Aim: This paper is a report of a study to explore primary care nurses' attitudes, beliefs and perceptions of own body size in relation to giving advice about obesity.
Background: Primary care nurses have a key role in the management of obesity. Their responses to the stigma of obesity and the effects of their own body size in this context have not been investigated.
Methods: A purposive sample of 15 primary care nurses of markedly different body size were interviewed in a qualitative study undertaken in 2006 in the north of England.
Findings: Participants were aware of obesity stigma and this, among other factors, contributed to perceptions of obesity as being a sensitive issue to discuss. Communication tactics were employed in managing the sensitivity, with emphasis placed on maintaining good rapport. Participants took care to avoid stereotypes in presenting their beliefs about obesity, which were complex and in some respects ambivalent. They were conscious of their own body size in interactions with patients. A slim build appeared to amplify sensitivities surrounding obesity and add concerns about appearing to lack empathy or authentic experience. Those with a large body size made a virtue of their perceived greater empathy and experience, but had concerns about being poor role models. Self-disclosure techniques oriented to demonstrating personal understanding and rapport were employed to manage impressions made by body size.
Conclusion: It is important to consider the effects of own body size in educating nurses, and further research should investigate its effects on patient outcomes.
Obesity is now seen as a global public health problem and nurses have an increasing role in providing lifestyle and other interventions to support weight management (WHO 2000, US Department of Health and Human Services 2001, Department of Health 2006). Apart from the risks for physical health, obesity has a range of impacts on psychosocial aspects of well-being and quality of life (Kolotkin et al. 2001). In Western societies this includes issues arising from widespread negative stereotypes and discrimination associated with a larger body size (Puhl & Brownell 2001).
Whilst there have been studies of nurses' beliefs, attitudes and practice behaviours in relation to obesity management, their awareness of and responses to the stigma of obesity have not been particularly studied. Furthermore, the effects of the nurses' own body size in this context have not been fully investigated. This paper reports on a qualitative study undertaken in primary care in England during 2006. Obesity has been a public health priority for some time in this country, and it has a well developed primary care system that includes nurses and health visitors with a clear role in providing advice to adults who are obese (Chambers & Wakley 2002).
The literature with respect to nurses' awareness of obesity stigma and their perceptions with respect to their own body size is limited. However, the few studies of nursing practice, attitudes and beliefs in relation to obesity management consistently show that negative stereotypes, common within Western cultures, can be found among a proportion of nurses in these societies (Brown 2006). The negative stereotypes are rooted in beliefs that obesity is a condition that is preventable and readily controlled by individuals (Crandall et al. 2001).
It is also likely that attitudes and beliefs of nurses are complex, particularly where nurses have a role in helping patients in managing obesity, but again the previous research is limited (Brown 2006). Mercer and Tessier (2001) in a qualitative study of practice nurses identified ambivalence as a key theme, linked to reservations and frustrations by the nurses that patients were motivated to change or that interventions lead to positive outcomes. In other qualitative studies nurses also show awareness of the stigma associated with obesity and there is indication of them expressing empathy and support for patients as a result of this (Wright 1998, Petrich 2000).
A number of the quantitative studies have identified nurses' own body image or body size as a variable affecting attitudes and practice. However, the findings are somewhat contradictory and offer limited understanding of this association. Bagley et al. (1989) found that nurses dissatisfied with their own body image were more likely to express harsher attitudes about obese patients. On the other hand, Culbertson and Smolen (1999) in a survey of a similar population of student nurses did not find this association. Hoppe and Ogden (1997) found that nurses' beliefs about the preventability of obesity were associated with a higher body mass index (BMI) but other beliefs and attitudes were not associated. They also found nurses with a higher BMI more likely to give more detailed advice to patients. On the other hand, Hankey et al. (2003) found that practice nurses with a ‘normal’ BMI had better knowledge of some aspects of obesity complications than those who were overweight. No other associations with BMI were identified but their study did indicate that over a quarter of the 509 nurses sampled were overweight or obese themselves.
Overall the existing research is limited and there is a risk of reducing the few studies to generalizations that all nurses have negative attitudes about obesity. It would be useful to understand more about the complexity of attitudes in different contexts within nursing and also more about how the nurses' own body size affects efforts to tackle this issue with patients. (The term ‘patients’, rather than clients or service users, will be used in the rest of the paper.) In view of the limited research in this area it is appropriate to undertake a qualitative study to explore the perceptions of nurses more fully.
The aim of the study was to explore primary care nurses' attitudes, beliefs and perceptions of own body size in relation to giving patients advice about obesity.
In response to intellectual currents in social theory there has been some eroding of previous ontological and epistemological distinctions in research methodology (Hiley et al. 1991). Our study design drew on a pragmatic qualitative methodology that has emerged in this context in the United Kingdom (UK) (Bryman 1988, Hammersley & Atkinson 1995); particularly in the practice of publicly funded policy research (Ritchie & Spencer 1994, Ritchie & Lewis 2003). This approach accepts broad standards of scientific rigour, including (adapted) concepts of reliability and validity (Seale 1999, Snape & Spencer 2003). It nevertheless emphasizes core interpretivist commitments that span qualitative approaches with a view to exploring, ‘issues in depth and from the perspectives of different participants, with concepts, meanings and explanations developed inductively from the data’ (Lewis & Ritchie 2003, p. 267).
The participants had responded to a postal survey about obesity management in primary care undertaken in the north of England in 2006. The survey collected data about clinical activity and also about respondent's own height and weight. The respondents were stratified to include those who had reported themselves as undertaking obesity management clinical activity in the previous month. A list of 48 potential interviewees was then generated comprised of high, low and medium level BMI and half were initially contacted about participating in an interview. Although more than 15 agreed to take part data collection was stopped at the point at which no new themes were emerging with respect to the study aims.
The characteristics of the sample are shown in Table 1. All participants were female reflecting the gender composition of the original survey sample. The participants were Registered Nurses with substantial experience of working in primary care (range 2–27 years; mean 12·7 years). They comprised of nine practice nurses, four district nursing staff and two health visitors. This distribution reflects the level of obesity management activity of the different occupational groups found in the survey. Six participants had a BMI below 21 kg/m2; five participants had a BMI above 29·7 kg/m2; the remaining four had a BMI in a medium range.
Table 1 Participant characteristics
An interview guide was prepared and pretested (Table 2). Data collection took place during autumn 2006 within working hours in a workplace setting where a private room was available. The interviews were audio-recorded.
Table 2 Interview guide
Approval for the study was gained from a Local Research Ethics Committee. Written consent and permission for audio-taping was obtained from each participant prior to interview. Whilst confidentiality was assured and all data were carefully anonymized, some interviewees still felt that it was potentially sensitive to have their body size details recorded along with age and other personal information. For this reason, exact BMIs and job titles have not been provided in study reports.
Interviews were transcribed verbatim and any clues to the participant's identity removed from the transcript. Anonymized transcripts were then entered into QSR NVIVO to facilitate data management and analysis (Gibbs 2002). Analysis drew on the pragmatic ‘framework approach’ developed for policy research (Ritchie et al. 2003). It consisted of a series of systematic steps, initially undertaken in parallel with data collection, and with a number of iterations to refine and strengthen the rigour of findings. We independently familiarized ourselves with the data to generate and then agree an initial coding framework. This was refined following discussions with a steering group comprised of primary care professionals and patient representatives. All interviews were then coded (indexed) to the framework by one author and the quality of this checked by the other. Data display and summary tools were used to facilitate analysis, with careful further scrutiny of the data for cases or instances that did not fit identified themes.
The report of the findings below is structured around three main themes: Sensitivity about obesity, Complexity of obesity and Own body size.
There was evidence for this theme in every interview, expressed in terms of obesity being a potentially awkward, difficult, uncomfortable, sensitive issue to address with patients and one in which care was needed:
I feel a little bit uncomfortable about it. [Participant (P) 8]
Because it is like a critical thing to say to somebody in a way… so you've got to be a bit careful. [P15]
The sensitivity arose primarily from perceptions of obesity as a stigmatized condition for which society judges individuals negatively, and from an awareness of negative psychological and health impacts of obesity:
I think very large people do, are obviously perceived differently to the rest of the population, and probably in a more negative way. [P12]
And it has a major impact on, on the, everything about their self-esteem, er, getting jobs, everything. I think it's … a major concern and, I think it's getting worse. [P10]
Concerns were heightened about maintaining a good rapport with the patient in this context of awareness of negative social pressures. The awkwardness was worst at the outset of a relationship and in initially broaching the topic:
I find it quite difficult because I don't want to offend someone, I don't wanna start off by putting them on sort of the back foot, and then them never coming back. [P13]
The degree of awkwardness in raising the topic of weight depended on the nursing context and the purpose of the consultation. The easiest situation was one in which the patient had referred themselves with weight as a main problem. It was also felt to be relatively easy to introduce the topic into a consultation focused on management of clearly related long-term conditions such as diabetes. Participants in roles where obesity was an incidental issue found it harder to overcome this awkward initial stage.
Other contributory factors in heightening sensitivity and awkwardness were related to interviewees' degree of educational preparation and the presence or absence of specific protocols. Those without specific preparation or a protocol to draw on seemed to feel most awkward about discussing obesity.
A further factor was perceptions of it being a clinically difficult area in which to achieve change or be able really to help the patient. The frustrations of obesity management contributed to the perception of it being a sensitive area that can be challenging for maintaining trusting relationships:
He tells me that he eats nothing but fruit and vegetables, and um, that he can't understand why he hasn't lost any weight. And in some ways it, when a patient says that to you, it's very difficult to say, ‘Look, I don't necessarily believe what you're telling me because, if you did all that, you'd be losing weight.’ [P1]
You can't ignore it, but I think to have it as an issue that, every time they come in, it's an issue, is very demoralizing for the patient and probably negative to the relationship we have with them. [P12]
It was evident that participants employed a number of tactics in managing the sensitivity of obesity in their interactions with patients. The key one for almost all of them was the softening of terms and generally avoiding the term ‘obesity’ because of its negative connotations. This is additional evidence of awareness of the stigma associated with the condition:
No, I wouldn't say to a patient, ‘You're obese’, no. I would say, ‘You need to lose some weight because it's affecting your health’ … So, no, I wouldn't focus on the word – I think it's quite cruel really. [P14]
I just talk in terms, you know, ‘Have you ever thought, you know, trying to lose weight?’ or this sort of thing, not just saying, ‘You're obese.’ I think that they must know they're overweight – you don't want to rub it in. [P5]
Related tactics included use of visual aids that to some extent avoided labelling or shifted the judgement to a computer programme or chart:
I actually, sort of, put it sideways and say, ‘Well the computer's saying that, in fact, you are overweight or obese’. [P8]
Another tactic was talking around related issues of lifestyle or general health rather than directly about weight or obesity:
I think sometimes, even to talk about any issue, food or anything, at least it's a bit more gentle but I would never say to somebody, if somebody said to me, ‘You are, do you know you are clinically obese?’ I would be absolutely floored. [P4]
The exception to this was a nurse who was working to a detailed protocol for supervising patients on obesity medication and in this context felt able to use the term ‘obesity’.
Apart from softening terms used in relation to body fat, a number of other tactics were apparent which were oriented to maintaining rapport and remaining patient-focused. A great emphasis was put on taking an individualized approach and taking care not to appear judgemental:
You've got to gradually build that relationship and then, I think, if you approach it like that, I think you get some good results… I think you've got to let them express themselves to you and tell them that, you know, we're here to help, we're not here to invade your privacy, and say you have to do this, this and this. [P11]
Every person's different, so it's like looking at what's right for that particular person. I try and make it individual and suited for that person. [P13]
In general participants took care to avoid stereotypes or overly simplistic explanations. Particular emphasis was placed on empathy and an individualized, non-judgemental approach. The resulting picture was therefore a multi-factorial one in which various causes and motivations were stressed: ‘It's not cut and dried, obesity.’ [P10]. However, it is also one in which there was ambivalence in trying to reconcile explanations with differing consequences for responsibilities. The general approach was to steer a balanced course between factors of personal responsibility and factors beyond the control of individuals. Participants clearly wanted to distance themselves from a simplistic or judgemental position:
There's lots, there's so many factors involved in this – like cultural things, media things, availability of food, social status, how many people, how many kids they've given birth to. But there's so many different things, um, that come into that, yeah. Part of it is a personal thing but it isn't only. It's like it's a big, it's a lot of different factors. You can't say, ‘It's your fault that you're overweight’ – that isn't, that's not where I'm coming from. [P13]
It was evident that this was a difficult course to steer, and eventually some participants would return to the importance of personal lifestyle in obesity:
So it is lifestyle, it is, you know, them. [P2]
I think we're all responsible – we are what we eat. [P6]
A complex range of wider factors were seen to have more or less influence in causing obesity. Participants showed an awareness of wider environmental, cultural and economic factors that may influence eating and physical activity patterns. There was also awareness of how family and personal circumstances affect lifestyle choices. Generally, somewhat less emphasis was put on explanations such as genetic or medical conditions. Typically, then, the view was that external factors and pressures are mitigating circumstances but that ultimately patients have some degree of personal responsibility. Views on where the balance lay varied among participants, but most acknowledged this tension.
Beliefs about patient motivations and responsibilities were also complex and ambivalent. The general stance was one of care to avoid generalizing and to show awareness of how motivation changes over time:
Yeah, varies very much from person to person – you can't generalize that. [P13]
Beyond this ‘official line’, some participants expressed frustrations based on their clinical experiences:
I think yes and no. Yes, they do want to change, they want to be slim, but they want an easy way out. [P10]
We've got quite a few patients that really do need to lose weight that don't, you know, and they just carry on eating normally and so that's the hardest obstacle really, you know, is patient education and compliance. [P2]
Only one participant felt that their own size was something that they were not at all conscious about. This individual was the least involved in clinical practice relating to obesity and also had a medium BMI. For most participants, their own size was an issue of which they were more or less conscious in their interactions with patients where obesity was the focus:
You're conscious of your whole self in a way, ‘cos it's a very personal one-to-one thing, yeah, but if you're discussing weight, obviously you're quite conscious of your own. [P15]
You know, everyone's judging each other in that sort of situation. [P4]
A low BMI appeared to amplify sensitivities surrounding obesity, with additional concerns about appearing to lack empathy or authentic experience. Whilst for some participants this was a matter of perceptions, others had direct experience of difficulties arising:
I've had patients turn round to me and say, ‘It's alright for you, you're not overweight’… If they don't perceive you as ever having a problem with weight or with what you eat, then they obviously think you can't possibly understand what I'm, you know, on about. So it can be difficult. [P13]
I think sometimes patients do perceive, if you are slim then you don't know what they're feeling or how they're feeling or you don't know how hard it is. [P4]
A number of strategies could be identified for those with a low BMI in managing these issues. Avoiding broaching the subject with patients was one strategy:
I've never, I would never have introduced it unless someone brought it to me. [P9]
A further strategy was to present information about oneself as weak in some other area of lifestyle so as to rebuild the rapport that might have been affected by being slim:
But I'll say, I say, ‘Well I, I'm hopeless at swimming, I don't get enough exercise’ and I think in a way you're trying to make yourself come across as being real. You know, because we all are real, aren't we? … otherwise it can be very preachy – you're preaching at people and they'll think, ‘Oh, what do you know?’ Or you know, ‘You don't need to worry.’ [P15]
Another strategy was to make the case for the value of experience with relatives and other patients:
I've had to really work at that. Um, because, you know, and explain to them that either I've had the experience myself and even if you haven't, maybe empathise with someone else you know who's had the same experience as them. You've got to build a relationship and break down the barriers because really they're pre-judging you as well. [P4]
Those with a high BMI also felt self-conscious about their size in this context and also reported negative experiences:
I think sometimes, um, with some patients talking about healthier eating issues, I can see them focus on my stomach… I do feel very conscious of and sometimes I think maybe I should just move into something and go and do something else where I don't have to feel self-conscious … But, you know, I'm not rude, and I wouldn't be rude to patients even if they were extremely rude to me. I just sort of brush it off and, um, smile it off, but after they've gone I'm sort of like, ‘How dare they say that?’ [P14]
Some participants expressed feelings of guilt about whether they were being a good role model, with heightened concerns about deviating from a healthy lifestyle:
Sometimes I think, ‘Maybe I'd be a better, better example, better role model if I was thinner.’ [P12]
However, participants also made a virtue out of their size in relation to the rapport and quality of service that could be offered to patients:
I think because I'm fat I find it easier. I use it as a tool…I think because I'm overweight and, um, constantly have looked at different diets and yo-yo'd all of my life that I have a bit of truth to what I advise… I just pass on tips. [P6]
I think she…empathised with me because obviously I was overweight, and I said…‘We'll compare notes and we'll, you know, we'll do it’…If you've got some sort of condition and somebody else has got it, you know what it's like and you go that extra bit for them. [P3]
Maybe I do it in a kinder way than somebody that would be stick thin, and I've had patients comment on that as well, you know. [P14]
Thus, some participants' felt that they were able to empathize more strongly with patients who were obese and could draw on vivid first-hand experience in giving advice. However, there was evidence of a tendency to make assumptions that the patient's experience matched their own and to base advice on personal hunches rather than research evidence:
So I'm saying to patients, not only watch your fats but watch your sugars, with no basis whatsoever except my personal experience. [P6]
There was also a tendency in those with a high BMI to be more critical and judgemental about obese people, possibly because these participants were critical of themselves and also more open about discussing obesity. In contrast, those with a low BMI appeared more careful about assuming that their own experience applied to patients and about making comments that could be perceived as critical towards people who are obese.
Our purposive sampling strategy meant that a small sample provided rich data relevant to body size and obesity management issues. The findings contribute to insights about these issues and (tentatively) to the development of theories that help us understand them more fully. Consistent data collection tools were used and all interviews were audio-taped and transcribed verbatim. Systematic and comprehensive methods of data analysis were employed including internal validation by independent analysis, constant comparative methods and deviant case analyses. Evidence (within the confines of a journal article) has been provided to support interpretation. However, the use of triangulation and participant checks was weaker in this study. It was essentially a single method study with external validation by groups of patients and clinicians but not the research participants themselves.
Although small, the sample was reasonably ‘symbolically representative’ (Lewis & Ritchie 2003) of body size ranges and nursing occupations in primary care. No participants dropped out of the study. Inevitably the sample was skewed to those at extremes of body size and it did not include any men. Nevertheless, important proportions of nurses are of slim or large builds and the majority of primary care nurses are women. A different sampling strategy would be required to illuminate gender issues. The context of the findings has been described to help readers evaluate transferability to other contexts. However, this was a small exploratory study and the findings and conclusions are therefore tentative.
The findings suggest that attitudes to obesity and obese patients are complex within primary care nursing in the UK, and not the apparently simple reflection of wider negative cultural stereotypes found in some previous studies (Bagley et al. 1989, Culbertson & Smolen 1999, Petrich 2000). Previous qualitative studies have also shown that nurses have some ambivalence about obesity management and find it an awkward issue to raise and discuss (Wright 1998, Mercer & Tessier 2001). Our study develops understanding of these issues by showing participants' awareness of wider negative valuations of obesity and how their attitudes centred on concerns about maintaining good rapport and ongoing relationships with the patient in this context.
Our findings highlight efforts to develop good quality brief counselling techniques in primary care in the UK over the last two decades. A pragmatic and eclectic approach of ‘motivational interviewing’ is widely employed by nurses in this context, even if few have had further specific education about obesity (Rollnick et al. 1999, Saunders & Selvey 2005). The approach includes notions of being patient-centred, non-judgemental, and aware of the psychosocial aspects of conditions. It also places great emphasis on the importance of rapport and relationships to support lifestyle change. Attention to these aspects of practice was evident in our findings, and this type of education and development must ameliorate the effects of negative stereotypes about obesity.
Like others, we have found that nurses have beliefs that obesity is preventable and that patients are to some degree responsible for their size (Hoppe & Ogden 1997). However, our study shows that these beliefs were accompanied by others about the importance of a wide range of factors that are not within the patient's personal control. Furthermore, we identified a fairly sophisticated balancing act performed by the nurses to remain consistent with a non-judgemental approach yet also to believe that there are prospects for individuals to make changes. Given current understanding about obesity (Rosmond 2004) and the focus of obesity management interventions (NICE 2006), this is probably the only realistic stance. Nevertheless, it should be noted that beliefs about personal responsibility underpin negative attitudes (Puhl & Brownell 2003, Brown 2006) and also that patients tend to put more emphasis on factors beyond their personal control than do healthcare professionals (Ogden et al. 2001).
A nurse's physical appearance is probably the first information that is available to the patient and it remains continuously available throughout the consultation. First impressions make a lasting influence on evaluations of the person (Hogg & Vaughan 2002). It is not surprising, therefore, that participants felt this to be a salient aspect of their interactions and one that required management in terms of how they presented themselves to patients. The notion of impression management (or self-presentation) is well-developed in social psychology. It refers to controlled and automatic activities undertaken in social interactions to construct and protect desired identities (Goffman 1959, Schlenker 2003). The impression management strategies of nurses in interactions with obese patients have not been studied, and this could be a fruitful area for further research. Our study shows that nurses who are slim think that they have to manage the impression that they lack empathy and authentic experience in relation to obesity. Those with a large body size consider that they must manage impressions that they are poor role models or that they are giving advice which they themselves have not taken.
Whilst it is clearly right that nurses approach the issue of obesity with care, being oversensitive or ambiguous is not helpful. A study of primary care patients indicates that they detect awkwardness and that it adds to their sense of a stigmatized condition (Brown et al. 2006a, 2006b). This, in turn, has consequences for quality of life and satisfaction with services. Our findings about tactics to manage the sensitivity of obesity may be helpful for clinicians and nurse educators to consider.
That a nurse's own body size, particularly for those that were slim, inhibited them (avoidance) from raising the issue of obesity with patients is a serious issue for practice. More positively, nurses of all sizes employed self-disclosure techniques to demonstrate evidence of personal understanding and rapport with patients. Self-disclosure is an important term within counselling theory that refers to (deliberate) acts of revealing information about one's self to others within a therapeutic relationship (Davis & Fallowfield 1991, Burnard 2005). In the case of one's body size information is revealed whether one likes it or not and the issue is rather one of constructively managing this with further self-disclosure. These issues of avoidance and improving counselling skills can be addressed by better training and provision of appropriate practice resources.
Our findings suggest that interactions with obese patients may differ for nurses of different body size, reflecting findings of previous research. What effects this has on patient satisfaction and intervention outcomes have not been examined. Further research is needed, but clearly education in relation to self-awareness about body size and other psychosocial aspects of obesity management is important.
Thanks particularly to Louise Brewins, Brigitte Colwell, Margaret Fisher, Akaterini Psarou, Annette Setterfield and Chris Stride for support in undertaking the study.
IB was responsible for the study conception and design and the drafting of the manuscript. JT performed the data collection and IB and JT performed the data analysis. IB obtained funding.
Bagley C., Conklin D., Isherwood R., Pechiulis D. & Watson L. (1989) Attitudes of nurses toward obesity and obese patients. Perceptual and Motor Skills 68, 954. [Context Link]
Brown I. (2006) Nurses' attitudes towards adult patients who are obese: literature review. Journal of Advanced Nursing 53(2), 221–232. Ovid Full Text Bibliographic Links [Context Link]
Brown I., Jones G., Thompson J. & Tod A. (2006a) Obesity, stigma and quality of life: a qualitative study. International Journal of Interdisciplinary Social Sciences 1(2), 169–178. [Context Link]
Brown I., Thompson J., Tod A. & Jones G. (2006b) Primary care support for tackling obesity: a qualitative study of the perceptions of obese patients. British Journal of General Practice 56, 666–672. [Context Link]
Bryman A. (1988) Quantity and Quality in Social Research. Unwin Hyman, London. [Context Link]
Burnard P. (2005) Counselling Skills for Health Professionals. Nelson Thornes, Cheltenham. [Context Link]
Chambers R. & Wakley G. (2002) Obesity and Overweight Matters in Primary Care. Radcliffe Medical Press, Oxford. [Context Link]
Crandall C., D'Anello S., Sakalli N., Lazarus E., Wieczorkowska G. & Feather N. (2001) An attribution-value model of prejudice: anti-fat attitudes in six nations. Personality and Social Psychology Bulletin 27, 30–37. [Context Link]
Culbertson M. & Smolen D. (1999) Attitudes of RN students toward obese adult patients. Journal of Nursing Education 38(2), 84–87. Bibliographic Links [Context Link]
Davis H. & Fallowfield L. (1991) Counselling theory. In Counselling and Communication in Health Care (Davis H. & Fallowfield L., eds), Wiley, Chichester, pp. 23–58. [Context Link]
Department of Health (2006) Care Pathway for the Management of Overweight and Obesity. Department of Health, London. [Context Link]
Gibbs G. (2002) Qualitative Data Analysis: Explorations with NVivo. Open University Press, Buckingham. [Context Link]
Goffman E. (1959) The Presentation of Self in Everyday Life. Doubleday, New York. [Context Link]
Hammersley M. & Atkinson P. (1995) Ethnography: Principles in Practice. Routledge, London. [Context Link]
Hankey C., Eley S., Leslie W., Hunter C. & Lean M. (2003) Eating habits, beliefs, attitudes and knowledge among health professionals regarding the links between obesity, nutrition and health. Public Health Nutrition 7, 337–343. [Context Link]
Hiley D., Bohman J. & Shusterman R. (eds) (1991) The Interpretive Turn: Philosophy, Science, Culture. Cornell University Press, Ithaca, NY. [Context Link]
Hogg M. & Vaughan G. (2002) Social Psychology. Prentice Hall, Harlow. [Context Link]
Hoppe R. & Ogden J. (1997) Practice nurses' beliefs about obesity and weight related interventions in primary care. International Journal of Obesity 21, 141–146. Bibliographic Links [Context Link]
Kolotkin R., Meter K. & Williams G. (2001) Quality of life and obesity. Obesity Reviews 2, 219–229. Bibliographic Links [Context Link]
Lewis J. & Ritchie J. (eds) (2003) Generalising from qualitative research. In Qualitative Research Practice, Sage, London, pp. 263–286. [Context Link]
Mercer S. & Tessier S. (2001) A qualitative study of general practitioners' and practice nurses' attitudes to obesity management in primary care. Health Bulletin 59(4), 248–253. [Context Link]
NICE (2006) Obesity: Guidance on the Prevention, Identification, Assessment and Management of Overweight and Obesity in Adults and Children. National Institute for Health and Clinical Excellence, London. [Context Link]
Ogden J., Bandara I., Cohen H., Farmer D., Hardie J., Minas H., Moore J., Qureshi S., Walter F. & Whitehead M. (2001) General practitioners' and patients' models of obesity: whose problem is it? Patient Education and Counselling 44, 227–233. [Context Link]
Petrich B. (2000) Medical and nursing students' perceptions of obesity. Journal of Addictions Nursing 12(1), 3–16. [Context Link]
Puhl R. & Brownell K. (2001) Bias, discrimination and obesity. Obesity Research 9, 788–805. Bibliographic Links [Context Link]
Puhl R. & Brownell K. (2003) Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias. Obesity Reviews 4, 213–227. Bibliographic Links [Context Link]
Ritchie J. & Lewis J. (eds) (2003) Qualitative Research Practice. Sage, London. [Context Link]
Ritchie J. & Spencer L. (1994) Qualitative data analysis for applied policy research. In Analyzing Qualitative Data (Bryman A. & Burgess R., eds), Routledge, London. [Context Link]
Ritchie J., Spencer L. & O'Connor W. (2003) Carrying out qualitative analysis. In Qualitative Research Practice (Ritchie J. & Lewis J., eds), Sage, London, pp. 217–262. [Context Link]
Rollnick S., Mason P. & Butler C. (1999) Health Behavior Change: A Guide for Practitioners. Churchill Livingstone, Edinburgh. [Context Link]
Rosmond R. (2004) Aetiology of obesity: a striving after wind? Obesity Reviews 5, 177–181. Bibliographic Links [Context Link]
Saunders M. & Selvey K. (2005) General Practice Nursing. In Community Health Care Nursing (Sines D., Saunders F. & Frost M., eds), Blackwell, Oxford, pp. 128–145. [Context Link]
Schlenker B. (2003) Self-presentation. In Handbook of Self and Identity (Leary M. & Tangney J., eds), Guildford, New York, pp. 492–518. [Context Link]
Seale C. (1999) The Quality of Qualitative Research. Blackwell, Oxford. [Context Link]
Snape D. & Spencer L. (2003) The Foundations of qualitative research. In Qualitative Research Practice (Richie J. & Lewis J., eds), Sage, London, pp. 1–23. [Context Link]
US Department of Health and Human Services (2001) The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. GPO, Washington. [Context Link]
WHO (2000) Obesity: Preventing and Managing the Global Epidemic. World Health Organization, Geneva. [Context Link]
Wright J. (1998) Female nurses' perceptions of acceptable female body size: an exploratory study. Journal of Clinical Nursing 7(4), 307–315. Ovid Full Text Bibliographic Links [Context Link]
Keywords: attitudes; body size; empirical research report; nursing; obesity management; primary health care; qualitative study; stereotypes
No comments:
Post a Comment