Anti-obesity campaigns and public stigma: The role
of fear appeals and self-efficacy appeals.
Wieke Schrakamp
Student number: 10631739
Master thesis
Research supervisor: Dr. A.S. Velthuijsen
Abstract
The aim of this thesis was to investigate whether fear appeals and appeals to enhance self-efficacy in anti-obesity campaigns can change the public’s attitudes towards obese people. 229 participants were randomly exposed to one out of four conditions. They were shown a print ad with either fear appeal, self-efficacy, none, or both appeals. To answer the first part of the research question, to which extent fear appeals in health campaign messages can
stigmatize or enhance stigmatization, the attitudes towards obese people of participants exposed to fear appeals and participants not exposed to fear appeals were compared. To answer the second part of the research question, whether self-efficacy moderates these potential effects, the attitudes of participants exposed to self-efficacy and participants not exposed to self-efficacy, while both being exposed to fear appeals, were compared.
Acknowledgements
I want to express my gratitude to my research supervisor, Dr. Aart Veldhuijsen, without whom I would still be out on the street spotting bears, possibly with binoculars. Thanks for teaching me to just ignore them and continue in the direction I was heading. Without that, I may not have reached the end of this road. Thank you Aart, Nhu Ngan Trang and the
Graduate School of Communications giving me the space to finish this thesis. Gemke, Menno and Nynke Schrakamp and Jan-Bart van Beek, thanks for supporting me in every possible way. Mom, thanks for being my rubber duck. I’m very grateful to everyone who took the time to participate in the survey, and to those who spread it, with a special thanks to Pum
Vaandrager, Alexander Ploeg, Gemke Schrakamp, Nynke Schrakamp and Dr. Jorge Moctezuma.
Introduction
“I am considered morbidly obese, but these type of campaigns make people think that it’s because of overeating and laziness and that makes people judge you on false facts.” This is the reason a woman named Kim Moore gives for petitioning, along with 750 others, to cancel an Australian anti-obese campaign on a the website change.org
(https://www.change.org/p/wa-state-gov-t-heart-foundation-cancer-council-cancel-your-anti-obesity-campaign). The campaign, called LiveLighter (http://livelighter.com.au/), spread a series of messages using fear to promote a healthy lifestyle in print, on television and radio. Judging from Kim Moore’s reaction, she feels stigmatized by the fear appeals used in the campaign. But is it true, what she implies, that these messages change the public’s attitudes towards obese people in a negative way? Can fear appeals in health campaign messages stigmatize or enhance stigmatization? The latter is the main question in this thesis.
The current prevalence of obesity worldwide has more than doubled since 1980, and is still increasing. In 2014, 13% of all adults aged 18 years and over were obese, they had a Body Mass Index (BMI, weight in kilograms/(length in meters)2) of 30 kg/M2 or higher. Obesity is defined as abnormal or excessive fat accumulation that may impair health. The fundamental cause of obesity is an energy imbalance between calories consumed and calories expended, the global increase of energy-dense foods and the decrease of physical activity causes this rapid increase of obesity (World Health Organization, 2015). Obesity is associated with severe diseases such as diabetes, cardiovascular diseases and depression (Luppino et al., 2010), and other complaints like fatigue, bad condition and musculoskeletal complications (Visscher & Seidell, 2001). Because of the high prevalence, severity and the fact that it is largely preventable, obesity takes a prominent place in health communication campaigns. The intended effects of those campaigns, decreasing the obesity prevalence, are examined
scarce. There is evidence that anti-obesity campaigns can cause, intended or not, obese receivers to feel humiliated, ashamed of their bodies and stigmatized (Guttman & Salmon, 2004; Latner & Stunkard, 2003; Lewis et al., 2010). This can cause adverse effects and
decrease the motivation to adopt a healthier lifestyle (Vartanian & Smyth, 2013). Literature to back up Kim Moore’s reaction on the petition and to answer the research question of this thesis is scare. Some studies do assume that anti-obesity campaigns can cause stigmatization, but the scientific evidence lacks (Cho & Salmon, 2007; Guttman & Salmon, 2004;
Tomiyama, 2014; Vartanian & Smyth, 2013). Fear appeals in health campaigns are often accompanied by appeals to enhance self-efficacy, because this has proven to be more effective (Witte & Allen, 2000). Self-efficacy is the believe that people have that they can change unhealthy lifestyles. Self-efficacy appeals can work adversely since it can affect the self-esteem of obese receivers (Guttman & Salmon, 2004). In this thesis, we will also examine if appeals to self-efficacy can change the public’s attitudes towards obese people, when accompanying fear appeals in anti-obese campaigns.
Theoretical Background
Stigma
A stigma is an attribute or characteristic that individuals possess (or are believed to possess) that conveys a social identity that is devalued in a particular social context (Link & Phelan, 2001). Health related stigma is characterized by social disqualification of individuals and populations who are identified with particular health problems (Weiss, Ramakrishna, & Somma, 2006). Those who fail to comply to the health behavioural norms can be punished trough guilt, rejection, isolation, limited access to services and in some cases special taxation (Kim & Shanahan, 2003). For example, obese people are identified as lazy and lacking in willpower (Tomiyama, 2014). These effects of stigmatization can result in adverse effects on
health; stigmatising obese individuals can decrease their motivation to diet, exercise and lose weight (Brewis, 2014; Vartanian & Smyth, 2013). Important in the context of this thesis is the notion that stigmatized people often experience that stigma contributes to a, sometimes
hidden, burden of illness. In this way and other ways, stigma influences the effectiveness of treatment, which is a major interest of disease control (Weiss et al., 2006).
Stigma can be distinguished into different types. In the context of this thesis, when we talk about stigma, we mean public stigma (e.g. ‘the public thinks that obese people are lazy’). Other types of stigma that we use when discussing theory and literature are self-stigma, which refers to the internalisation of public stigma (e.g. ‘I am obese, therefore I am lazy) and
perceived stigma, which refers to public stigma perceived by someone who is obese (e.g. the public thinks I am lazy because I am obese’) (Rüsch et al., 2009).
Stigma occurs most of the time as a result of observing generalization and discrimination of all kinds of things that happen normally and are not always correct. By observing several times that obese persons are doing nothing, one might decide that not only these obese persons are lazy but all members of the class of obese persons have this characteristic. Stigmatisation can occur through two different processes, rule-based processes and associative processes (Pryor, Reeder, Yeadon, & Hesson-McLnnis, 2004). Rule-based processes occur slowly and consciously. Associative processes occur rapidly, automatically and unconsciously, they arouse automatic affective reactions; just exposing a stigmatised person to an individual can arouse negative evaluations. Once the stigma had been established, it is difficult to discredit it. This thesis investigates associative processes.
In this thesis, the main contention is that health campaigns can have an impact, intended or unintended, on stigmatization. Health campaigns attempt to promote public health by targeting certain values, norms, behaviours and audiences. However, doing so possibly
triggers unintended values, norms, behaviours and audiences as well. As Rogers (Rogers, 2003, p449) wrote: “A system is like a bowl of marbles. Move any one of its elements and the position of all the others are inevitably changed.” Assuming this, health campaigns may result in effects that can be intended as well as unintended. The intended effects of health
campaigns, or certain aspects of it, are widely researched and evaluated. Unintended effects of health campaigns, are often unnoticed or underreported because evaluations of health
campaigns usually focus on the intended effects (Cho & Salmon, 2007). If unintended effects are evaluated however, they are often evaluated on the level of the target audience, for
example self-stigma or perceived stigma (Bayer, 2008; Vartanian & Smyth, 2013).
Evaluations and research to investigate public stigma, on the level of the population that is not necessarily targeted, is scarce (Cho & Salmon, 2007). Unintended effects can be positive, negative or neutral, but it is important to realize that those labels are subjective. An unintended effect can be influencing the intended effect in the wrong direction (e.g., boomerang effect) or it can be a totally different effect that doesn’t influence the intended effect or effects it indirectly. According to a study investigating the unintended effects of prevention, three undesirable effects can occur: stigmatizing the sick, occluding structure and increased surveillance of one’s self or others (Broom, 2008). Stigmatizing the sick can
possibly be an unintended effect that arises from campaigns, but can be of strong positive influence on the intended effect, so desirability is subjective. This thesis will merely investigate stigma as a possible effect of health campaigns, without attaching an ethical judgement on whether stigmatizing health messages should be used. An example of health messages that resulted in successful behavioural change through the use of stigmatization are the USA’s control policies (e.g., smoke free air laws) and campaigns stressing the dangers and disadvantages of smoking and second hand smoke that resulted in social unacceptability of smoking through social norming. This social unacceptability resulted in increased
perceived stigma for smokers. This stigma resulted in a decrease in tobacco use which is positive, but smokers who can’t or won’t quit are left with the negative consequences of being stigmatised (Stuber, Galea, & Link, 2008).
There are also several anti-obesity campaigns that appear to embrace the stigmatization of obese individuals as a strategy for public health. By fueling and sustaining stigma, the
campaign designers aim to induce the motivation and the social pressure for obese individuals to lose weight and to prevent obesity in the society. Vartanian and Smyth (2013) criticize these campaigns because of adverse effects on motivation and positive behavioral changes we discussed earlier in this chapter. Another argument they describe is that is unclear to which extend individuals are responsible for being obese. Their main argument is that public health messages concerning obesity must first, do no farm (Vartanian & Smyth, 2013). However, scientific proof on whether anti-obesity campaigns do indeed arise or sustain public, or other types of stigma lacks in their article. Studies on the impact of anti-obese public health
campaigns on obese children and adults show that they can directly influence self-stigma and perceived stigma (Guttman & Salmon, 2004; Latner & Stunkard, 2003; Lewis et al., 2010).
There is hardly any proof of anti-obese campaigns influencing public stigma. It is sometimes assumed in articles, but these assumptions often seem to be based on gut feelings rather than scientific evidence (Cho & Salmon, 2007; Guttman & Salmon, 2004; Tomiyama, 2014; Vartanian & Smyth, 2013).
Fear appeal
A fear appeal is a persuasive message that attempts to arouse fear in order to divert behaviour through the threat of impending danger or harm (de Hoog, Stroebe, & de Wit, 2005). It presents a risk, presents the vulnerability to the risk, and then often describes a suggested form of protective action to enhance self-efficacy. “The ultimate goal of fear appeals is to
effectively promote reflective message processing and to influence individual affect towards the message” (de Hoog et al., 2005). Mixed results have been produced from studies that attempt to demonstrate the effectiveness of fear appeals for behaviour modification (Walters, Bennett, & Noto, 2000). Strong fear appeals can produce strong behavioural changes when applied correctly, for a fear appeal to be effective it is important to give the receivers a the feeling that they can do something about their behaviour (Witte & Allen, 2000). Fear appeals can also work adversely, using them can cause receivers to ignore the messages or the desired behaviour (Cho & Salmon, 2007). There is also a concern that fear appeals give rise to
stigmatization of those who are seen to be already suffering the negative consequences of the undesirable behaviour. For example, in 2012, an Australian anti-obese campaign called ‘LiveLighter’ (http://livelighter.com.au/) spread a series of messages using fear to promote a healthy lifestyle in print, on television and radio. One of those print messages can be seen in figure 1. The fairly shocking graphics and the use of the word ‘toxic’ are used to induce fear. A women named Lydia Turner initiated a petition to cancel these messages, saying that
“Scaring and shaming people about their bodies is not the answer.”
(https://www.change.org/p/wa-state-gov-t-heart-foundation-cancer-council-cancel-your-anti-obesity-campaign). 751 individuals signed the petition, but the campaign wasn’t cancelled. People who signed the petition were asked to name their reasons and these were shown on the bottom of the page. Some people felt directly stigmatized (e.g. Louise Lewis: This campaign doesn’t make me want to lose weight, it just makes me feel humiliated and ashamed; Kim Moore: Because as an obese person who's weight is medical and not food related […] I am considered morbidly obese, but these type of campaigns make people think that it’s because of overeating and laziness and that makes people judge you on false facts. I have had people make nasty comments about me, loud enough that I can hear them. Its these comments that make me depressed, not my body size. I know many people who have anxiety issues because of how people judge their size. These type of campaigns are nothing more than bully / scare tactics, which do more harm than good) The reactions shown on the petition-site imply that obese people can feel directly stigmatised. In some reactions people assume that using fear appeal can enhance public stigma towards obese individuals, this was however, never backed up with references to literature. These assumptions can also be found in some articles in the context of fear appeals and obesity, but they often seem to be based on gut feelings rather than scientific evidence. The aim of this thesis is to find scientific evidence on whether or not these assumptions are just, resulting in the following research question and first hypothesis:
RQ: To which extent can fear appeals in health campaign messages stigmatize or enhance stigmatization? And does self-efficacy moderate these potential effects?
H1: Messages containing fear appeals will lead to higher levels of stigmatization than messages that lack fear appeals.
Self-efficacy
According to self-efficacy theory the level of self-efficacy an individual has is believed to influence their choice of behaviour as well as the amount of time, and the amount of effort expended on that behaviour. How fear appeals and self-efficacy work can be explained through the Extended Parallel Process Model (EPPM) (Witte & Allen, 2000). The evaluation of a message containing fear appeals starts with perceived threat and perceived self-efficacy. If the threat is low, the message will be seen as irrelevant causing the receiver to ignore the message. If the threat is perceived as high, fear occurs. To eliminate fear, the receiver can engage is fear control or danger control. If self-efficacy is low, the receiver does not believe that he or she is capable of averting the threat and will produce defensive responses such as denial or ignoring the threat, hereby controlling the fear. If self-efficacy is high, the receiver will feel that danger can be controlled by performing the suggested preventative behaviour (Bandura, 1977; Witte & Allen, 2000; Witte, 1992). Appeals to enhance self-efficacy, such as personal responsibility are often used in health communication. Using these appeals can potentially have paradoxical consequences, for they might evoke feelings of guilt, blame or shame in individuals dealing with the health problem that the message refers to. Using appeals to enhance self-efficacy requires responsible application (Guttman & Ressler, 2010). This thesis will investigate whether appeals to self-efficacy can evoke these feelings of guilt, blame or shame of the receiving audience towards obese people, thereby stigmatising them.
H2: The assumed relation between fear appeals and stigmatization is stronger for messages with higher levels of self-efficacy than messages with lower levels of self-efficacy.
Figure 2. Theoretical model of the hypotheses
Methods
Participants and research design
A convenience sample of 229 participants was used, randomly divided over the four research conditions. The selection proceeded through messages on social media, inviting people to participate. Participants had to be able to read Dutch. To test the hypotheses, this research uses four conditions in a 2 (fear appeal vs. no fear appeal) x 2(high efficacy vs. no self-efficacy) between-group design. 58 participants were male, 171 were female and the average age was 37 (SD = 11). Table 1 shows the distribution of participants over the four conditions.
self-efficacy no self-efficacy total
fear appeal 66 49 115
no fear appeal 56 58 114
Total 122 107 229
Table 1. Distribution participants over conditions
Procedure and stimulus material
In an online survey, participants were exposed to one of four conditions. They were told that the research was in the context of obesity. They were shown a pictures of different body
types, both male and female, that gave the participants an indication of which body types they could assume to be obese. Next, they were asked a series of questions with respect to the dependent variables (stigma) and control variables. A representation of the entire survey in included.
Stigma. The focus of this thesis was whether exposure to fear appeal and/or
self-efficacy influenced stigma. To measure this, we compared the attitude towards obese people between the conditions. The measure ‘attitude’ was composed out of the following four bipolar, and three unipolar items that were scored on a seven point scale; ‘generally speaking,
I find obese people very unfriendly / very friendly’; ‘generally speaking, I find obese people.. very unpleasant/ very pleasant’; ‘obese people have.. no willpower/ a lot of willpower’; ‘obese people have.. no perseverance/ a lot of perseverance’; ‘generally speaking, I take obese people.. not very serious/ very serious’; ‘generally speaking, I find obese people.. unattractive/attractive’; ‘I think obese people are.. unwise/ wise’. The individual scores of
these items were added and divided by the number of items. The items formed a valid scale, Cronbach’s α = 0.74; M = 17.83; SD = 3.54.
Control variables. The variables described in this paragraph were controlled for. To
investigate whether knowing obese people interacted in the relation between the dependent and independent variables, respondents were asked ´I know… people who are obese´ and were given a seven point bipolar scale that ranged between very few and a lot. We also controlled for respondents having obese friends; ´I have … friends who are obese´ with a seven point bipolar scale that ranged between very few and a lot. Respondents were asked to fill in their weight in kilograms and their length in centimetres, which was used to make the variable BMI (mass/(length/100)2). For education level, respondents were asked to choose the highest level of education that they received, out of five Dutch education levels: geen/ lager- of
HBO/WO (HTS, HEAO). The respondents were asked to choose between male and female for
their gender and the last variable that was controlled for was age, which the respondent had to fill in in years.
The stimulus material consisted of one campaign poster out of four manipulated campaign posters. Fear appeal in conditions 1 and 2 were low, they showed the neck and chin of an obese person. The text on the posters read ‘Obesity is unhealthy’. To raise fear appeal in condition 3 and 4, a noose made out of sausages was shown around the neck. The text read ‘Obesity is suicide’. Conditions 1 and 3 were low in self-efficacy as there were no
characteristics to raise it. Conditions 2 and 4 were higher in self-efficacy, the text ‘eat healthy, sport regularly’ was added. Figure 3 shows conditions 1,2,3 and 4 respetively.
Results
In order to test the hypothesis that messages containing fear appeals will lead to higher levels of stigmatization than messages that lack fear appeals, we used an analysis of covariance (ANCOVA) with fear appeal as independent variable. The dependent variable was the attitude. Because we wanted to control for the possibility that attitudes are also dependent on the number of obese people the respondents know or the number of obese friends they have,
Figure 3. Respectively condition 1, no fear appeal; no self-efficacy. Condition 2, no fear appeal; self-efficacy. Condition 3, fear appeal; no self-efficacy. Condition 4, fear appeal; self-efficacy.
we took the question about these people as a covariate. We also controlled for gender, age, BMI, and level of education.
The expected results for fear appeal emerge from the data. The attitude towards people who are obese was more positive in the groups that weren’t exposed to fear appeal (Mno_fear = 3.65,
SD = .72), than the groups that were exposed to fear appeal (Mfear = 3.49, SD = .69). These
differences are significant (F(1,222) = 4.03, p = .046)
To test the second hypothesis, that the assumed relation between fear appeals and
stigmatization is stronger for messages with higher levels of self-efficacy than messages with lower levels of self-efficacy, only respondents exposed to fear appeals, so either in condition 3 and 4, were included in the ANCOVA. The attitude of people that weren’t exposed to self-efficacy (Mno_efficacy = 3.54, SD = .68) didn’t significantly differ from the attitude of people
that were exposed to self-efficacy (Mefficacy = 3.45, SD = .70). There was no significant main
effect for self-efficacy (F(1,107) = .42, p = .89.
Whether individuals have little or a lot of friends who are obese was a covariate in the main effects in both the fear appeal analysis (F(1,222) = 11.9, p = .00) and the self-efficacy
analysis (F(1,107) = 8,1, p = .01). In the explorative analyses it became clear that most people with a lot of friends who were overweight were mainly in condition 3 and a lesser number in condition 1. In the conditions 2 and 4 lesser participants had friends who were overweight.
No other analyses were successful in order to understand the outcomes of the experiment in any better way.
The other variables that were controlled for were age, gender, sex, BMI and level of education, these showed no significant effect.
Discussion
The aim of this research was to investigate to which extent fear appeals in health campaign messages can stigmatize or enhance stigmatization. Literature on this topic is scarce and contradictory, but it led us to the following hypothesis: Messages containing fear appeals will lead to higher levels of stigmatization than messages that lack fear appeals. The results showed that, as expected, the attitude of respondents towards obese people was slightly, but significantly, less positive for respondents that were exposed to fear appeals compared to respondents that weren’t. The second hypothesis was that the assumed relation between fear appeals and stigmatization is stronger for messages with higher levels of self-efficacy information than messages with lower levels of self-efficacy information. The results were not significant, so this hypothesis was rejected. Whether respondents had a lot of obese friends was a significant covariate both analysis. Further exploratory analyses showed that having a lot of obese friends was not normally distributed among the four conditions. As a consequence, we can not be sure that our data are useful and reliable. One explanation for the distribution problem might be that in the conditions 2 and 4, relative more people with friends who were overweight completed the whole questionnaire and were included in the sample. Maybe in these conditions people without friends who were overweight stopped filling in the questionnaire prematurely, thereby causing a skewed distribution.
Further investigating stigmatisation of obese people on the level of the public in health campaign messages using fear appeals is scientifically relevant, since scientific evidence is scarce. Most studies conducted in this context focussed on perceived stigma or self-stigma on the level of obese receivers. As with fear appeals, more research is needed to investigate the role of self-efficacy appeals in stigmatization of obese people on the level of the public since most studies in this context were also on the level of an obese receiver. Further investigation of both appeals is also of practical relevance. As Vartanian and Smyth (2013) wrote, health
campaigns must “first, do no harm”. Using fear appeals and appeals for self-efficacy must be done responsibly. This is only feasible when the consequences of using these appeals are properly investigated. This thesis was in the context of obesity, but other topics of health
communication in regard to stigmatisation on a public level are scarcely researched as well.
In further research it may be useful to use a different test to measure the attitude towards obese people. Whereas respondents attitudes where now measured explicitly, a test to measure implicit attitudes such as the Implicit Associations Test (IAT) can be beneficial, to decrease potential social bias that can may influence responds. It might also be beneficiary to investigate the association between the appeals (fear appeal and appeals to self-efficacy) and stigmatization in a longitudinal study, because stigmatization is a slow process that usually occurs after repetitive exposure. Repetitive exposure can lead to reduced compassion and sympathy (Cho & Salmon, 2007).
References
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change.
Psychological Review, 84(2), 191–215. doi:10.1037/0033-295X.84.2.191
Bayer, R. (2008). Stigma and the ethics of public health: Not can we but should we. Social
Science & Medicine, 67(3), 463–72. doi:10.1016/j.socscimed.2008.03.017
Brewis, A. A. (2014). Stigma and the perpetuation of obesity. Social Science & Medicine
(1982), 118C, 152–158. doi:10.1016/j.socscimed.2014.08.003
Broom, D. (2008). Hazardous good intentions? Unintended consequences of the project of prevention. Health Sociology Review, 17(2), 129–140. doi:10.5172/hesr.451.17.2.129 Cho, H., & Salmon, C. T. (2007). Unintended effects of health communication campaigns.
De Hoog, N., Stroebe, W., & de Wit, J. B. F. (2005). The impact of fear appeals on processing and acceptance of action recommendations. Personality and Social
Psychology Bulletin, 31(1), 24–33. doi:doi:http://dx.doi.org/10.1177/0146167204271321
Guttman, N., & Ressler, W. H. (2010). On being responsible : Ethical issues in appeals to personal responsibility in health campaigns. Journal of Health Communication, 6(2), 117–136.
Guttman, N., & Salmon, C. T. (2004). Guilt, fear, stigma and knowledge gaps: Ethical issues in public health communication interventions. Bioethics, 18(6), 531–552.
doi:10.1111/j.1467-8519.2004.00415.x
Kim, S.-H., & Shanahan, J. (2003). Stigmatizing smokers: Public sentiment toward cigarette smoking and its relationship to smoking behaviors. Journal of Health Communication,
8(4), 343–67. doi:10.1080/10810730305723
Latner, J. D., & Stunkard, A. J. (2003). Getting worse: The stigmatization of obese children.
Obesity Research, 11(3), 452–456. doi:10.1038/oby.2003.61
Lewis, S., Thomas, S. L., Hyde, J., Castle, D., Blood, R. W., & Komesaroff, P. A. (2010). “I don’t eat a hamburger and large chips every day!” A qualitative study of the impact of public health messages about obesity on obese adults. BMC Public Health, 10(309). doi:10.1186/1471-2458-10-309
Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annu. Rev. Sociol., 27, 363–85. Luppino, F. S., de Wit, L. M., Bouvy, P. F., Stijnen, T., Cuijpers, P., Penninx, B. W. J. H., & Zitman, F. G. (2010). Overweight, obesity, and depression. Arch Gen Psychiatry, 67(3), 220–229.
Pryor, J. B., Reeder, G. D., Yeadon, C., & Hesson-McLnnis, M. (2004). A dual-process model of reactions to perceived stigma. Journal of Personality and Social Psychology,
87(4), 436–452. doi:10.1037/0022-3514.87.4.436
Rogers, E. M. (2003). Consequences of Innovations. In Diffusion of Innovations, 5th Edition. Rüsch, N., Corrigan, P. W., Wassel, A., Michaels, P., Larson, J. E., Olschewski, M., … Batia,
K. (2009). Self-stigma, group identification, perceived legitimacy of discrimination and mental health service use. British Journal of Psychiatry, 195, 551–552.
doi:10.1192/bjp.bp.109.067157
Stuber, J., Galea, S., & Link, B. G. (2008). Smoking and the emergence of a stigmatized social status. Social Science & Medicine, 67(3), 420–30.
doi:10.1016/j.socscimed.2008.03.010
Tomiyama, J. A. (2014). Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model. Appetite, 82, 8–15.
doi:10.1016/j.appet.2014.06.108
Vartanian, L. R., & Smyth, J. M. (2013). Primum non nocere: Obesity stigma and public health. Journal of Bioethical Inquiry, 10(1), 49–57. doi:10.1007/s11673-012-9412-9 Visscher, T. L. S., & Seidell, J. C. (2001). The public health impact of obesity. Annu. Rev.
Public Health, 22(60), 355–375.
Walters, S. T., Bennett, M. E., & Noto, J. V. (2000). Drinking on campus: What do we know about reducing alcohol use among college students? Journal of Substance Abuse
Treatment, 19, 223–228. doi:10.1016/S0740-5472(00)00101-X
Weiss, M. G., Ramakrishna, J., & Somma, D. (2006). Health-related stigma: Rethinking concepts and interventions. Psychology, Health & Medicine, 11(3), 277–87.
Witte, K. (1992). Putting the fear back into fear appeals: The extended parrallel process model. Communication Monographs, 59, 329–349.
Witte, K., & Allen, M. (2000). A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Education & Behavior, 27(5), 591–615.
doi:10.1177/109019810002700506
World Health Organization. (2015). Obesity and overweight. Retrieved February 25, 2015, from http://www.who.int/mediacentre/factsheets/fs311/en/
