Addressing the complexity of equitable care for larger patients: A critical realist framework

Abstract

The notion of obesity as a pathological state within the individual remains the dominant perspective in public health and biomedicine. However, there has been a growing call to re-examine this assumption from a social justice lens. Given that obesity is itself a contested term, there is a lack of consensus on what constitutes a social justice approach to addressing weight and health. Underpinning such debates amongst social justice researchers is a divide between realist and constructionist framings of obesity. The realist framing considers obesity to be a biomedical fact posing health and social consequences, and proposes collective, systems-based solutions to preventing and managing obesity. In contrast, the constructionist framing challenges the taken-for-granted assumptions that obesity is an epidemic and that fat necessarily signifies poor health. Despite such theorizing about social justice and obesity, to-date no empirical research has explored the views and experiences of 1) social justice-oriented healthcare practitioners who work with larger patients or 2) larger patients who receive social justice-informed care. This article features interviews with practitioners (n ​= ​22) across multiple professions in Canada who describe themselves as adopting a social justice approach to caring for larger patients, as well as with practitioners' patients (n ​= ​20) who self-identify as larger bodied. Drawing on a critical realist theoretical framework, the analysis uncovers the ontological and ideological assumptions driving participants' varying conceptualizations of obesity. To conclude, the article considers how participants’ different understandings of weight and health impact clinical practice and interactions, particularly in terms of whether social justice goals are fulfilled.