Hajizadeh Anisa, Heath Laura, Ahmad Aryati, Kebbe Maryam, Jebb Susan Anne, Aveyard Paul, Hughes Gemma
Nuffield Department of Primary Care, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2 6GG, United Kingdom.
School of Nutrition and Dietetics, Universiti Sultan Zainal Abidin, Kampung Gong Badak, 21300, Terengganu, Malaysia.
Soc Sci Med. 2023 Jul;329:115997. doi: 10.1016/j.socscimed.2023.115997. Epub 2023 May 30.
Clinical trials have shown that providing advice and support for people with excess weight can lead to meaningful weight loss. Despite this evidence and guidelines endorsing this approach, provision in real-world clinical settings remains low. We used Strong Structuration Theory (SST) to understand why people are often not offered weight management advice in primary care in England. Data from policy, clinical practice and focus groups were analysed using SST to consider how the interplay between weight stigma and structures of professional responsibilities influenced clinicians to raise (or not) the issue of excess weight with patients. We found that general practitioners (GPs) often accounted for their actions by referring to obesity as a health problem, consistent with policy documents and clinical guidelines. However, they were also aware of weight stigma as a social process that can be internalised by their patients. GPs identified addressing obesity as a priority in their work, but described wanting to care for their patients by avoiding unnecessary suffering, which they were concerned could be caused by talking about weight. We observed tensions between knowledge of clinical guidelines and understanding of the lived experience of their patients. We interpreted that the practice of 'caring by not offering care' produced the outcome of an absence of weight management advice in consultations. There is a risk that this outcome reinforces the external structure of weight stigma as a delicate topic to be avoided, while at the same time denying patients the offer of support to manage their weight.
临床试验表明，为超重人群提供建议和支持能够带来显著的体重减轻。尽管有这一证据以及支持该方法的指南，但在现实临床环境中的应用率仍然很低。我们运用结构化理论（SST）来理解为何在英国的初级医疗保健中，人们常常得不到体重管理建议。我们使用SST分析了政策、临床实践和焦点小组的数据，以考量体重污名与专业职责结构之间的相互作用如何影响临床医生向患者提及（或不提及）超重问题。我们发现，全科医生（GPs）常常将肥胖视为一个健康问题来解释他们的行为，这与政策文件和临床指南一致。然而，他们也意识到体重污名是一个可能被患者内化的社会过程。全科医生将解决肥胖问题视为工作中的一个优先事项，但表示希望通过避免他们认为谈论体重可能导致的不必要痛苦来关爱患者。我们观察到临床指南知识与对患者生活经历的理解之间存在矛盾。我们认为，“通过不提供护理来关爱”的做法导致了会诊中缺乏体重管理建议这一结果。存在这样一种风险，即这一结果强化了体重污名这一外部结构，使其成为一个应避免的敏感话题，同时又拒绝为患者提供管理体重的支持。
