OUTCOMES RESEARCH IN REVIEW
Why Are General Practitioners Reluctant to Play a Significant Role in Managing Childhood Obesity?
O’Donnell JE, Foskett-Tharby R, Gill PS. General practice views of managing childhood obesity in primary care: a qualitative analysis. JRSM Open 2017;8(6):1–9.
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Objective. To explore the views of general practice staff on managing childhood obesity in primary care.
Design. Qualitative study.
Setting and participants. General practices across England (n = 7303) of varying practice list size (low/medium/high) and “deprivation” level (low/medium/high, based on Index of Multiple Deprivation (IMD) score, which measures deprivation based on income, employment, health, education, barriers to services, living environment and crime) were stratified into a 3 x 3 matrix, resulting in recruitment targets of 3 to 5 practices per each of 9 recruitment strata. Practices in each strata were grouped into batches and approached in a random list order to take part in the study. Recruitment continued until the strata target was reached. Interviews were conducted by 2 researchers, either in the interviewee’s workplace or by telephone.
Main outcomes measures. The interview topic guide included 2 questions related to childhood obesity: (1) theirperceptions of the barriers and enablers to general practitioners taking a more active role in childhood obesity; and (2) their views on what was needed to improve integrated local pathways to manage childhood obesity. Follow-up questions were used in response to issues raised by interviewees. All interviews were audiotaped, professionally transcribed verbatim, and checked for accuracy. Copies of transcripts were available to interviewees, although none requested to see them. Key themes were identified through thematic analysis of transcripts using an inductive approach. Initial codes were discussed and combined to form themes which were discussed until agreement was reached that these reflected the data. Results are based upon a synthesis of all the interviews.
Main results. A total of 32 practices were recruited, of which 30 identified 52 staff (56% female) to participate in semi-structured interviews: 29 general practitioners (28% female), 14 practice managers (86% female), 7 nursing staff (100% female), 1 health care assistant (female), and 1 administrative staff (female). Almost all interviewees identified childhood obesity as an increasingly important issue with potential long-term health implications. However, most did not frame it as a medical problem in itself or view its management as a general practice responsibility.
Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt that consultation time was limited and focused on addressing acute illness. Generally, raising the issue was described as sensitive. Interviewees also felt ill equipped to solve the issue because they lacked influence over the environmental, economic, and lifestyle factors underpinning obesity. They described little evidence to support general practice intervention and seemed unaware of other services. Interviewees felt their efforts should be directed towards health problems they identified as medical issues where evidence suggests they can make a difference.
Conclusions. Although general practice staff viewed childhood obesity as an important issue with the poten-tial to impact on health outcomes, they were unconvinced that they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistic identification of overweight children and referral to specialist/obesity services
The prevalence of childhood overweight and obesity continues to rise in the United States and worldwide with extensive economic, physical, and psychosocial consequences [1–6]. Lifestyle interventions that target obesity-related behaviors including physical activity, sedentary behavior, and diet, are considered the therapy of choice [7–10]. Indeed, the US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status . Similar recommendations can be seen in other national guidelines regarding the management of childhood obesity .
Beyond screening and referral, some have outlined more specific opportunities for health professionals to play a more significant role in confronting child obesity, particularly among general practitioners and primary care providers [13–15]. In addition, several reviews have looked at the expanding role of primary care in the prevention and treatment of childhood obesity [16,17]. However, it remains unclear whether provider perspectives about their role in addressing childhood obesity align with such guidelines and suggestions. In fact, several studies have discussed barriers to weight management and obesity counseling among adults by physicians, which include lack of training, time, and perceived ineffectiveness of their own efforts [18–20]. This study adds to the literature by qualitatively assessing perspectives of general practice staff from a variety of practices regarding their role in addressing childhood obesity.
In qualitative research, typically small samples require careful consideration of the representativeness of participants in terms of characteristics and relevance to the wider population. As the authors highlight, a key strength of this study is that staff from a large number of practices in different geographical areas across England were recruited and broadly represented general practices in terms of practice list size and deprivation. This may contribute to greater likelihood of generalizability compared to similar studies that are limited to specific states in a country or small geographic areas. Additional strengths of this study include the use of a specific framework to guide analysis, 2 independent coders to analyze transcripts, and a brief discussion of how the researcher, through the structure of the interview, may have introduced bias to the results. However, the authors did not include whether any outlying or negative/deviant cases were presented that did not fit with discussed themes or if there were any differences in findings by gender or by years since qualified to practice. Additionally, the authors did not specify if results were confirmed or validated by their study participants to increase reliability and trustworthiness of analysis and interpretation.
Applications for Clinical Practice
Although the authors highlight that their findings suggest that policies expanding the role for general practitioners in prevention, identification, and management of childhood obesity at a population-level are unlikely to be successful, findings may instead highlight specific barriers to target and overcome in order to expand the role for general practitioners. Even though contact with well children may be limited, standard practices to incorporate brief counseling could contribute to a shift in practice and patient expectations of what is discussed during visits. Increased training and awareness of resources and innovative technologies that can assist patients with addressing obesity-related environmental, economic, and lifestyle factors can also be incorporated into medical education and professional development. In addition, practices can partner with community-based programs and organizations implementing childhood obesity interventions to expand referral options. General practitioners and primary care providers remain an important source of health information and expertise, and thus should play a key role in supporting broader initiatives to address childhood obesity.
—Katrina F. Mateo, MPH
1. WHO | Facts and figures on childhood obesity. 2014.
2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806–14.
3. de Onis M, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr 2010;92:1257–64.
4. Pizzi MA, Vroman K. Childhood obesity: effects on children’s participation, mental health, and psychosocial development. Occup Ther Health Care 2013;27:99–112.
5. Pulgarón ER. Childhood obesity: a review of increased risk for physical and psychological comorbidities. Clin Ther 2013;35:A18–32.
6. Trasande L, Elbel B. The economic burden placed on healthcare systems by childhood obesity. Expert Rev Pharmacoecon Outcomes Res 2012;12:39–45.
7. Wang Y, Wu Y, Wilson RF, et al. Childhood obesity prevention programs: comparative effectiveness review and meta-analysis. Agency for Healthcare Research and Quality; 2013.
8. Martin A, Saunders DH, Shenkin SD, Sproule J. Lifestyle intervention for improving school achievement in overweight or obese children and adolescents. Cochrane Database Syst Rev 2014;(3):CD009728.
9. De Miguel-Etayo P, Bueno G, Garagorri JM, Moreno LA. Interventions for treating obesity in children. World Rev Nutrition Dietetics 2013;108:98–106.
10. Reinehr T. Lifestyle intervention in childhood obesity: changes and challenges. Nat Rev Endocrinol 2013;9:607–14.
11. US Preventive Services Task Force, Grossman DC, Bibbins-Domingo K, et al. Screening for obesity in children and adolescents. JAMA 2017;317:2417–26.
12. Richardson L, Paulis WD, van Middelkoop M, Koes BW. An overview of national clinical guidelines for the management of childhood obesity in primary care. Prev Med (Baltim) 2013;57:448–55.
13. Brown CL, Halvorson EE, Cohen GM, et al. Addressing childhood obesity: opportunities for prevention. Pediatr Clin North Am 2015;62:1241–61.
14. Güngör NK. Overweight and obesity in children and adolescents. J Clin Res Pediatr Endocrinol 2014;6:129–43.
15. Saxena S, Laverty AA. Confronting child obesity in primary care. Br J Gen Pract 2014;64:10–1.
16. Bhuyan SS, Chandak A, Smith P, et al. Integration of public health and primary care: A systematic review of the current literature in primary care physician mediated childhood obesity interventions. Obes Res Clin Pract 2015;9:539–52.
17. Vine M, Hargreaves MB, Briefel RR, Orfield C. Expanding the role of primary care in the prevention and treatment of childhood obesity: a review of clinic- and community-based recommendations and interventions. J Obes 2013;2013:1–17.
18. Forman-Hoffman V, Little A, Wahls T. Barriers to obesity management: a pilot study of primary care clinicians. BMC Fam Pract 2006;7:35.
19. Jay M, Gillespie C, Ark T, et al. Do internists, pediatricians, and psychiatrists feel competent in obesity care? using a needs assessment to drive curriculum design. J Gen Intern Med 2008;23:1066–70.
20. Leverence RR, Williams RL, Sussman A, Crabtree BF. Obesity counseling and guidelines in primary care: a qualitative study. Am J Prev Med 2007;32:334–9.
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