Changes in anti-fat attitudes among undergraduate nursing students

Journal Pre-proof Changes In Anti-Fat Attitudes Among Undergraduate Nursing Students María de los Ángeles Rodríguez-Gázquez, Ana Ruiz-Iglesias, José Rafael González-López PII: S0260-6917(20)31434-9 DOI: https://doi.org/10.1016/j.nedt.2020.104584 Reference: YNEDT 104584 To appear in: Nurse Education Today Received date: 18 April 2019 Revised date: 14 July 2020 Accepted date: 25 August 2020 Please cite this article as: M. de los Ángeles Rodríguez-Gázquez, A. Ruiz-Iglesias and J.R. González-López, Changes In Anti-Fat Attitudes Among Undergraduate Nursing Students, Nurse Education Today (2020), https://doi.org/10.1016/j.nedt.2020.104584 This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier. 1 CHANGES IN ANTI-FAT ATTITUDES AMONG UNDERGRADUATE NURSING STUDENTS María de los Ángeles Rodríguez-Gázqueza, Ana Ruiz-Iglesiasb, José Rafael GonzálezLópezc* a MARG. Ph.D, Full Professor, Faculty of Nursing, University of Antioquia, Colombia. C/70 No. 52-21, Medellín, Colombia. Email: maria.rodrig[email protected] b ARI. RN, Research Assistant, Faculty of Nursing, Physiotherapy and Podiatry, Universidad de Sevilla, Spain. C/ Avenzoar, n° 6, 41009, Seville, Spain. Email: [email protected] c JRGL. Ph.D, Associate Professor, Faculty of Nursing, Physiotherapy and Podiatry, Universidad de Sevilla, Spain. C/ Avenzoar, n° 6, 41009, Seville, Spain. Email: [email protected] Corresponding author: José Rafael González-López. Associate Professor, Faculty of Nursing, Physiotherapy and Podiatry. Department of Nursing, Universidad de Sevilla, Spain. C/ Avenzoar, n° 6, 41009, Seville, Spain. Phone number: 0034 954556362. Email: [email protected] Blinding codes in the manuscript: XXX1: Faculty of Nursing, Physiotherapy and Podiatry at Universidad de Sevilla (Spain). ABSTRACT Background: The number of people with obesity has been increasing significantly in recent decades. Nursing students play a role in the care of obese patients, but the presence of a Journal Pre-proof Journal Pre-proof 2 stigma regarding this patient group reduces the quality of care due to a climate of mistrust and lack of expectations. Objectives: To analyse if the anti-fat attitudes of nursing students at the XXX1 change during their degree training. Design: A cross-sectional study was carried out. Settings: XXX1 undergraduate nursing institution in Spain. Participants: 578 nursing students enrolled at the XXX1 in all academic years, from the first through the fourth. Methods: Following ethical approval, each participant took part in an individual self-report via the Anti-Fat Attitudes (AFA) Questionnaire, in its validated Spanish version. Results: The mean standardised AFA total was 2.29.; by domains: 1.29 in Dislike, 2.87 in Fear of fat, and 3.73 in Willpower. Analysis of variance tests showed significant differences in the AFA total score and domains by sex and academic year. Multiple linear regression analysis demonstrated that the highest prejudices were shown by enrolled participants in their first year, particularly when the AFA total score was considered. Conclusions: Nursing students at the XXX1 do not have many prejudices towards obese people. Anti-obesity attitudes among nursing students decrease as the students progress in their degree, implying that the specific training received (degree curriculum) also enables students to develop their non-technical skills. Keywords (Medical Subject Headings): Attitudes; Education; Graduate; Nursing Students; Obesity; Prejudice. INTRODUCTION/BACKGROUND The World Health Organisation defines obesity as an excessive or abnormal accumulation of fat that can be harmful to health, with a body mass index greater than 30 kg/m2 (World Journal Pre-proof Journal Pre-proof 3 Health Organisation, 2013). An increased intake of food rich in calories and decrease in physical activity continue to be highlighted as the main causes of this condition, although evidence suggests that it is the result of a combination of biological and environmental factors (Daníelsdóttir et al., 2010). Obesity has consequences for health, including cardiovascular diseases, locomotive system disorders, and certain cancers, such as colon and breast cancer (World Health Organisation, 2013). At a global level, this is a public health problem, as the number of people affected has increased significantly in the last three decades, strongly impacting obesity-related morbidity and mortality (Swinburn et al., 2011). In 2016, 39% of the world’s adult population was overweight and 13% was obese, representing a total of 1,900 million people. Furthermore, among children and adolescents the prevalence of overweight and obesity has increased considerably, from 4% in 1975 to more than 18% in 2013 (World Health Organisation, 2013). In Spain, based on data collected by the National Statistics Institute (2016), 52.6% of the population 18 years old or more had exceeded a normal weight; of these, 16.9% were obese and 35.7% were overweight. This increase in the number of people with obesity and overweight, along with the multiple associated pathologies that this presents, requires the health system’s continuous attention and involvement (Phelan et al., 2015; Saxena and Kumar, 2017). However, there exists a negative perception and attitude towards obese people on the part of health professionals, not for who the patients are, but for their weight (Keyworth et al., 2013). The origin of this attitude could be related to the frustration that medical personnel feel when carrying out the complex care of these people (Darling and Atav, 2019; Phelan et al., 2015). The presence of a stigma towards obese people at the heart of the health system reduces the quality of care provided to them as it generates a climate of mistrust and lack of expectations Journal Pre-proof Journal Pre-proof 4 among professionals regarding the treatments and interventions established for the care of these people and the patients’ failure to bond with them (Dietz et al., 2015; Hall and Kahan, 2018). This situation of discrimination is compounded by the fact that the health infrastructure and equipment are not adapted to these people (Tanneberger and Ciupitu-Plath, 2017). This is why, in some cases, such patients do not benefit from additional medical tests or particular treatments, causing them embarrassment and shame (Saxena and Kumar, 2017). Nurses and future nursing professionals in particular play a very important role in the care of obese patients (Pervez and Ramonaledi, 2017) as they are the ones in most direct contact with them, mainly in primary care consultations, and are in charge of developing interventions as well as strategies that foster changes in behaviours harmful for health (Phelan et al., 2015; Williams-Hailey, 2015). However, most previous research reports that nursing students also harbour prejudices against obesity (Nicholls et al., 2016; Snethen et al., 2014) since they have trouble and lack training in dealing with people who are obese (Dunagan et al., 2016) and also witness negative attitudes among qualified nurses (Keyworth et al., 2013). In addition, the key role that training plays in reducing this kind of prejudice among health students has been pointed out (Brown and Flint, 2013; O’Brien et al., 2010), but no scholars have analysed in depth whether this anti-fat attitude changes during training at university. Specifically, Pervez and Ramonaledi (2017) and Tsai et al. (2017) argued that nursing schools should enhance training regarding knowledge, skills, and appropriate attitudes during degree-seeking to enable students to provide quality healthcare for obese people. In light of these points, the present study will analyse how nursing students’ prejudices against obesity evolve during their degree training at university. METHODS Sample Journal Pre-proof Journal Pre-proof 5 A cross-sectional study was carried out. Students from the first to the fourth academic years who enrolled in 2018 in the nursing programme at the XXX1 were included. A total population study was proposed since it is well defined, accessible, and not too large for data collection. However, not all the students were approached since they did not attend lessons on the collection day. Instrument The study used an appropriate validated scale in Spanish (Magallares and Morales, 2014) called the Anti-fat Attitudes Questionnaire (AFA) (Crandall, 1994). The AFA is a scale that indicates explicit prejudices against obesity and is made up of 13 items divided into three domains (Dislike—items 1 to 7, Fear about fat—items 8 to 10, and Willpower—items 11 to 13), with Likert-type answer options from 1 (completely disagree) to 7 (completely agree). The AFA total score is the sum of the values of the scale’s items. For the AFA and each domain, the scores and their standardised values (dividing the score by the number of items) are presented since they enable a comparison among the values and with previous results. In both cases, the higher the score, the stronger the anti-obesity attitude. The Spanish version of this scale had an internal consistency of 0.85 measured by Cronbach’s alpha (Magallares and Morales, 2014). The Cronbach’s alpha coefficient for the AFA total score was 0.73. By domains, the domain Fear of fat had the highest reliability (0.82), followed by Willpower (0.75) and Dislike (0.58). Considering that the internal reliability of the Dislike domain was low, some extra tests were carried out to determine whether the reliability of this domain would increase if an/some item/s was/were deleted (Field, 2013; Mansour, 2015). It was detected that if item 2—‘I don’t have many friends that are fat’—was eliminated, the internal consistency of the Dislike domain would change from 0.58 to 0.68, and consequently the Cronbach´s alpha coefficient for AFA total score was 0.74. According to Hu and Bentler (1999), confirmatory factorial Journal Pre-proof Journal Pre-proof 6 analysis demonstrated a good model fit without this item (χ2=157.790, df=66, p=0.000; CFI = 0.942; RMSEA= 0.060; NFI=0.918). Standardised estimates parameters and latent factor correlations are presented in supplementary data. Therefore, the Dislike domain ultimately considered only six items and the AFA total score 12 items. Techniques and procedures Ethical and administrative approval for the study were obtained from the XXX1 prior to contacting potential participants in January 2018. As the objective of this research is to maximise the response rate, for each class group the questionnaires were collected in person instead of online. The collection was made in the courses given at the Faculty with the highest attendance rate for each academic year (all students from the same academic year have to be enrolled in the same courses, but the real attendance rate varies). Only students available in class on the day of data collection and consented were eligible and issued the deidentified self-report AFA questionnaire with additional demographic variables to complete. This was collected immediately from each student after completion. Due to the fact that the researchers did not know the number of attendees and who they were, there is not a selection bias. Statistical analysis The information collected was analysed with IBM SPSS version 23 programme (IBM, Armonk, NY, USA). The statistical analysis used the following: a) descriptive statistics of independent variables (age group, sex, and academic year); b) descriptive statistics, an internal consistency check through the Cronbach alpha statistic, and a pairwise correlation analysis of the AFA total score and domains; c) one-way ANOVA of the AFA total score and domains considering the age group, sex, and academic year variables; and d) multiple linear regression models estimated for each dependent variable (the AFA total score and scores of Journal Pre-proof Journal Pre-proof 7 each AFA domain). The global F test was examined to determine whether the models were significant. RESULTS In this study, the sample consisted of 578 nursing students at the XXX1, representing 64.9% participation of the total population. The representation of students in their first academic year was greater since their attendance at subjects was mandatory (Table 1). Table 1 also shows the predominance of women aged 25 years old or less among the respondents. Table 2 presents the mean scores and standardised values for the AFA total and each AFA domain. When the domains were compared, the Willpower domain showed the highest standardised value, followed by Fear of Fat. Three AFA domains had positive and significant correlations between each other: Dislike with Fear of fat (r = 0.22) and with Willpower (r = 0.22); and Fear of fat with Willpower (r = 0.24). Table 3 presents the results of the mean differences between the respondents’ demographic variables and their AFA scores. Nursing students from the first year were those who show the highest value for the AFA total score (F=5.212, p < 0.001), Fear of fat (F=5.490, p < 0.001) and Willpower (F=3.891, p < 0.009). Sex was an independent variable that showed a statistically significant difference for the Dislike (F=8.297, p < 0.004) and Willpower (F=5.272, p < 0.022) domains. In both cases, females are those who present the lowest values. In addition, younger students are those who got the highest score for the Fear of fat domain (F=3.138, p < 0.044). Before performing the regression analysis, a correlation test was carried out among the independent variables. This revealed a significant strong positive correlation between age group and academic year (r = 0.456, p < 0.001). Because the total AFA was found to be statistically different for each academic year (Table 3, p<0.001), but not between age groups, the latter independent variable was excluded from the regression model to avoid collinearity. Journal Pre-proof Journal Pre-proof 8 Multiple linear regression models (Table 4) showed a negative statistically significant relationship of sex with Dislike and Willpower. This meant that women had fewer prejudices towards obesity than men in terms of Dislike and Willpower. When their academic year was considered, this was shown to have a statistically significant influence on anti-obesity attitudes. As was reported in Table 3, specifically, these attitudes decreased as students progressed in their degree, with the highest scores reported in the first year and the lowest scores in the last year. However, from the second to third year, it appeared that nursing students’ anti-obesity attitudes increased slightly. While the academic year did not show any effect on the Dislike domain, it had a statistically significant relationship with the Fear of fat and Willpower domains (Table 4). Regarding the Fear of fat domain, the results from Table 3 showed that second-year students had the least prejudices against obesity, followed by fourthyear students. In contrast, when the Willpower domain was considered, students in the last half of their degree (third and fourth year) had lower prejudices. DISCUSSION In this study of 578 nursing students at the XXX1, the questionnaire return was 65%, which is considered high (Gillis and Jackson, 2002). The reliability of the AFA total score was slightly lower than that reported in a sample of university students in Spain (Magallares and Morales, 2014), but it is considered acceptable (Tavakol and Dennick, 2011). The Cronbach’s alpha coefficients of Fear of fat and Willpower were very close to those reported by Phelan et al. (2014) and Robinson et al. (2014). Although the Dislike domain had a lower internal reliability than in previous research (Magallares and Morales, 2014; Phelan et al., 2014; Robinson et al., 2014), it is very close to 0.7. Thus, the result on AFA internal consistency check, adjustment in Dislike domain and pair-wise correlation tests specifically strengthens the psychometric properties of AFA selfreport instrument and supports its use as appropriate for data collection in this study. 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Rev. 12, e324–e337. https://doi.org/10.1111/j.1467-789X.2010.00841.x Table 1. Descriptive statistics of respondents’ independent variables Variables Frequency (%) Frequency by sex (%) Age group Women Men ≤ 20 years old 307 (53.11) 250 (81.40) 57 (18.60) 21–25 years old 234 (40.48) 195 (83.30) 39 (16.70) ≥ 26 years old 37 (6.41) 22 (59.50) 15 (40.50) Academic year 1st 175 (30.28) 137 (78.30) 38 (21.70) 2nd 186 (32.18) 148 (79.60) 38 (20.40) 3rd 123 (21.28) 109 (88.60) 14 (11.40) 4th 94 (16.26) 73 (77.70) 21 (22.30) Sex Women 467 (80.79) Men 111 (19.21) Table 2. Respondents' mean scores and standardised values on the AFA total and domain sub-scales Domains Mean score (SD) Standardised score Dislike 7.78 (3.06) 1.29 (0.51) Journal Pre-proof Journal Pre-proof 21 Fear of fat 8.60 (4.62) 2.87 (1.54) Willpower 11.20 (4.17) 3.73 (1.39) AFA Total 27.58 (8.34) 2.29 (0.69) SD = standard deviation. Table 3. Differences between Respondents sex, academic year, age group and AFA total and Domain mean scores (n=578) AFA total score Dislike Fear of fat Willpower Sex Male 28.505 8.532 7.95 12.02 Female 27.364 7.606 8.75 11.01 Academic year 1st 29.617 8.091 9.65 11.87 2nd 26.672 7.468 7.83 11.38 3rd 27.016 7.984 8.73 10.30 4th 26.340 7.575 7.97 10.80 Age group ≤ 20 years old 28.245 7.863 9.01 11.35 21–25 years old 26.829 7.598 8.23 11.00 ≥ 26 years old 27.027 8.297 7.46 11.27 Statistically significant mean differences tests are reported in bold (p<0.05). Table 4. Multiple linear regression analysis for Anti-Fat Attitudes (AFA total and Domains) of nursing students (N=578) Variables B SE t P Total score Constant 31.499 1.680 18.75 0.000 Journal Pre-proof Journal Pre-proof 22 Sex -1.056 0.875 -1.21 0.228 Academic year 2nd -2.932 0.868 -3.38 0.001 3rd -2.492 0.974 -2.56 0.011 4th -3.283 1.054 -3.12 0.002 Dislike Constant 9.798 0.619 15.83 0.000 Sex -0.957 0.322 -2.97 0.003 Academic year 2nd -0.611 0.319 -1.91 0.056 3rd -0.009 0.358 -0.02 0.980 4th -0.523 0.388 -1.35 0.179 Fear of fat Constant 8.229 0.930 8.85 0.000 Sex 0.798 0.486 1.65 0.100 Academic year 2nd -1.833 0.481 -3.82 0.000 3rd -1.002 0.539 -1.86 0.064 4th -1.678 0.584 -2.88 0.004 Willpower Constant 13.472 0.841 16.01 0.000 Sex -0.896 0.438 -2.05 0.041 Academic year 2nd -0.486 0.434 -1.12 0.264 3rd -1.480 0.488 -3.04 0.003 4th -1.082 0.528 16.01 0.000 Total score: F=4.28, P < 0.001, ∆R2=0.026, P< 0.002 Dislike: F=3.40, P < 0.001, ∆R2=0.009, P< 0.154. Journal Pre-proof Journal Pre-proof 23 Fear of fat: F=4.81, P < 0.001, ∆R2=0.028, P< 0.001. Willpower: F=6.98, P < 0.001, ∆R2=0.018, P< 0.015. Author statement María de los Ángeles Rodríguez-Gázquez: Conceptualization, Methodology, Formal analysis, Writing - Original Draft; Ana Ruiz-Iglesias: Methodology, Data curation; José Rafael González-López: Conceptualization, Methodology, Validation, Formal analysis, Writing - Original Draft, Writing - Review & Editing. Highlights - Prejudices against obesity decrease as nursing students’ progress in their degree - Men score higher than women in the regression models of Dislike and of Willpower - Developing non-technical skills in nursing degree fosters tolerance to obese people Journal Pre-proof Journal Pre-proof