1.1 SALUD, BIENESTAR Y SATISFACCIÓN
1.1.3 Bienestar, optimismo y satisfacción con la vida
GP No. 7: Definitely group based – definitely getting them more active say with the school – teaching about good diet – motivating them and their family in every way possible yes that’s exactly what I am talking about
All the things I suppose that I recognise that I can’t do well enough in general practice and they need a more holistic approach and they need a bigger input from other people
Would support wider approach that can’t be delivered in a practice setting
Acknowledge limitation of primary care
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APPENDIX TEN. Summary subordinate themes (GP No.7)
UNDERSTANDING THE FAMILY. • Ridicule v Normalisation
• Denial and reluctance to engage with the problem / with the GP. • Family as a group
• Acceptance
• Gratitude for raising the topic • Requesting help – motivation
• Impact on family – emotional well being
COMPLEXITY OF NEGOTIATION CAUSED BY DIFFERENCE • Different impacts on different people
• Different presentations • Different influences • Different responses • Age specific
• Different causes – complex multifactorial
PROFESSIONAL DILEMNAS AND INDIVIDUAL CONFLICT • Reluctance to raise – consequences of raising.
• Duty to raise
• Internal conflict – purist v pragmatic • Conscientious
• Limits and span of legitimate role • Empowered
• Ethics of raising matter but no credible response • Difficult to deploy rational linear scientific approach
• Semantic field: triadic, medical , disease, accurate prevalence • Embarrassment of reality v evidence based practice.
CONSULTATION SKILLS / KNOWLEDGE
• Consultation shift – from immediate to a health promoting activity • Skills and Motivation to deal with sensitive topics
• Adapting the message – language change
• Lifestyle advice not within legitimate clinical expertise • Value of piggy back consultations
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• Communicating with children
• Knowledge of patient v textbook knowledge COMPETING PRIORITIES
• Competing demands in presentation. • Competing priorities.
• Time available in consultation
• Time consuming – long term investment
• Complexity of maintaining long term commitment • Significance / severity determines priorities
RESPONSES
• History taking when presented
• Defining and diagnosing – exploring – interpreting • Practice organisation framing behavioural responses • Getting stuck – referral to secondary care
• Second opinion syndrome – placate parents / professional reassurance • Brief interventions – basic not lecturing
• Community activities – holistic responses
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APPENDIX ELEVEN. Example of subordinate theme – Individual and professional dilemmas – all GPs.
Subordinate themes
Cluster themes Illustrative Quote.
Role legitimacy and adequacy Lifestyle advice/ not within legitimate clinical expertise
There’s lots of weight management stuff out there in the libraries and so hopefully people are accessing it as part of a lifestyle, rather than bothering a GP who has got so much to do dealing with chronic disease and acute illness than dealing with something that is really a lifestyle issue.(GP No. 3)
parenting advice I can’t really give them advice about what to do if the child won’t try new foods or kicks off at the dinner table – that’s the Health Visitors job (GP No. 3).
Limits and span of legitimate role
is it my role to be, you know ..a family dietician ( GP No. 7)
Empowered or are we empowered to actually do anything about it if we do raise it the issue (GP No. 9) Its Public health’s
job
It needs all the community coming together – schools – supermarkets, playing fields (GP No. 2) Reluctance to
raise
Part of me also has a slight reluctance because there are all sorts of … you know .. What we do with it if I raise it (GP No .7)
Duty to raise so yes part of me feels that we have a duty to raise these issues with the families - particularly when you have a young person coming in with a parent and the child is clearly very obese .. (GP No. 5) Conscientious
/Concern if miss opportunity
you know we are in the business of identifying risk factors for disease and for conditions particularly when you have a young person coming in with a parent and the child is clearly very obese (GP No. 8) Internal conflict – but yes the sort of the purist in me would say yes we should have a role in actually managing ...
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purist v pragmatic identifying (GP No. 7) Raising unrealistic
expectation
you know .. What we do with it if I raise it (GP No. 7) Poor service
response
dietetics - there are very poor provisions of dieticians in this area – across the patch and I am not even sure if they look at such kids in fact so… you are very limited. (GP No. 4)
Poor feedback You don’t know ... you never know …because they don’t come back 6 months later and say thank you very much I have got Jimmy with me and now he is a size 10 –you don’t know whether you have done a good job … it’s a bit soulless really. (GP No. 3)
Competence, Knowledge and training
Hard and difficult I suppose because they are children you feel you have to help even thought is can be really hard. (GP No. 6)
Hit into problems So we do use the paediatricians sometimes particularly when you hit an impasse with parents who say “ooh there must be something medical behind this”, they seem to believe there has got to be a
condition rather than it just being a matter of overeating.’ (GP No. 7) Emotionally
draining
I think it’s very sad because we don’t deal with the problem as often as we possibly could and when we do deal with it I am not convinced that we deal with it terribly well.(GP No. 8)
Getting stuck It’s all very well to have names and phone numbers and places, but knowing individuals is what helps with referrals, I can say with confidence “I know this person who is really good and will help you” but if I say “go to this place” it’s not the same.’ (GP No. 2)
Reality v evidence based practice
Starts laughing Do you want the honest answer.. laughing(GP No. 7) Knowledge of
pathways and Protocols
‘If we did pick up a kid with obesity I would be a little lost as to know what to do with them – because there aren’t the facilities ,, there is nowhere ,,, where I know about – we haven’t really got a treatment protocol for these kids’(GP No. 4)
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guidelines can’t remember seeing it (GP No.2) Communication
skills
clearly if you have a consultation with a 5 year old who is obese clearly you can’t start lecturing the child (GP No. 8)
Specialist Interest I am not very good at it – I am not the child health doc in our practice – what we tend to do if we think the child is very heavy for their age, we tend to refer to the in-house doctor who is our child doc, he is much better at making an official assessment if the child is overweight.’ (GP No. 2) Specific Paediatric
Knowledge
But there is something a bit scary about children ... It’s like with drugs you can’t just treat them as mini adults... you have to know your stuff. (GP No. 2)
Training Training well - Lifestyle advice –I don’t think I have had a specific training you would hope that you would pick that up as part of your general training. (GP No. 2)
Service Knowledge
It’s all very well to have names and phone numbers and places, but knowing individuals is what helps with referrals, I can say with confidence “I know this person who is really good and will help you” but if I say “go to this place” it’s not the same. (GP No. 2)
Behavioural Techniques
I’m a mum and I know how to get a child to act, but it’s harder with parents. I suppose the whole thing of losing weight is just as hard with adults(GP No. 10)
Poor practice I think it’s very sad because we don’t deal with the problem as often as we possibly could and when we do deal with it I am not convinced that we deal with it terribly well.(GP No. 8)
Experiential evidence
I can be trained ... I can know the dangers…and all that but what am I actually going to do for them there and then …its about putting them on a programme that’s going to make them lose weight .. Because just seeing me every week isn’t going to work. (GP No. 4)
Motivation Motivation to deal with sensitive topic
You can be motivated to work with people if you feel you can really help them, but if you are struggling to do anything worthwhile for them in the time that’s available, then that’s far more difficult really. I think our role will probably be best in terms of knowing who to refer to get the appropriate help rather than doing it ourselves. (GP No. 1)
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APPENDIX TWELVE SUMMARY OF THE GP TYPOLOGIES
The Gatekeeper Outside of the Professional Domain
Informer and Educator Helper and Facilitator Description Lifestyle behaviours are
complex and require specialist input from qualified experts such as paediatricians or specialist dieticians.
Intervention considered outside of the
professional role, best addressed through population health approaches.
Risk factors for childhood obesity are individual lifestyle issues.
Ensure family has sufficient information on health risks/benefits of lifestyle risk factors to make
an informed choice about lifestyle behaviour. Provide additional assistance to motivated families.
Facilitate families to change their behaviour through providing tailored support strategies, moving towards change over time. Synergistic role with other providers and population health approaches Epistemological
Framework
Biomedical / Scientific rationalist with quest for medical certainty
Biomedical. Biomedical – biographical. Families have multiple, interacting, and compounding problems; physical, psychological and social. Interpretivist - socio- ecological perspective. Narrative based medicine/ Integrating family’s biological, psychological, and social presentation into a coherent clinical whole.
Understanding the Family Focus on health problems of childhood obesity. Limited to medical history, presenting conditions Remains detached from wider social cultural and economic circumstances of
Focussed on deficient behaviours of parents and their unhealthy lifestyles. No awareness and of wider factors on parental
behaviours. Crude and negative assumptions
Display an awareness of the impact of socio- economic disadvantage and its link with childhood obesity. Recognised wider social contextual factors on the family.
Demonstrated extensive long term knowledge of many aspects of families’ lives;
Fully acquainted with wider social determinants and impact of factors such
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the family about the health
behaviours of the families and disparaging views of parents.
Particularly sensitive to parental anxieties.
as limited access to play and leisure facilities, the cost of healthy foods and parental working patterns. Professional Dilemmas Restricted opportunities to
screen, absence of clinical pathways, guidelines and specialist secondary services
No evidence base available for intervention.
Found prevention role difficult and not their preferred clinical response.
Experienced feelings of frustration at the failure of parents who were
conceptualised as being almost impervious to behavioural changes. Frustrated at limited response of the wider community to address childhood obesity.
The need to address the health consequences of their child’s weight, often proved to be an
unreasonable expectation in the face of wider structural factors, social constraints and parenting challenges. inherent in their biographical
knowledge of the family. Professional frustration at the limited support and facilities available to deal with family complexity
Acutely aware of the emotional impact of childhood obesity on the child and concerned that their interventions may impact on their fragile self esteem
Recognised complexity of parenting a child who was obese.
Aware that wider social economic and financial consideration may impact on their resources and ability of the family to address childhood obesity. Organisational Challenges Identified no support
within the practice to assist. Discouraged
Practice nurses from being involved.
Very little interest in training
Focussed organisational priorities of the practice on acute delivery of primary care.
Had very limited access to children as this was managed by other partners in the practice.
Felt that dealing with lifestyles issues was a drain on his scare clinical time.
Struggled with time to address complexities which
could be a disincentive to open up a conversation, particularly one which focussed on the sensitive area of childhood obesity
Excessive workload, conflicting and competing priorities and time
impacted on ability to provide intensive support and motivation to the families.
Fully committed to their Practice as a health promotion environment.
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