Software utilizado para el soporte a la investigación

The issue of the GPs’ perceptions of family health beliefs and behaviours was also significant. At times it was difficult to identify whether the issues the GPs identified as family behaviours, for example “they live on takeaways”, or the kids are all “couch potatoes” were actual known health behaviours of the families, or were generalisations tainted with popular normative beliefs about childhood obesity. It therefore could be argued that such responses

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were more reflective and indicative of the prevailing social, moral and cultural frameworks through which the individual GPs’ considered childhood obesity and made sense of their encounters with children who are obese. Rich and Miah (2009) suggest that contemporary health discourses on childhood obesity are no longer confined to medical contexts, but are encountered through television programmes, such as “Generation XXL” and “Honey We’re Killing the Children”, where parents are shamed and humiliated. Puhl et al., (2013) analysis concluded that such programmes have a substantial influence on public perceptions of childhood obesity. It is important that GPs are encouraged to explore, as part of their reflective practice, how their beliefs and attitudes towards childhood obesity are constructed from their social and cultural life experiences, as well as their clinical experiences. If GPs passively absorb some of the negative stereotypes often depicted in the media, they may be less motivated to intervene and offer much needed support to children who are obese. Moreover, it is argued that GPs and their Royal Colleges should have a leadership role at a national level in constantly challenging, through media debates, the blunt, harmful stereotypes and stigmatisation of children who are obese, which can lead these children to suffer substantial psychological and social harm. At a local level GPs, because of their expert status in the community (Hearn et al, 2008); also have a potential role in influencing community attitudes about childhood obesity, and advocating for change in broader health and social policy.

Further the issue of GPs’ perceptions of family health beliefs was also exemplified in the findings about the different explanatory models the GPs and the families held regarding the causes of childhood obesity. The findings in this study confirmed that whilst the GPs acknowledged the complex multifactorial aetiological theories for childhood obesity, including social, environmental and psychological influences, which is consistent with other research (Walker et al., 2007; Turner et al., 2009), they tended to be sceptical about solely hereditary causes of obesity, (King et al., 2007). Research on the parents’ perspective however indicates that they attribute a range of causal medical explanations for their child’s obesity, such as genetics or slow metabolism, (Jackson et al., 2005; Stewart et al., 2008). These different and dissonant explanatory concepts clearly had the potential to create tension between the GPs and the parents. However, one of the interesting findings of this study was that rather than risk damaging the relationship with the family, the GPs often suspended their scepticism and chose to negotiate mutually acceptable ground which accommodated some of the parent’s beliefs. The GPs in this study described how they would often refer the child to a

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paediatrician to allay their parents’ concerns and confirm that there were no underlying medical reasons for the child’s excess weight.

The findings in this study also highlight that the majority of the GPs located individual responsibility for the child’s weight with that of the parents, which is consistent with other research, (King et al., 2007; Walker et al., 2007; Redsell et al., 2011).The GPs in this study often focussed on how parents controlled access to certain foods, and were influential in the physical activity choices of their children. This is also found in other research which acknowledges that parents control many aspects of their child’s nutrition, (Dave et al., 2009; O’Connor et al., 2010; Vereecken et al., 2010), and physical activity, (Sonneville et al., 2009; Gubbels, et al., 2011). However, such research can be challenged as it often characterises a relatively hierarchical, uni-directional nature of the parent and child relationship, consistent with assumptions in policy discourses (DoH, 2009) that parents can successfully manage and control their children.

For the GPs in this study there was an acknowledgement that the position was often more complex. They discussed examples, which can also be found in the literature, of active resistance from children (Baughcum et al., 2000) who were able to demand different food (Wilson and Wood, 2004) and dismiss physical activity practices recommended by their parents (Jackson et al., 2005). Some of the GPs made sense of such dynamics by referencing their own familial circumstances, acknowledging that children can exert significant influence on parental decision-making about food choice (Dixey et al., 2006). This finding again challenges some of the national childhood obesity programmes such as Change4Life (DoH, 2009), which are based on the premise that parents have the agency, ability and resources to control and direct children's lifestyle behaviours. Whilst evaluation of the success of Change4Life is still awaited, it could be argued that for some families who the GPs worked with, such programmes assume an unreasonable expectation given wider structural factors, family constraints and parenting challenges.

5.2.1.3. Parenting practices.

Parenting styles, family dynamics, and relationships within the family environment have consistently been identified as crucial factors linked to childhood obesity, (Golan et al., 2004; Rudolf et al., 2010). However, the GPs in this study rarely explored in-depth typologies of parenting as a way of making sense of parental behaviours and attitudes; instead they tended to focus on negative or permissive parenting styles. Their view that permissive parenting or

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“giving in” was more likely to be associated with weight gain in children, is consistent with other studies (Hesketh et al., 2005, Rhee et al., 2005, Stewart et al., 2008). However, few of the GPs explored how they could use this opportunity to work with parents on enhancing some of their parenting skills such as boundary setting, and positive discipline (Hughes et al., 2008). This is an important finding and is likely to impact on the responses that GPs could meaningfully offer in terms of managing childhood obesity. It also highlights the lack of knowledge GPs have about existing evidence based parenting services such as the Triple P- Positive Parenting programmes (Sanders et al., 2008) which are widely available at local Children Centres. This does appear to be a missed opportunity, and such services need to be widely promoted as many of the issues that GPs face in relation to child health could benefit from referrals or signposting to parenting courses.

5.2.1.4. Parental concerns regarding childhood obesity.

The findings in this study also indicated that there were significant differences in the underlying understandings, concerns and expectations of the parents and the GPs in relation to childhood obesity, which has clear implications for professional practice. The GPs in this study often expressed concern when parents disputed or refused to accept their medical opinion that their child was obese. However, the literature review in Chapter 2 highlighted a number of studies that have empirically demonstrated that parents have difficulty in recognising their child as being overweight (Carnell et al., 2005; Eckstein et al., 2006), and underestimate the weight status of their overweight or obese child (Jeffery et al., 2005; Jansen and Brug, 2006; Parry et al., 2008). Baur (2005) has argued that childhood obesity is different from other childhood chronic illnesses, such as asthma, where the child’s symptoms are usually clearly recognised as being abnormal by the family, with the result that medical treatment is then sought. However, in relation to childhood obesity there is the view that, as the prevalence of obesity is high, this problem may now have been normalised, (Kirk and Penney, 2013) and therefore parents struggle to assess if their child is overweight. This may particularly be the case if parents perceive obesity as temporary problem which will resolve as children grow older, (Stewart et al., 2008). In addition, Southwell and Fox (2011) report that parental misconception of weight may be a psychological process, which mothers particularly, use, to protect themselves from the perceived threat of stigma and blame. The fact that these issues were not considered or were poorly understood by the GPs in this research is likely to impact therefore on any meaningful support the GPs could offer.

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