title: Stigma and Knowledge as Determinants of Recommendation and Referral Behavior of General Practitioners and Internists.
abstract: Despite reported effectiveness, weight loss surgery (WLS) still remains one of the least preferred options for outpatient providers, especially in Germany. The aim of this study was to examine the effect of stigma and knowledge on recommendation of WLS and referral to a surgeon by general practitioners (GPs) and internists.
  
  
  
  The sample consists of 201 GPs and internists from Germany. The questionnaire included questions on the perceived effectiveness of WLS, the frequency of recommendations of WLS, and the frequency of referral to WLS. Stigma, as well as knowledge was also assessed in this context. Linear and logistic regression models were conducted. A mediation analysis was carried out within post hoc analysis.
  
  
  
  Knowledge (b = 0.258, p < 0.001) and stigma towards surgery (b = -0.129, p = 0.013) were related to the frequency of recommendation of WLS. Additionally, respondents, who were more likely to express negative attitudes towards WLS, were less likely to recommend WLS and thus refer patients to WLS (b = -0.107, p < 0.05). Furthermore, respondents with more expertise on WLS were more likely to recommend and thus refer patients to WLS (b = 0.026, p < 0.05).
  
  
  
  This study showed that stigma plays a role when it comes to defining treatment pathways for patients with obesity. The question remains how this might influence the patients and their decision regarding their treatment selection. Interventions are required to make treatment decisions by physicians or patients independent of social pressure due to stigma.
authors.affiliation: Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Ph.-Rosenthal-Str. 55, 04103, Leipzig, Germany. franziska.jung@medizin.uni-leipzig.de.|IFB Adiposity Diseases, Leipzig University Medical Center, Leipzig, Germany. franziska.jung@medizin.uni-leipzig.de.|Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Halle-Jena-Leipzig, Leipzig, Germany. franziska.jung@medizin.uni-leipzig.de.
authors.forename: Franziska U C E
authors.initials: FU
authors.lastname: Jung
authors.affiliation: Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Ph.-Rosenthal-Str. 55, 04103, Leipzig, Germany.|IFB Adiposity Diseases, Leipzig University Medical Center, Leipzig, Germany.
authors.forename: Claudia
authors.initials: C
authors.lastname: Luck-Sikorski
authors.affiliation: Department of Health Economics and Health Services Research, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Hans-Helmut
authors.initials: HH
authors.lastname: König
authors.affiliation: Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Ph.-Rosenthal-Str. 55, 04103, Leipzig, Germany.
authors.forename: Steffi G
authors.initials: SG
authors.lastname: Riedel-Heller
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D050110:Bariatric Surgery / Q000706:statistics & numerical data*; D005260:Female; D058006:General Practice / Q000706:statistics & numerical data*; D058005:General Practitioners / Q000523:psychology / Q000706:statistics & numerical data; D005858:Germany; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007388:Internal Medicine / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000523:psychology* / Q000628:therapy*; D011364:Professional Practice; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D057545:Social Stigma; D011795:Surveys and Questionnaires
keywords: General practitioners; Internists; Obesity; Stigma; Weight loss surgery