Dependencia de la Reversibilidad de la ruptura con el límite de corriente

One of the significant findings in this study was that the GPs rarely used objective height and weight charts, or measures of waist circumference, preferring to estimate the actual weight of the child. This finding again appears to contradict policy guidelines and pathways (NICE, 2006; 2013). However, it is a finding that has been confirmed in research with other GPs (King et al., 2007; Flower et al., 2007). Van Gerwen et al., (2009) suggest that multiple barriers might limit the assessment and monitoring of BMI in the primary care setting, including lack of familiarity with the use of BMI, lack of agreement about the utility of BMI as a screening and intervention tool, and lack of practice level resources. Smith et al., (2008) also found that health care professionals were generally poor at assessing the weight status of children through observation, and in particular tended to inaccurately underestimate overweight and obesity in children.

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The GPs in this study offered additional comments particularly around the sensitivities of weight and being careful not to embarrass the child by weighing and measuring them. Such findings were also replicated in O'Shea et al., (2014) who found that GPs do not routinely check children's weight, partly due to concern regarding the parental and child response. However O’ Shea et al., (2014) also found that almost all parents indicated checking weight was helpful, with only 4% of parents and just over 1 in 4 obese children responding negatively to weighing. Interestingly they found that children aged 5-6 years were most likely to respond positively. They concluded that whilst GPs are conflicted regarding the acceptability of weighing the child, almost all parents believed it to be helpful. It is therefore important that GPs are aware of such findings and open a dialogue with parents during any consultations regarding the value of weighing and measuring the child, rather than relying on subjective visual observations.

5.2.2.2. Sensitivity of the topic of childhood obesity.

The issue of sensitivity of the topic of childhood obesity has been consistently highlighted in the literature review (Walker et al., 2007; Stewart et al., 2008; Turner et al., 2009; Lachal et al., 2013), and the GPs in this study confirmed that they found the topic of a child’s weight to be both a sensitive and difficult one. Gabbay and le May’s (2011) research on decision making in primary care found that there was often a “deeply embedded logic in GPs’

thinking” (2011, p.60). A clear example of such embedded logic, and one that is an important finding was that the family represented an important long term investment by GPs; one that they were keen to nurture and sustain. Raising the topic of a child’s weight if not handled appropriately and sensitively could damage such a relationship. Sometimes the GPs reported tentatively raising the weight issue or dropping hints and then judging a parent’s reaction before deciding to continue the discussion. This finding was consistent with Summerskill and Pope’s (2002) research which considered consultations in which GPs had failed to implement conversations with patients regarding secondary prevention for cardiovascular disease. They concluded that the desire to avoid upsetting patients, and preserve a good relationship was sometimes more important than implementing secondary prevention.

Previously, the reluctance of GPs to raise the matter of a child’s weight has been presented in the literature as indicative of their limited interest in the topic of childhood obesity (Turner et al., 2009). Whereas the findings of this current study indicated that they were an integral part of a more rational decision making process which was determined and contextualised by other

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current extraneous considerations. Further, such findings challenge government policies such as “Every Contact Counts” (NHS Future Forum, 2012), which encourage all consultations to be health promotion ones. For the GPs in this study decisions to raise the topic of childhood obesity were often a compromise of multifarious considerations and different demands. It appeared that trying to juggle the competing imperatives of delivering individualised and responsive patient centred health care, whilst addressing Governmental determined public health concerns was often not feasible. It is suggested, therefore, that policy guidelines need to be aware that often GPs will exercise judgement about when to raise the topic. Whilst there is little doubt that every consultation provides a potential opportunity for this, it is clear that GPs are often likely to assess the family and child’s receptiveness before initiating any weight related discussions.

Linked with the topic of sensitivity was that of language choice. The current study highlighted tensions around language choice, with the GPs aware that the language used needed to be sensitive, but also had to be crafted in such a way that the concerns of the GPs were articulated. However, this is clearly a contentious area, for example Turner et al., (2011) found that many of the parents felt that GPs had been particularly insensitive when raising the topic of a child’s weight, either by using clumsy language or not acknowledging the distress that the topic was causing the child.

It is interesting that the findings in this study indicated a distinct gender difference in relation to language choice. None of the female GPs used derogatory or pejorative comments in any of the research interviews, preferring to choose terms such as “overweight” or “obese”. Perhaps, as women they were more sensitive to the societal constructions of the term “fat”, and more

vigilant about the negative connotations and the inappropriateness of using such language in professional and personal discourses, (Lupton, 2013). This is in contrast to the male GPs, who on occasions, used the word “fat kids” when describing their experiences, albeit several noted that these were terms they would not use directly with patients. This selective use of context specific language was originally identified by Goffman (1959) who introduced the concept of front stage communication; that which is usually not controversial and appropriate to present to anyone, including patients (Goffman 1959; Ross and Hunter, 1991). Whereas, according to Goffman (1959), back stage communications included making controversial statements about patients, and displaying inappropriate attitudes and beliefs that are outside of the acceptable professional framework (Wear et al., 2006). Whilst the intention not to use derogatory or discriminatory expressions during the consultation could resonate with the

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previous assertion that GPs were like actors using scripts at certain occasion to different audiences. It equally could be reflective of a more subtle alliance with social, cultural and moral constructions of obesity highlighting the potential stigmatising discourses on childhood obesity (Puhl and Latner, 2007). The issue of language choice in relation to childhood obesity is therefore one that GPs need support in addressing, and could benefit from guidance on how to discuss the topic in appropriate language that parents can respond to and accept.