment where people who are seen as overweight might expect, and receive, weight stigma. This thesis presents important new findings for (re)thinking physiotherapy’s intersection with body weight and forms a part of the process of helping the profession to think its way out of weight stigmatising tendencies. The findings of this thesis have implications for physiotherapy education and practice. Further, this thesis has applications for related health professionals and develops understandings of weight stigma more broadly. Using weight stigma as a stimulus for a wider (re)thinking, my research indicates that health professions that are predominantly biomedical in focus, such as physiotherapy, would benefit from incorporating broader perspectives including social, cultural, political and philosophical concepts into their core knowledges.