Estimación de las tensiones impuestas por los moldes MP y MM

There is a relatively small, but emerging body of evidence in the international literature in the USA (Drohan, 2001; Story et al., 2002; Murray and Battista, 2009), Australia, (King et al., 2007, Pagnini et al., 2009) and Canada, (He et al., 2010) that highlights the views of GPs regarding their role in the identification and management of childhood obesity within the primary care setting. Van Gerwen et al’s., (2009) systematic review of primary care physicians’ knowledge, attitudes, beliefs and practices included 11 articles; eight from the USA, one in Israel and two in France. The review found evidence of primary care physicians reporting on the importance of primary care systems addressing childhood obesity. The prime reasons given were the significance of this issue for children’s health (Price et al., 1989) the effect of being overweight on chronic disease risk, and the effects on the quality of the child’s life in the future, (Story et al., 2002).

Research in Australia (McCallum et al., 2007) concluded it was logical that any package of interventions aimed at childhood obesity should include an intervention based within primary

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care and working with GPs particularly given the importance of clinician acceptability, family involvement and sustainability. Whilst the Australian Weight of Opinion research (King et al., 2007) demonstrated that GPs felt confident and comfortable in dealing with assessment and managing the health consequences of obesity, their responses were mixed regarding their contributions to supporting families with behavioural interventions such as changing dietary behaviours. However, in contrast, Jelalian et al’s., (2003) research suggested that some American primary care physicians considered childhood obesity counselling frustrating and not professionally gratifying.

A further view was expressed by He et al., (2010) who reported the responses of a

representative random sample of 464 Canadian family practitioners to a self-administered 39- item survey, where the majority of GPs viewed childhood obesity as an “important” or “very

important” issue. Although the majority reported providing dietary (more than 85%) and exercise (98%) advice, their perceived success rate in treating childhood obesity was limited (less than 22%). The authors concluded that the Canadian primary care system was “not

sufficiently equipped to combat this extremely complex issue” (2010, p.426) highlighting too few government funded dieticians, time constraints and limited training for practitioners. In order to support efforts to identify or manage childhood obesity, they identified the need for office tools, patient educational materials and wider system-level changes addressing social and economic factors that may lead to increased rates of childhood obesity.

Campbell et al., (2000) also assessed, through a postal questionnaire, 840 Australian GPs' attitudes to their involvement in childhood obesity activities, and identified a range of predictive factors for the involvement of GPs. They found that involvement in childhood obesity increased by being female, receiving basic medical qualifications outside of Australia, attending continuing education and postgraduate training, and having confidence in dealing with babies, infants and preschool children. The most common barriers to involvement, according to Campbell et al., (2000) were insufficient time, inadequate financial reimbursement for long consultations, inappropriateness of raising the issues of childhood obesity in children presenting with acute illness, and lack of community resources.

To date, there have been three qualitative studies of the GP views and perspectives and experiences of the identification and management of childhood obesity in primary care in the UK, (Walker et al., 2007, Turner et al., 2009, and Redsell et al., 2011. A synthesis table of these UK studies is presented in Appendix Two. Turner et al., (2009) reported on 12 GPs

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from 7 practices in Bristol, and found that most GP participants stated that they thought primary care was an appropriate treatment setting, as it was based in the community and offered scope for opportunistic interventions. The GPs put forward the view that they were known to families and could refer patients on for further support; they also felt that childhood obesity needed to be addressed before associated clinical complications developed (2009, p. 858). Walker et al’s., (2007) study of 12 GPs in 11 practices in Rotherham however, found that the GPs in their study offered a more restricted view of their role which primarily was confined to raising the issue of a child's weight with parents, and managing only the associated medical problems. According to these GPs in this study the responsibility for

“solving the problem of obesity”, (2007, p.2) rested either with the family, or with a public health agency. Redsell et al’s study (2011) in the East Midlands focussed on 12 GPs’ views regarding identification of infants (those in the first 6 months of life) at risk of developing childhood obesity, and confirmed a strong rationale and acceptance by the GPs of the need to intervene in early childhood. However, the GPs were less likely to be consulted about infant feeding than Health Visitors, and were less confident about the advice they gave to parents, despite being more knowledgeable about the health risks of obesity. The GPs attributed their lower levels of confidence to the fact that infant feeding was not their primary role and that training was not readily available. Consequently their advice around infant feeding tended to be responsive, based on anecdotal or experiential knowledge. The GPs in this study reported adopting a parent-centred approach and were wary of adversely affecting the doctor-parent relationship. This research added to the literature by identifying that “GPs value strategies

that maintain relationships with vulnerable families”, (2011, p.58). However there is no indication in the paper how the term vulnerability is defined by the GPs or attempts to explore why the GPs felt this to be the case.