Método de Otis

Finally GPs No. 6, and No. 10, both female GPs, explored their interventions to support obese children consistently within the Laws et al’s., (2009) role of Helper and Facilitator, “helping move clients towards change over time by acting as a facilitator” (2009, p.10). It is proposed that these GPs practiced with an interpretivist framework (Reeve, 2010, Reeve et al., 2011; 2013) using many of the epistemological positions of Narrative Based Medicine (Launer, 2002). Both positions have been proposed as a practical way to respond to the complex reality of patients’ lives that are presented in a primary care setting (Greenhalgh and Hurwitz, 1999; Launer, 2002). Over the past two decades this framework has been increasingly acknowledged as a powerful alternative to the reductionist biomedical framework, in that it stresses the importance of a more empathic and holistic approach to patients, (Greenhalgh et al., 2005). Whereas the biomedical paradigm considers knowledge as a place of certainty and ‘truths,’ the Interpretivist offers an understanding of knowledge as being more “contextual, contingent and fluid” (Reeve, 2010, p.521). Narrative based medicine proposes the existence of multiple viewpoints, and that knowledge is constructed in the clinical interaction between the doctor and the patient, operating within a continuous interpretive and therapeutic framework that acknowledges the uniqueness and value of the patient’s story (Launer, 2002). The GPs in this study who took the role similar to that of the Helper and Facilitator continued to value the biographical accounts of the family experience as valid and epistemologically central to their everyday practice. They demonstrated extensive long term knowledge of many aspects of the families’ lives, often extending this knowledge to include the health attitudes and behaviours of grandparents and members of the extended family. This is consistent with Berge et al., (2012) whose findings showed the impact of “significant others” (2012, p. 35) on children’s weight status, dietary intake, and physical activity.Overall these GPs confirmed that establishing trust was critical to good practice and they prioritised relationship-centred care (Greenhalgh, 2002). They were more likely than any of the other GPs to focus on interventions that promoted a higher level of empowerment for the family, which they acknowledged may take time. Edmunds (2005) confirmed that this empathetic approach was

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positively received by parents of children who are obese, especially when the liaison was built over time.

However, this wider understanding of complexity and intricacy of families’ lives could lead to professional and individual dilemma for these GPs. Both of the GPs who displayed behaviours consistent with the Helper and Facilitator role, described how parents often adopted protective attitudes to their children who are obese, and the GPs appeared acutely aware of the important emotional role of food in family relationships (Lachal et al., 2013). For example they made sense of the strategies that parent’s use, such as indulgent food treats, to compensate for their child’s lack of self-esteem or difficulties with their peers.The GPs in this role were therefore often in a dilemma about whether maintaining healthy weight was more important than helping parents address the psychological issues of their child, (Dixey et al., 2006; Murtagh et al., 2006; Stewart et al., 2008). Often there were no easy solutions which impacted on the GPs feelings of self-adequacy (Nolan et al., 2012). Consistent with Narrative Based Medicine (Launer, 2002) the GPs in this role tried to make sense of the family situation through a shared exploration of the individual child and the families’ experiences, the families’ interpretation of childhood obesity, and the impact that the child’s weight was having on them. These were addressed through continuous conversations, and moving towards a co-construction of responses which acknowledges the uniqueness and value of the families’ story (Greenhalgh, 2002). For example, one GP after a long discussion with a mother about increasing physical activity and the expense of taking the whole family swimming was delighted to hear later from the parent that a neighbour had given her a bike for her child to use.

The GPs in this role were fully acquainted in their holistic approach to the wider social determinants which could lead to childhood obesity, (Bleich et al., 2012). Factors such as limited access to play and leisure facilities, the cost of healthy foods and parental working patterns were all considered as important in impacting on both the health choices of the families and the availability of parental skills and time needed to support their child who was obese. Many of these factors have also been identified in the literature on parent’s perspectives about the challenges that parents of obese children face (Edmunds, 2005; 2008; Stewart et al., 2008). As both of the GPs in this role, practiced in areas of deprivation, they were aware of the association between socio-economic status and obesity (Perez-Pastor et al., 2009, Knai et al., 2012), and the link with deprivation and lifestyle choices and behaviours, (Kinra et al., 2000).

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Both the GPs in the Helper and Facilitator role displayed a personal and practice commitment to addressing lifestyle management as an integral component of their role in providing holistic primary care (Gerner et al., 2006). They were keen to link discussion of risk factors to the presenting issue and displayed a high level of self-confidence and role legitimacy (Laws et al., 2009) in addressing the family’s risk factors. These GPs provided tailored, individual advice, and were willing to suggest brief behavioural interventions (Munsch et al., 2008) such as working with families on food diaries and advising them on their shopping routines. They also used motivational approaches (Rollnick et al., 1992; Rubak et al., 2009) to facilitate behaviour change, (McCallum et al., 2007) and to help the families set relevant and feasible goals. In contrast to previous research (King et al., 2007; Walker et al., 2007; Turner et al., 2009), they did not consider a lack of motivation from either the child or the family as a deterrent, but rather part of a continuous longer term process, and one in which they were able to utilise their skills to facilitate behaviour change (McCallum et al., 2007). The holistic understanding of the family which enabled them “to support the capacity of individuals in maintaining their daily lives” (Heath, 2009, p. 62) often resulted in them working with the families to find more practical solutions. For example they would advise where to buy local cheap healthier food and encourage them to use local parks. This focus on wider practical support was an approach that the parents in Stewart et al., (2008) found very beneficial. Whilst the GPs operating in this role, were more willing to invest time in addressing lifestyles issues in a more holistic way, they were conscious that their responses to children who are obese sometimes was diluted by excessive workload, conflicting and competing priorities and time (Lachal et al., 2013). The time required offering more intensive level of support and motivation to the families particularly challenged these GP and they tried to resolve these organisational constraints by offering additional consultations and arranging return visits for the families over a period of time.

Consistent with their holistic approach to childhood obesity the GPs in this role were sanguine in their beliefs that their support was one of many which may eventually have, a positive impact in addressing the cyclic relationship of obesity (Clocksin et al., 2002). As facilitators of change they judged the effectiveness of their intervention in terms of the process of change rather than solely achieving distinct weight reduction targets.

Finally, the GPs in this role held strong beliefs and values about their Practice having a positive health promotion focus; one had created a patient library with health promotion

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leaflets and books, and the other held regular themed events around lifestyles issues at the surgery with displays and local specialist speakers. However, they also believed that their role to support the family was synergistic with a wider socio-ecological perspective approach (Bronfenbrenner, 1979) and were prepared to challenge at population level. As a consequence these GPs were prepared to take on advocacy roles (Schwartz et al., 2002) or health champion roles (Eakin et al., 2004). For example one GP had written to supermarkets about chocolate being available at tills and another had been an active campaigner at her local school to ban soft drinks.

5.4. Summary.

Geneau et al., (2008) identified “many complex, causal loops of interrelated factors that shape the work of GPs” (2008, p.12). The initial aim of this research to explore the experience of identifying and managing children who are obese from the GPs’ perspective has been discussed in depth. Chapter 2 has highlighted the many divergent perspectives of GPs on childhood obesity. However, this research has added a further dimension in terms of the primacy the GPs gave to understanding the family and responding to family’s needs, and in navigating interventions in order to preserve the relationship with the family. Such decision making has been considered in this chapter through varying frameworks of role legitimacy, professional confidence and personal values. In congruence with the theme of individual and professional dilemmas, there were significant variations in terms of personal characteristics, style, motivations and attitudes. The research has also highlighted that despite a commitment to addressing a child’s weight, overall organisational challenges of time, competing priorities and resources both within the practice and outside of it often impacted on their motivations. The second aim of the research to identify variations in these accounts which impact upon the type of responses that GPs provide, has been given further focussed consideration by exploring the complexity and variances in relation to Laws et al., (2009) typologies of role types, and the underlying medical epistemologies, which add to the understanding of how GPs made sense of their experiences. It has also focused on how the results of this new analysis can be expounded upon through references to existing literature. The two GPs who have commented on the discussions chapter both noted their interest in the GP typologies and felt that they were helpful constructs. Interestingly one of the GPs observed that she recognised elements both of her own practice and had identified some of the role type behaviours in the other GP partners in her practice. Preliminary discussion of these role types

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have also been held with GP Educators at the North West Deanery and Public Health Consultants have indicated that they are identifiable, relevant and are likely to prove valuable in understanding the complexity of this phenomena. Key issues in terms of attending to these areas have started to emerge in this discussion chapter, and the final chapter of this report will therefore utilise the analysis to propose recommendations for future professional practice and policy development.