The literature review has provided valuable insights in order to progress the key research question of this thesis and explore the experience of identifying and managing children who are obese from the GP’s perspective. It has confirmed some of the challenges GPs face when they tried to address this complex phenomenon with a wide range of potential causes. The existing literature has confirmed that GPs in the UK and primary care practitioners in the US, Canada, Australia and other European counties express concern about the growing increase in childhood obesity (Murray and Batista, 2009; He et al., 2010), and view primary care as an appropriate treatment setting for the identification and management of childhood obesity, (King et al., 2007). However there are significant questions about the extent to which they can effectively manage this condition (Walker et al., 2007; Turner et al., 2009). The literature also suggests that despite the policy positioning of GPs as playing a key role in reducing childhood obesity (DoH, 2011) there is no credible research that shows they can be influential (Oude Luttikhuis et al., 2009; Wake et al., 2009). Moreover, there are a range of factors that impact on any interventions, including the GPs’ competence, skills, motivation and expertise, limited
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time and resources and a lack of effective treatments, support and referral options,(Walker et al., 2007; Turner et al., 2009; Redsell et al., 2011) The need to work with parents and children who the GPs perceive may be unwilling or unable to address the matters appears to evoke both frustration and a resignation of limited achievable impact, (Edmunds, 2005; Stewart et al., 2008; Turner et al., 2009).
It is clear that the diversity of perspectives of children, parents and GPs relating to childhood obesity reflects the complexities inherent in tackling childhood obesity. It is also apparent from the literature that parenting a child who is obese is a very complex (Lachal et al., 2013); often emotionally charged area (Stewart et al., 2008; Turner et al., 2011) and the motivations and needs of parents vary considerably (Edmunds, 2005). Moreover, family circumstances and the broader social and environmental contexts which underlie family behaviours in relation to weight management are areas that GPs feel least confident and professionally capable to address (Walker et al., 2007). The literature review has also confirmed that there is a growing recognition that childhood obesity is not a stable condition, rather it represents a dynamic process; in which behaviour, cognition and emotional regulation mutually interact,(Murtagh et al., 2006; Pagnini et al 2009; Staniford et al., 2011). Family structure and context, parental and familial attitudes, activity, nutritional patterns as well as familial stress (Barlow and Ohlemeyer, 2006; Stewart et al., 2008; Lachal et al., 2013) all have a critical role with respect to the identification and management of childhood obesity.
It is encouraging that despite the challenges GPs face, many GPs still feel that they have a role to play in addressing childhood obesity (King et al., 2007, He et al., 2010) and in the main are keen to maintain positive and productive relationships between parents and the child (Walker et al., 2007, Turner et al., 2009). They are aware that childhood obesity is likely to be a growing presentation in their clinical practice (Lachal et al., 2013) and the need to identify the most successful way in which they can intervene remains an important priority. The fact that despite the clear challenges and reservations highlighted in the literature GPs often do raise the topic of obesity with children and families and therefore the focus of this thesis becomes even more important.
One of the critical conclusions of this literature review is that the previous consideration of the experiences of GPs and childhood obesity in the UK setting, tend to frame and discuss GPs alongside other primary health care professionals; Walker et al., (2007) and Redsell et al., (2011) findings, discussions and conclusions refer to both GPs and Practice Nurses, and
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the unique focus on GPs is absent. Turner et al., (2009) extends the recruitment sample further including GPs, practice nurses, school nurses, and health visitors, and whilst this facilitates preliminary comparisons between the professionals it provides little in depth focus on the GPs. In other research (Staniford et al., 2011; Banks et al., 2012) the overall findings over simplify the GP community presenting them as a single entity, with similar perspectives. Moreover these papers offer little recognition of the multiple and diverse approaches, the varying perceptions of role congruence, motivations and views and the range of practice found in the complex world of General Practice (Gabbay and le May, 2011). The literature review has therefore highlighted the need for the research in this thesis to avoid any reductionist generalisations (Hertz, 1997; Stanley, 2004) about one professional group. It has also confirmed that there have been no studies that have explored the different perspectives and experiences of sub groups of GPs, such as more experienced GPs, newly qualified GPs or salaried GPs to add more detailed insight. The intention of this thesis to focus solely on GPs who have been in practice for over 25 years, is detailed in Chapter 3, Section 3.8.1 and is expected to add a new and valuable contribution to the existing literature.
A further limitation highlighted in each of the 3 key qualitative studies in the UK, is the acknowledgement that the participants in each of these studies volunteered to participate and therefore it may be assumed that they hold particular views about obesity management, (Turner et al., 2009) or reflect the views of local clinicians with an interest in obesity research, (Walker et al., 2007). Redsellet al., 2011 concluded that in addition to a poor response rate of 34% to their postal survey, the interview participants may have been biased towards health care professionals with an interest in the subject, (2011, p. 61). Whilst most of the authors state this point in relation to the fact that this may affect the generalisability of the study, it does questions whether these self-selecting participants represented a partial picture of GPs who had a greater interest in management of childhood obesity than GPs in general, (Detorri et al., 2009), or who were keener to discuss the issue of childhood obesity than others, (He et al., 2010). Chapter 3 of this thesis will explore how this challenge was addressed in the current study.
A final conclusion from the literature review conducted in this chapter, is that exploratory studies similar to this thesis, are relatively sparse, and there are currently no explicitly formulated theoretical frameworks which assist, or give additional insight in exploring the diversity and variations of responses to childhood obesity by GPs. It is intended that this identified gap in the literature will be addressed in Chapter 5 of this thesis where an
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exploration and possible explanation focussing on the epistemological frameworks of the GPs will be presented to add further insight into the diversity of the responses of GPs to childhood obesity. It is expected that by presenting an appropriate ways of conceptualising the findings in a framework that has relevance to general practice, this will lead to the identification of more detailed and relevant recommendations for GPs to enhance the future delivery of effective primary care service interventions for childhood obesity.
The following chapter will detail how the findings of the literature review, and importantly some of the key limitations were addressed through the methodological approach, analytical procedures and methods used in this thesis.
49 Chapter 3: Research methodology and methods. 3.1. Introduction.
To address the research aim of exploring GPs’ experiences of identifying and managing childhood obesity in a primary care setting, a number of methodological, epistemological and practical choices had to be made in relation to the research design. This chapter confirms that this thesis aligns itself with the phenomenological and hermeneutic traditions of Interpretative Phenomenological Analysis (IPA) (Smith et al., 2009). Sections 3.2 to 3.5 discuss the chosen research approach, the rationale behind this choice, the limitations of this approach, and alternative methods considered to address the research question. Section 3.6 makes a case for the quality of this research, using Yardley (2000) quality principles. Section 3.8 focuses on the methods used within this study, including the sampling strategy, recruitment of participants, the development of a retrospective, semi-structured interview guide, and ethical considerations. Section 3.9 describes the detailed method of qualitative analysis, the chronology of the data collection stage, and the emergence of themes which are presented in full in Chapter 4. Finally, the chapter concludes with an exploration of the reflection and reflexivity practice (Lee, 2009, p.42) adopted by the researcher.