Bioethical Inquiry (2022) 19:511–520

https://doi.org/10.1007/s11673-022-10199-3

ORIGINAL RESEARCH

A public health framework for reducing stigma:

the example of weight stigma
Alison Harwood & Drew Carter & Jaklin Eliott

Received: 16 July 2020 / Accepted: 1 April 2022 / Published online: 20 July 2022
# The Author(s) 2022

Abstract We examine stigma and how it operates, then Keywords Stigma . Stigmatization . Obesity .
develop a novel framework to classify the range of posi- Overweight . Weight stigma . Health behaviour . Obesity
tions that are conceptually possible regarding how stigma prevention and control . Obesity psychology . Prejudice .
ought to be handled from a public health perspective. In Public health . Social justice and psychology .
the case of weight stigma, the possible positions range Stereotyping
from encouraging the intentional use of weight stigma as
an obesity prevention and reduction strategy to arguing
not only that this is harmful but that weight stigma,
Introduction
independent of obesity, needs to be actively challenged
and reduced. Using weight stigma as an illustrative exam-
The stigmatization of diseases, conditions, and charac-
ple, we draw on prior theoretical work on stigma mecha-
teristics has a long history within public health. Tuber-
nisms and intervention strategies to develop a framework
culosis, leprosy, HIV/AIDS, cancer, mental illness, and
for improving the understanding, evaluation, and planning
smoking are just some that have been stigmatized
of anti-stigma interventions. This framework has the po-
(Bayer 2008; Bell et al. 2010; Evans-Polce et al. 2015;
tential to help public health actors to map out how protest,
Mahajan et al. 2008). Research on these and related
contact, education, and regulation strategies can be used to
stigma has found that stigma acts as a significant and
reduce direct discrimination, structural discrimination, and
dangerous barrier to seeking or accessing healthcare and
internalized stigma (self-stigma).
itself has harmful effects on physical and mental health
(Brown, Macintyre, and Trujillo 2003; Mahajan et al.
2008; Puhl 2011; Puhl and Brownell 2001). Similarly, a
A. Harwood growing body of literature has examined weight stigma
The Office of Research Ethics, Compliance and Integrity, The
specifically and documented a range of harmful effects
University of Adelaide, Adelaide, South Australia 5005, Australia
e-mail: [email protected] on health, independent of weight (Bertakis and Azari
2005; Brewis 2014; Hatzenbuehler et al. 2013;
D. Carter (*) MacLean et al. 2009; Stuber, Meyer, and Link 2008).
Adelaide Health Technology Assessment, School of Public
Health, The University of Adelaide, Adelaide, South Australia
Obesity is a deeply stigmatized condition. Individ-
5005, Australia uals classified as overweight or obese are stereotyped as
e-mail: [email protected] lazy, undisciplined, incompetent, weak-willed, and glut-
tonous (Brownell et al. 2010; Puhl, Andreyeva, and
J. Eliott
Associate Professor, School of Public Health, The University of Brownell 2008a; Puhl and Heuer 2009). Beliefs that
Adelaide, Adelaide, South Australia 5005, Australia self-indulgence, gluttony, and laziness cause obesity
e-mail: [email protected] function to hold individuals classified as overweight
512 Bioethical Inquiry (2022) 19:511–520

responsible for their condition (Dejong 1980, 77). As stigma ought to be intentionally reduced, and the spec-
Cahnman reflects, “Clearly, in our kind of society … trum and matrix that we innovate are frameworks for
being overweight is considered to be detrimental to understanding how public health actors can, respective-
health, a blemish to appearance, and a social disgrace” ly, handle and combat stigma, including weight stigma.
(1968, 283). Academic literature attests that weight
stigma can result in psychosocial harms, including so-
cial isolation and discrimination. In turn, these harms Stigma and How it Operates
can negatively impact a person’s self-esteem, academic
achievement, employment opportunities, and health. There is variation in how stigma is defined, in part due
Many individuals who are perceived to be overweight to two things. First, the concept of stigma has been
or obese experience discrimination in interpersonal and applied to a wide variety of things, such as mental
structural forms, including social ostracism, disrespect- illness, HIV/AIDS, leprosy, disability, cancer, and
ful treatment, and fewer opportunities, owing to differ- non-health related issues, such as exotic dancing, IQ,
ential treatment in areas of employment, education, and choice of profession, and sexual orientation (Bayer
healthcare (Hatzenbuehler, Phelan, and Link 2013; Link 2008; Bell et al. 2010; Lewis, 1998; Mahajan et al.
2001; MacLean et al. 2009; Musher-Eizenman et al. 2008). Second, a wide variety of analytical tools have
2004). been used to examine stigma and its effects, reflecting
Many academics recognize that intentional stigmati- the multidisciplinary nature of stigma research (Brown,
zation is both ineffective and morally problematic as a Macintyre, and Trujillo 2003; Klepp et al. 1997; Pinfold
policy option to reduce obesity (Puhl 2011; Salvy et al. et al. 2014).
2011; Zabinski et al. 2003). But seldom have govern- In his seminal work, Erving Goffman described a
ments or other actors actively attempted to reduce stigmatized attribute as “an attribute that is deeply
weight stigma, and the few attempts that have been discrediting”; the stigmatized attribute reduces the bearer
made have had mixed results (Bell and Morgan 2000; “from a whole and usual person to a tainted, discounted
Haines, Neumark-Sztainer, Eisenberg, and Hannan one” (Goffman 1963, 3). More recently, Link and Phelan
2006a; Irving 2000; Musher-Eizenman et al. 2004; have argued that stigmatization is a product of “the co-
Sigelman 1991; Sigelman et al. 1986). In this paper, occurrence of certain interrelated components,” positing
we develop a conceptual framework to promote the that relationships between particular components result
success of anti-stigma efforts. in the stigmatization of individuals and subpopulations
First, we examine stigma in general and how it (2014, 367). These components include distinguishing
operates. We then develop a novel Spectrum of Ap- and labelling human differences, associating those differ-
proaches to Stigma, classifying the range of positions ences with negative attributes and stereotypes, separating
that are conceptually possible to adopt regarding how “us” and “them,” and the status loss and discrimination
stigma ought to be handled. In the case of weight stigma, experienced by the stigmatized (367–376). Link and
the positions range from encouraging the intentional use Phelan go on to contend that the stigmatization of indi-
of weight stigma as an obesity reduction strategy to viduals and sub-populations relies upon “access to social,
arguing both that this is a harmful approach and that economic, and political power that allows the identifica-
weight stigma needs to be actively reduced indepen- tion of differentness, the construction of stereotypes, the
dently of obesity. We then develop our novel Matrix separation of labelled persons into distinct categories, and
of Anti-Stigma Interventions, a conceptual framework the full execution of disapproval, rejection, exclusion,
that stands to improve the understanding, evaluation, and discrimination” (375–376). In other words, the dom-
and planning of anti-stigma interventions in the case of inating values and opinions of one group are expressed in
weight stigma and beyond. Finally, we demonstrate ways that result in individuals who belong to another
how the matrix can be used to understand past interven- group being discriminated against.
tions aimed at reducing weight stigma and we highlight Link (2001) presents three mechanisms through
promising elements of those interventions. Overall, our which stigmatization can have negative consequences
method is to mount an ethical argument and to make for stigmatized individuals: direct discrimination, struc-
theoretical advancements by drawing on prior theories tural discrimination, and social psychological processes
and empirical studies. Our argument is that weight operating through the stigmatized person.
Bioethical Inquiry (2022) 19:511–520 513

Direct discrimination involves attitudes and beliefs potentially reinforcing one another. For example,
directly issuing in discriminatory behaviour: person weight discrimination refers to differential treatment
A’s stigmatization of something attributed to person based on someone’s weight, whereas weight stigma
B causes person A to engage in overt forms of dis- refers to the discrediting of people based on their weight.
crimination against person B (e.g., rejecting their job
application or excluding them socially). Structural
discrimination refers to inequalities in life chances, Spectrum of Approaches to Stigma
not necessarily overt discrimination. Finally, social
psychological processes operating through the stigma- A range of approaches to stigma are possible and some
tized person are also described in other literature in of them are discernible within the academic literature on
terms of “self-stigma” or “self-stigmatisation” obesity. At one end of the spectrum are writers who
(Barlösius and Philipps 2015; Evans-Polce et al. 2015; encourage the use of weight stigma as a motivational
Rüsch, Angermeyer, and Corrigan 2005). People devel- tool to achieve weight loss and weight management
op conceptions of a stigmatized condition such as men- across society. At the other end are writers who argue
tal illness as part of being socialized into their culture; that stigmatization is not only ineffective as a weight
these conceptions then become “lay theory.” Expecta- loss tool but is actually harmful, and therefore weight
tions are formed as to whether most people will devalue stigma ought to be combatted directly (see Fig. 1).
a person with a mental illness and reject them as a friend, The first position on the spectrum is to intentionally
spouse, or employee (Link 2001, 10). If a person then utilize or perpetuate stigma. Several writers argue for the
goes on to develop a mental illness, they may fear that active and intentional stigmatization of individuals per-
those expectations will be applied to them (Nolan and ceived to be overweight or obese (e.g., Callahan 2013a;
Eshleman 2016). When stigmatizing messages become Freind 2012; Liddle 2013). The basic argument is as
part of an individual’s own outlook, this can have seri- follows. Stigmatized individuals are marked as being
ous negative consequences. For example, fear of rejec- outside the social norm. This leads those individuals to
tion may mean acting less confidently, withdrawing be treated poorly in various ways, which is unpleasant to
from or avoiding particular situations, and having experience, and this will motivate individuals to actively
strained and uncomfortable social interactions. In turn, change to conform to the social norm (Callahan 2013a).
this may cause social networks to be constrained, lead- Callahan seeks to replicate the “success” of anti-
ing to social isolation, compromised quality of life, smoking campaigns, admitting that the “force of being
unemployment, and income loss. It is important to note shamed” and being “beat upon socially” to stop
that Link’s three mechanisms are mutually reinforcing. smoking were as persuasive to him as threats to his
For example, as a result of receiving poor treatment via health (2013, 38). Callahan acknowledges that smoking
direct discrimination (mechanism 1), an individual may is a behaviour, whereas weight and body size are not
come to expect further poor treatment (mechanism 3). behaviours. Indeed, he notes that weight and body size
We use the term “weight stigma” to refer to the are closely linked to character and selfhood (2013a, 38),
stigmatization of individuals perceived to be overweight and so to attack weight and body size is to attack people.
or obese. A range of terms are used to draw attention to However, he maintains that social pressure will push the
this and related phenomena. These terms include the public to accept the strong government interventions
“stigmatisation of obesity” (Couch et al. 2016), “weight needed to change the ways they eat, exercise, and work
bias” (Browne 2012; Puhl and Brownell 2003; Puhl so as to make inroads into obesity as a public health
et al., 2008a, b; Schwartz et al. 2003; Washington problem (39).1
2011), “fat shaming” (Farrell 2011), “anti-fat attitudes”
(Hague and White 2005; Puhl et al., 2008a, b), “weight 1
In response to criticism, Callahan (2013b) explained that he had
made an “error in editing the manuscript” and that his main point
stigma” (Nolan and Eshleman 2016; Puhl and Heuer
was “to use social pressure on those not yet obese or just a little
2010), “weight-based teasing/bullying” (Neumark- overweight to induce them to stay that way; that is, deploy it as a
Sztainer et al. 2002; Puhl, Luedicke, and Heuer 2010), prevention strategy.” Callahan (2013b) stated that he does not “favor
and “weight discrimination” (Paul and Townsend 1995; stigmatizing the overweight or obese, and surely not discriminating
against them”. However, Voigt, Nicholls, and Williams (2014, 104)
Roehling 1999). Some of these terms are not wholly find fault, observing that Callahan had “restated his assumption” that a
synonymous, and they can interact in multiple ways, lot of weight-loss behaviour had been “spurred by stigma.”
514 Bioethical Inquiry (2022) 19:511–520

1. Intentionally 2. Unintentionally 3. Unintentionally 4. Intentionally do 5. Unintentionally 6. Intentionally

utilize or utilize or do not utilize or not utilize or reduce reduce
perpetuate perpetuate perpetuate perpetuate

The health promotion campaign Strong4Life fea- targeted intervention of this type may also imply that a
tured black-and-white photographs of overweight chil- particular group is in need of “fixing,” and this can be
dren that resembled grim mug shots, with captions stigmatizing (“Oh, you go to that class”) (MacLean et al.
including “It’s hard to be a little girl if you’re not,” 2009, 90). One can occupy the fourth position on the
“Chubby isn’t cute. It leads to diabetes,” and “Big bones spectrum by keeping stigmatizing effects in focus or “on
didn’t make me this way. Big meals did” (Fitbomb the table” (Saguy and Riley 2005) and by ensuring
2012). By portraying obesity as deeply discrediting consistency and coherency in non-stigmatizing mes-
and shameful, such materials utilize and perpetuate sages (MacLean et al. 2009, 92).
weight stigma. To use a different example, a campaign The fifth position on the spectrum is to unintention-
that focuses on personal responsibility for one’s weight ally reduce stigma. For example, positive portrayals of
can similarly perpetuate the stereotype that people with individuals with overweight or obesity (individuals who
overweight or obesity lack discipline, tend to make demonstrate success, intelligence, or determination, say)
unhealthy choices, and only have themselves to blame can function to counter stigmatizing messages without
(Byrne and Niederdeppe 2012; MacLean et al. 2009; being consciously aimed at achieving this.
Saguy and Riley 2005). If this utilization and perpetua- The sixth position on the spectrum is to intentionally
tion of weight stigma is intentional, then the campaign reduce stigma. To occupy this position is to consciously
occupies the first position on the spectrum; but if it is claim that weight stigma is harmful and therefore ought
unintentional, then the campaign occupies the second to be actively combatted and reduced. Academics in-
position, which is to unintentionally utilize or perpetuate creasingly occupy this position, as a growing body of
stigma. One is best placed to determine exactly which evidence attests that weight stigma has deleterious ef-
position a campaign adopts when intentions behind the fects on physical and mental health in a range of ways.
campaign are documented and communicated. According to Hatzenbuehler, “the accumulated litera-
The third position on the spectrum is to unintention- ture makes a compelling case that stigma represents an
ally not utilize or perpetuate stigma. This position must additional burden that affects people above and beyond
be included on the spectrum for conceptual complete- any impairments or deficits they may have”
ness. For example, it is possible to imagine a health (Hatzenbuehler et al. 2013, 814).
campaign that, simply by communicating accurate in-
formation about obesity, avoiding over-simplification
and discrediting messaging, manages to not utilize or Matrix of Anti-Stigma Interventions
perpetuate weight stigma, even though weight stigma
was never consciously considered when planning the Corrigan et al. (2001) identified three intervention strat-
campaign. egies to reduce stigma. First, protest strategies aim to
The fourth position on the spectrum is to intention- “suppress negative representations and attitudes”
ally not utilize or perpetuate stigma. To occupy this through direct confrontation or explicit criticism
position is to consciously consider existing weight stig- (Corrigan et al. 2001, 187–188). Second, contact strat-
ma and ensure that messaging does not exacerbate it. egies facilitate constructive interactions between mem-
For example, exercise classes specifically designed for bers of the public and members of the stigmatized
people with excess weight may be motivating, in that group. Finally, education strategies aim to improve
they may provide a sense of comradery for participants knowledge of stigmatized issues. We propose the addi-
and lower the self-consciousness that may have previ- tion of a fourth category, regulation strategies, to pro-
ously acted as a barrier to physical activity. However, vide scope for legal and regulatory approaches, which
Bioethical Inquiry (2022) 19:511–520 515

typically seek to moderate discriminatory behaviour how different strategies can be used to target different
through justified coercion or, conversely, incentives. mechanisms of stigma. In addition, the matrix can be used
Now recall the three mechanisms by which stigma by a number of actors, including governments, non-
operates: direct discrimination, structural discrimina- government organizations, advocacy groups, and individ-
tion, and psychological processes operating through uals, both to map out possible anti-stigma interventions in
the stigmatized person (self-stigma). Below we illustrate future and to better understand past or existing
how considering these three generic mechanisms along- interventions.
side the four anti-stigma intervention strategies just An intervention adopting a particular strategy (pro-
sketched serves to help map out different anti-stigma test, contact, education, or regulation) may have effects
interventions. We are, in effect, multiplying or on more than one mechanism of stigma. For example,
intersecting the three mechanisms with the four anti- anti-bullying and anti-discrimination policies may have
stigma strategies to produce a novel output. What fol- effects on direct discrimination as well as structural
lows is a Matrix of Anti-Stigma Interventions, a con- discrimination. However, if anti-stigma interventions
ceptual framework aimed at improving the understand- commonly act on multiple mechanisms of stigma, then
ing, evaluation, and planning of interventions to reduce why is it helpful to present the full matrix, illustrating
weight stigma and other forms of stigma (see Table 1). how each intervention strategy might target each stigma
The matrix builds on the works of Link (2001) and mechanism? Instead, could it not suffice simply to un-
Corrigan et al. (2001), which pertain to stigma in general, derstand that there are three stigma mechanisms and
not solely weight stigma, so the matrix is widely applicable. interventions commonly have effects for two or all three
Each cell in the matrix contains an example of the use of of them? Such a general understanding risks glossing
one intervention strategy to counter one of the generic over possibilities in public health practice. Each cell in
mechanisms of stigma. We acknowledge, however, that the matrix represents a distinctive possibility for a par-
an intervention strategy may function to reduce stigma in ticular intervention strategy to act on a particular stigma
multiple ways, especially in view of Link’s mechanisms mechanism. To stop short of systematically unpacking
being mutually reinforcing. The mutually reinforcing nature these possibilities risks missed opportunities for plan-
of Link’s mechanisms also suggests that an intervention or ning, understanding, and evaluating interventions. The
suite of interventions featuring multiple strategies—some anti-bullying and anti-discrimination policies that have
combination of protest, contact, education, and regulation effects on both direct and structural discrimination (and
strategies—may prove most effective. This actually high- downstream even self-stigma) can nonetheless feature
lights the usefulness of the matrix, in that the matrix shows distinctive components that focus on a particular stigma

Table 1 Matrix of Anti-Stigma Interventions

Generic Direct Discrimination Structural Discrimination Psychological Processes

Mechanism → (Self-Stigma)
Intervention
Strategy ↓

Protest Condemn the discriminatory Boycott an organization that has Speak out against negative
behaviour of an individual discriminatory policies or practices representations in the media
Contact Facilitate contact with people in Increase the presence of stigmatized Participate in support groups (online or in
the stigmatized group who people in circles of power and person)
have obvious positive qualities influence
Education Educate people about the harms Educate managers and people working Educate stigmatized people about the
of labelling and stereotyping with the public about the rights of self-stigma process and teach them
and about how to not individuals to be treated fairly and the skills for building self-esteem and
discriminate against others legislation in place to protect those rights coping with discriminatory treatment
Regulation Introduce anti-bullying and Introduce regulatory requirements or Empower media regulators to act against
anti-discrimination policies incentives for organizations to meet stigmatizing messages
that specify punitive measures equal-opportunity targets
for non-compliance
516 Bioethical Inquiry (2022) 19:511–520

mechanism, and appreciating this by way of the matrix daily life. This includes the discriminatory treatment that
can make for a more nuanced understanding of the people experience, since discriminatory treatment itself
policies. But perhaps more importantly, there will be pol- sends a stigmatizing message. The online blogs also
icies and interventions whose planning or evaluation will enact a contact strategy to reduce self-stigma by
problematically neglect one or more cells in the matrix. In allowing participants to share their experiences and
particular, the matrix has the potential to alert intervention support one another.
planners to possibilities that they might otherwise have Given the prevalence of obesity, it is likely that many
glossed over. For example, in formulating anti-stigma reg- individuals have some contact with individuals who
ulation, a planner using the matrix can remember to at least have overweight or obesity, whether through interper-
consider a concerted regulatory approach to self-stigma, sonal relationships or just in navigating the outside
namely a policy component knowingly targeted at this world. However, it is not necessarily the case that such
and not simply at direct and structural discrimination. Or, contact promotes acceptance and tolerance, and there-
to use a different example, a planner armed with the matrix fore the nature of contact is significant: having positive
might quickly glimpse the possibility of adding to their contact with people who have overweight or obesity and
contact strategy an intervention component that targets are successful, intelligent, charismatic, and so on may
self-stigma alongside direct discrimination, say by adding help to counter the stereotyping that contributes to
the simple but meaningful step of directing participants to mistreatment. This equates to using a contact strategy
support groups. Without the matrix, the planner might have to reduce direct discrimination.
neglected this and remained solely focused on direct dis- Using an education strategy to reduce direct discrim-
crimination when other possibilities abounded. ination, schools and workplaces can provide training
We now illustrate how the matrix can be used to struc- and education about fair treatment and the importance
ture thinking about anti-stigma interventions using the ex- of not discriminating against others. MacLean et al.
ample of reducing weight stigma specifically. This involves (2009, 91) note the importance of educating and training
unpacking individual cells in the matrix. professionals, such as doctors, nurses, and educators,
Using a protest strategy to reduce self-stigma, individ- about stereotyping. However, it is well documented that
uals and advocacy groups can speak out against misrepre- educational approaches to reducing weight stigma have
sentation, negative stereotyping, and stigmatizing messag- been resoundingly ineffective (Bell and Morgan 2000;
ing in the media. They can do this by directly contacting the Musher-Eizenman et al. 2004; Sigelman 1991;
offending media companies or by using social media to Sigelman, Miller, and Whitworth 1986). This may be,
raise awareness of how stigmatizing messaging is problem- in part, because past educational interventions were not
atic. For instance, on 6 April 2018, a British academic sent administered for long enough or without adjoining in-
an open letter to the National Union of Journalists with the tervention modes that might permit the development of
express support of many political, university, and advocacy empathy, for example role-play or contact with stigma-
actors (All-Party Parliament Group on Obesity, 2018). The tized people.
letter highlighted stigmatizing media portrayals and argued Using an education strategy to reduce structural dis-
that these conflicted with the Union’s Code of Conduct, crimination could take the form of educating managers,
which expresses a commitment not to incite hatred or teachers, and healthcare providers about the rights of
discrimination and to ensure that information is accurate individuals to be treated fairly and the legislation in
and fair (Flint 2018). place to protect those rights. Clearly this requires that
Several online blogs and social media groups2 func- such legislation be in place, and this legislation equates
tion to provide a forum for people to discursively resist to the use of a regulation strategy to reduce direct
the stigmatizing messaging that they encounter in their discrimination and probably structural discrimination
as well.
2 Using an education strategy to reduce self-stigma
For example, Fit is a Feminist Issue: Feminist Reflections on Fitness,
Sport, and Health (https://fitisafeministissue.com/), Fit Fatties could take the form of explaining relevant psychological
(https://www.facebook.com/groups/fitfatties/), Fierce Freethinking processes to stigmatized people and highlighting that
Fatties (https://fiercefatties.wordpress.com), Fat Heffalump: Living negative messages, such as those present in the media,
with Fattitude (https://fatheffalump.wordpress.com/), The Association
for Size Diversity and Health—Health at Every Size Blog can influence how we perceive ourselves, reducing our
(https://healthateverysizeblog.org/). sense of self-worth. It could also take the form of
Bioethical Inquiry (2022) 19:511–520 517

promoting self-esteem building in general. The avail- Likewise, the matrix guides people to mobilize known
ability of counselling in schools and workplaces could intervention strategies, again reminding people that
further help individuals to develop coping skills when more than one is available. In this way, the matrix can
faced with weight-related teasing or discrimination. If also be used to identify gaps and opportunities when it
healthcare providers were made more aware of self- comes to reducing stigma. If one or more stigma mech-
stigma in patients, then they could potentially better anisms (columns) are not being targeted, then this rep-
monitor for self-esteem issues and body dissatisfaction, resents a missed opportunity or gap that might be closed
then recommend counselling or other measures as via future intervention. Meanwhile, if one or more in-
needed. tervention strategies (rows) are not being mobilized,
Using a regulation strategy to reduce direct discrim- then this represents an opportunity to mobilize different
ination takes the form of implementing and enforcing or more diverse strategies, which may increase the over-
policies to moderate behaviour and reduce the incidence all effectiveness of anti-stigma efforts.
of discriminatory treatment. This is commonplace in
schools and workplaces, for example. Using a regula-
tion strategy to reduce structural discrimination takes the Understanding and Building on Past Interventions
form of legislation such as equal opportunity acts, which to Reduce Weight Stigma
are in place in relation to ethnicity and disability (for
example, Australia’s Racial Discrimination Act 1975 We now demonstrate how the matrix can be used to
and Disability Discrimination Act 1992 and South understand past interventions, say for the purpose of
Australia’s Equal Opportunity Act 1984). Legislation conducting an evaluation. Some programmatic attempts
can protect stigmatized groups from systemically dis- to reduce weight stigma have been made, with mixed
criminatory hiring practices, by way of further example. results. We examine selected examples that allow us to
Using a regulation strategy to reduce self-stigma can most clearly demonstrate the usefulness of the matrix in
take the form of empowering regulatory bodies to take evaluating these. In this section, we also draw out the
proportionate punitive action against media companies most promising intervention elements that may benefit
that broadcast stigmatizing messages. For example, any future interventions aimed at reducing weight stigma.
concerns or complaints regarding news, programmes, or Simplistic beliefs about obesity aetiology contribute
advertisements shown on Australian television can be to weight stigma, especially the beliefs that obesity
directed to the Australian Communications and Media results from laziness, gluttony, and a lack of self-
Authority. Any punishment and consequent reduction discipline and that accordingly overweight individuals
of stigmatizing messages would result in fewer sources should be held responsible for their weight (Bell and
being available to reinforce and perpetuate self-stigma. Morgan 2000; Dejong 1980, 1993; Musher-Eizenman
Social media providers can also self-regulate by imple- et al. 2004). To counter simplistic beliefs, interventions
menting and enforcing policies aimed at suppressing or that provide accurate information about obesity have
countering stigmatizing messages. Ethical and political been implemented, especially amongst young children.
complexities concerning censorship need to be navigat- Very Important Kids was an intervention designed to
ed in both cases. reduce teasing and weight stigma among children in
In practice, someone evaluating or planning an anti- grades four, five, and six. It incorporated an after-
stigma intervention can look at the matrix and identify school programme and theatre production for students,
the cells that most apply. Which columns are most staff training, a no-teasing campaign, and various levels
relevant or important given the focus of the interven- of family involvement. Referring to the matrix, the
tion? Now, which rows? Once the key cells have been intervention used an education strategy targeted at direct
identified, the contents of those cells can then be eval- discrimination. While the intervention saw positive re-
uated or worked out in terms of the planned anti-stigma sults in the reduction of overall teasing, the reduction of
intervention. In this way, the matrix provides a structure weight-based teasing specifically was minimal (Haines,
for anti-stigma intervention evaluation and planning that Neumark-Sztainer, Perry, et al. 2006b). The successes
may facilitate more systematic progress. In particular, it of the intervention may have been due to so many
guides people to target known stigma mechanisms, students participating and the messages being sustained
reminding people of a number of potential mechanisms. and consistent (Haines, Neumark-Sztainer, Perry, et al.
518 Bioethical Inquiry (2022) 19:511–520

2006b, 890). This lesson should be remembered when The spectrum should not be misconstrued as imply-
planning similar anti-stigma interventions. ing that each position on it is equally valid or defensible,
Eating Disorders Awareness and Prevention (EDAP) since this is not necessarily so. Evidence shows that
developed a puppet programme for children aged six to some positions are neither valid nor defensible in the
ten years to promote acceptance of a diverse range of case of weight stigma. Weight stigma manifests in peer
body shapes, healthy attitudes about food and eating, rejection and social isolation (Brewis 2014), teasing and
and a healthy self-concept (Irving 2000). The pro- bullying (Neumark-Sztainer et al. 2002), and the loss of
gramme used “scripts” to address issues that contribute opportunities across many domains such as education,
to disordered eating, including emotional distress, body employment, and health care (Bertakis and Azari 2005;
acceptance, and dieting (Irving 2000, 223). Referring to Puhl and Heuer 2010; Roehling 1999; Spahlholz et al.
the matrix, the intervention used an education strategy 2016). Extensive empirical evidence has consistently
targeted at direct discrimination and psychological pro- demonstrated the harmful effects of weight stigma
cesses (self-stigma). The EDAP puppet programme (Brewis 2014; Link 2001; Major and O’Brien 2005).
showed promising results. Student evaluations indicated Experiencing weight stigma contributes to poor health
that the programme successfully discouraged teasing in in a range of ways, including in the development of
all forms, not just related to body shape and size. The disordered eating and in acting as a barrier to physical
programme also successfully encouraged students to activity and healthcare access (Hatzenbuehler et al.
treat everybody well, including themselves. Negative 2013; Nolan and Eshleman 2016; Puhl and Suh 2015).
attitudes towards larger bodies were reduced, as larger Weight stigma perpetuates weight gain and retention
bodies were evaluated more favourably post-pro- (Brewis 2014). Given these effects, the strategic use of
gramme. It is possible that the programme’s creative weight stigma to try to motivate weight loss and reduce
engagement with students contributed to its success. obesity (position one on the spectrum) is not merely
Again, this lesson should be remembered when plan- ineffective but counterproductive. Only efforts to inten-
ning similar anti-stigma interventions. tionally reduce weight stigma (position six on the spec-
Familiarity with the matrix here alerts one to the trum) fully reckon with the empirical evidence.
absence of other intervention strategies and targeted Finally, we built on work by Corrigan et al. (2001)
mechanisms. For instance, perhaps the interventions and Link (2001) to develop the Matrix of Anti-Stigma
could have readily added compatible strategies, such Interventions (see Table 1). This is a conceptual frame-
as a contact strategy targeted at direct discrimination work to help structure thinking about anti-stigma inter-
via a person with obesity interacting positively with ventions in the case of weight stigma and beyond. The
participants. The interventions also neglected to target matrix provides anti-stigma intervention evaluation and
structural discrimination: adults leading the school and planning with structure so as to more systematically
community could have been educated about the rights of make progress and achieve social change to improve
people with obesity, for example. This analysis shows public health. It guides people to target known stigma
how the matrix can be used to identify gaps and oppor- mechanisms, reminding people that there is more than
tunities when it comes to reducing stigma. one mechanism. Likewise, it guides people to mobilize
known intervention strategies, again reminding people
that there is more than one strategy. In this way, the
matrix can be used to identify gaps and opportunities
Conclusion when it comes to reducing stigma.

Weight stigma can be approached in a range of ways,

Acknowledgements The authors gratefully acknowledge the
from intentionally utilizing or perpetuating weight stig- support of the HealthyLaws research team and advisory committee
ma in attempts to reduce obesity to intentionally reduc- in connection with the grant funding.
ing weight stigma, partly to achieve the same end. By
placing these approaches along a spectrum (see Fig. 1),
Funding Open Access funding enabled and organized by
we have provided a conceptual framework for under-
CAUL and its Member Institutions. This work was supported in
standing the range of possible approaches to dealing part by an Australian National Preventive Health Agency Grant,
with stigma in general. project ID: 182BRA2011.
Bioethical Inquiry (2022) 19:511–520 519

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