Childrens’ and parents’ views and experiences of attending a childhood obesity clinic: a qualitative study

Integrating COM-B and the person-based approach to develop an ACT based therapy programme to raise self-determination in adolescents with obesity

BACKGROUND

This paper details the development of the Adolescent Intrinsic Motivation 'AIM2Change' intervention to support weight-management in young people previously unable to make changes whilst attending a tier 3 weight management service for children and young people. AIM2Change is an acceptance and commitment therapy based intervention that will be delivered one-to-one online over a seven-week period.

METHODS

To develop this intervention, we have triangulated results from a qualitative research study, patient and public involvement groups (PPI) and a COM-B (capability, opportunity, motivation, behaviour) analysis, in a method informed by the person-based approach.

RESULTS

The integrated development approach yielded a broad range of perspectives and facilitated the creation of a tailored intervention to meet the needs of the patient group whist remaining pragmatic and deliverable.

CONCLUSIONS

The next steps for this intervention will be in-depth co-development of the therapy sessions with service users, before implementing a proof of concept trial.

Family Management of Severe Obesity in Adolescents

PURPOSE

Severe obesity, defined as a body mass index (BMI) ≥120th percent of the 95th BMI percentile for age and sex, is the fastest growing subcategory of obesity among youth, yet little is known about how this group understands and incorporates weight management strategies. The aims of this study were to explore how parents and adolescents understand severe obesity and incorporate management into their daily lives and evaluate the applicability of the Family Management Styles Framework (FMSF) to better understand the impact of severe obesity for adolescents.

DESIGN AND METHODS

Directed content analysis grounded in a modified version of the FMSF was used to analyze one-time in-home face-to-face interviews with adolescents aged 12-17 years (N = 14) who received pediatric weight management care and a parent (N = 17).

RESULTS

Both adolescents and parents described the day-to-day management as challenging and impactful to parent-child and sibling relationships. They described the need for sustained support and coaching in meeting daily physical activity requirements and related stories of weight stigma experienced. Further, parents' and adolescents' views were mostly congruent, except in their view of effectiveness of daily routines and how family attitudes and actions did or did not support the adolescent.

CONCLUSIONS

The FMSF was successfully applied to understand family management of adolescents with severe obesity. These adolescents have complex physical and psychological needs impacting effective weight management and family life.

PRACTICE IMPLICATIONS

Technology interventions should be considered to improve physiological and psychological outcomes for youth with severe obesity.

Perceptions of non-successful families attending a weight-management clinic

OBJECTIVE

This study seeks to understand family's perceptions of their care at a paediatric weight management service, with a view to informing service improvement.

DESIGN

A qualitative service review conducted via semistructured interviews with parents (n=11) and children (n=3) who attended the clinic. The recruitment was open to all, but those who were not succeeding in their weight-loss goals self-selected to participate. Self-Determination Theory was used as a framework to explore families' experiences of the clinic.

SETTING

Recruitment occurred during clinical appointments and interviews were conducted over the phone in the days following the appointments.

PATIENTS

The service sees paediatric patients with a body mass index >99th percentile, with comorbidities or safeguarding concerns.

INTERVENTIONS

The clinic's service includes appointments typically every 2 months, with a multidisciplinary team including consultant endocrinologists, a dietician, a clinical psychologist, a social worker and a clinical nurse specialist.

MAIN OUTCOME MEASURES

Families' feedback on the multi-disciplinary team (MDT) clinic, and their perceptions of how improvements could be made.

RESULTS

Families perceive a lack of autonomy, competency and feel a lack of connectivity both in their lives broadly and within their experience at the clinic.

CONCLUSIONS

Interventions in families struggling with weight improvements should see the clinical team placing more emphasis on working alongside parents to develop young people's sense of self-determination. Expectations must be set that success originates from changes outside of clinical appointments and that the clinical team is in place to support the family's development of sustainable, self-determined lifestyle habits.

A Scoping Review: Family and Child Perspectives of Clinic-Based Obesity Treatment

PROBLEM

Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment?

ELIGIBILITY CRITERIA

Studies were eligible for inclusion in this review that 1) reported parent, family or child perspectives of obesity treatment; 2) addressed concepts identified in the obesity literature as barriers or facilitators to success in obesity treatment from the perspective of the parent/family/child, including reasons for failure to return to clinic and satisfaction with care.

SAMPLE

Twelve studies qualified for final inclusion in this scoping review RESULTS: Families report a lack of interventions tailored to their unique needs and resources. Barriers and facilitators encompass 1) structural issues (e.g., clinic location and scheduling); 2) financial issues; 3) patient and family issues; and 4) personal behaviors, motivation, and expectations.

CONCLUSION

Data are lacking on the clinic-based treatment of children with severe obesity, and few studies report on non-maternal perspectives.

IMPLICATIONS

Clinical practice must be tailored to individual family needs. Future research should concentrate on identifying missing variables which impact successful treatment outcomes through more rigorous qualitative studies, standardized outcome measures, focus on children with severe obesity, and fathers' and siblings' perspectives.

Satisfaction and acceptability of paediatric weight management services amongst parents and carers: A mixed-methods study

To optimize treatment for children and adolescents with obesity and minimize attrition, consideration of parents' engagement and satisfaction with paediatric weight management services is crucial. The aim of this study was to conduct a mixed-methods evaluation of parental acceptability and satisfaction of available paediatric weight management services in New South Wale, Australia's most populous state. Parents/carers referred to one of six weight management services between March 2018 and July 2019 were invited to participate. The study involved: (a) surveys and one-on-one phone interviews to assess overall satisfaction, acceptability of service design and delivery, treatment expectations, and service accessibility, strengths, weaknesses and areas of improvement; (b) a survey to determine costs to families of attending the service; and (c) a survey assessing families' reasons for treatment non-attendance. N = 146 participants completed the survey to assess service satisfaction and acceptability and 37 of these also participated in phone interviews. Ninety-three per cent were satisfied with the overall care they received and patient weight loss/cessation of weight gain and improvement in the family's overall health were rated as the most valued changes. Content analysis of interviews highlighted participants' recognition of positive changes achieved during treatment and appreciation of the resources provided, and the encouraging/empathetic nature of staff. The most common reasons for treatment attrition were difficulty in accessing the weight management service and flexibility of appointment times. Findings from this study can be utilized in future planning and development of paediatric weight management services to facilitate integrated, responsive and effective care of children and adolescents with obesity.

The "Stages Towards Completion Model": what helps and hinders children with overweight or obesity and their parents to be guided towards, adhere to and complete a group lifestyle intervention

Purpose: Lifestyle interventions can be effective in the management of overweight and obesity in children. However, ineffective guidance towards interventions and high attrition rates affect health impacts and cost effectiveness. The aim of this study was to gain insight into the factors influencing participation, in particular guidance towards, adherence to and completion of an intervention.

Methods: A narrative literature review was performed to identify factors related to participation, leading to the development of the “Stages towards Completion Model”. Semi-structured interviews (n = 33) and three focus group discussions (n = 25) were performed with children and parents who completed two different group lifestyle interventions, as well as with their coaches.

Results: The main barrier to participating in a lifestyle intervention was the complex daily reality of the participants. The main facilitator to overcome these barriers was a personal approach by all professionals involved.

Conclusions: Participation in a lifestyle intervention is not influenced by one specific factor, but by the interplay of facilitators and barriers. A promising way to stimulate participation and thereby increase the effectiveness of interventions would be an understanding of and respect for the complex circumstances of participants and to personalize guidance towards and execution of interventions.

Risk and Protective Factors Associated with Childhood Obesity in a Sample of Low-Income, Single Female, Parent/Guardian Households: Implications for Family Therapists

The United States is in the midst of a childhood obesity epidemic that disproportionately impacts underserved and diverse populations. In this study, in-depth qualitative interviews were conducted with 16 low-income, single, female, parent/guardians of an overweight or obese 3- to 8-year-old from socioeconomically disadvantaged backgrounds. Following the tenets of the thematic analysis approach, interviews focused on identifying risk and protective factors influencing parental and child health behaviors associated with child weight status. Results from the interviews are organized according to the Socioecological Framework to help identify risk and protective factors at various system levels. Findings from this investigation have relevance for family therapists as they can inform clinical and advocacy-focused interventions with disadvantaged families affected by childhood obesity.

Acceptability of Hospital-Based Pediatric Weight Management Services among Patients and Families: A Narrative Synthesis

High rates of attrition from pediatric weight management services are well documented in the literature; however, studies reporting on acceptability of "real-world" services have not previously been reviewed. This narrative synthesis aimed to summarize quantitative and qualitative research reporting on satisfaction of families who attended a secondary or tertiary pediatric weight management service. Electronic databases were searched for studies of family and/or patient satisfaction with hospital-based pediatric weight management services. Included articles were scored on their methodological quality. Searches returned 4509 articles of which 17 were eligible. Education, practical strategies to assist behavior change and the approach of staff were reported as the most valued service aspects. Practical, organizational, and service content issues were reported as the primary reasons for poor engagement or discontinuation of treatment. The majority of recommendations for service improvement related to service content, with the following subthemes: program content, delivery of the weight management intervention, individualized treatment, and treatment expectations. Potential strategies for reducing attrition and improving consumer satisfaction include assessment of families' readiness to change at the outset of treatment and implementation of treatment non-negotiables. Development of a standardized measure of patient satisfaction for use in pediatric weight management service development, evaluation, and comparison is recommended.

Viewpoints of adolescents with overweight and obesity attending lifestyle obesity treatment interventions: a qualitative systematic review

BACKGROUND

Current UK guidance recommends that adolescents with obesity attend a family-based multi-component obesity intervention. However, these programmes suffer from low recruitment and high rates of attrition. Understanding the views of adolescents is necessary for developing future interventions. The aim of this systematic review was to synthesize and explore the views of adolescents who have attended an obesity intervention.

METHODS

Published literature was identified by searching six databases. Studies of adolescents (12-17 years) who attended an obesity intervention were examined. Only studies that collected and analysed data qualitatively were included. Full texts were analysed using thematic synthesis.

RESULTS

Twenty-eight studies were included. Thirty-five analytical themes were developed that were broadly divided into seven domains. Key themes included ensuring adolescents receive a 'tailored intervention' that involves 'active engagement'. Support from professionals, family and peers were valued highly. Adolescents expressed 'prior fears of attending interventions' and wanted 'longer term support'. 'Enjoyment of sport and physical activity' was evident, and adolescents were strongly motivated by improving body image and social desirability.

DISCUSSION

Considering the views of adolescents attending obesity interventions may help to inform policy makers in the development of future interventions. This may lead to an improvement in recruitment and attrition rates.

The acceptability, effectiveness, and impact of different models of care for pediatric weight management services: protocol for a concurrent mixed-methods study

Background

Pediatric obesity is a serious, but clinically neglected, chronic health problem. Despite the high prevalence, excess weight problems are rarely managed when children attend clinical services. It is recommended that obesity treatment uses a “chronic-care” approach to management, with different types and intensity of treatment dependent upon severity of obesity. There are several new secondary and tertiary weight management services being implemented within New South Wales (NSW), Australia in 2017/2018 with differing models of care. This study will ascertain what factors affect acceptability, reach, and participation, as well as measure the clinical effectiveness of these services.

Methods

This is a acceptability and effectiveness study building upon existing and planned secondary and tertiary level service delivery in several health districts. This study will recruit participants from seven different pediatric weight management services (PWMS) across five Local Health Districts in NSW, Australia. Using a mixed-methods approach we will document a range of process, impact and clinical outcome measures in order to better understand the context and the effectiveness of each PWMS model. The project development and implementation is guided by the Theoretical Domains Framework. Participants will include parents of children less than 18 years of age attending PWMS, clinicians working as part of PWMS and health service managers. Data will be captured using a combination of anthropometric measures, questionnaires, one-on-one semi-structured interviews and focus groups.

Discussion

Results from this study will assess the acceptability and effectiveness of different models of care for pediatric weight management. Such information is required to inform long-term sustainability and scalability of secondary and tertiary care services to the large number of families with children above a healthy weight.

Lifestyle weight management programmes for children: A systematic review using Qualitative Comparative Analysis to identify critical pathways to effectiveness

This study aimed to identify critical features of successful lifestyle weight management interventions for overweight children (0-11years). Eleven qualitative UK-based studies examining children's, parents' and providers' perspectives and experiences of programmes were synthesised to identify components felt to be critical. Studies for this views synthesis were identified from existing reviews and an update of one review's search, which was run in December 2015. The identified components were then explored in a synthesis of intervention evaluations (five 'most effective' and 15 'least effective') conducted in western Europe, North America, Australia or New Zealand. The intervention evaluations were identified from existing reviews and an update of one review's search, which was run in March 2016. This evaluation synthesis was carried out using Qualitative Comparative Analysis. Three important mechanisms were present in all the most effective interventions but absent in all the least effective: 1/ showing families how to change: a) providing child physical activity sessions, b) delivering practical behaviour change strategy sessions, c) providing calorie intake advice; 2/ ensuring all the family are on board: a) delivering discussion/education sessions for both children and parents, b) delivering child-friendly sessions, c) aiming to change behaviours across the whole family; 3/ enabling social support for both parents and children by delivering both child group sessions and parent group sessions. To conclude, programmes should ensure the whole family is on board the programme, that parents and children can receive social support and are not just told what to change, but shown how.

Changing eating behaviours to treat childhood obesity in the community using Mandolean: the Community Mandolean randomised controlled trial (ComMando)--a pilot study

BACKGROUND

Around one in five children in England is obese when they leave primary school. Thus far, it has not been demonstrated that primary care interventions to manage childhood obesity can achieve significant weight reduction. Training obese children to eat more slowly as an adjunct to other healthy lifestyle behaviour change has been shown to increase weight reduction in a hospital setting.

OBJECTIVES

This pilot study aimed to test recruitment strategies, treatment adherence, clinic attendance and participants' experiences of using a device [Mandolean® (previously Mandometer®, Mikrodidakt AB, Lund, Sweden)] to slow down speed of eating as an adjunct to dietary and activity advice in treating obesity in primary school-aged children.

DESIGN

A two-arm, parallel, randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. Participants were randomised by the Bristol Randomised Trials Collaboration randomisation service with allocation stratified by hub and minimised by age of the child, gender, and baseline body mass index (BMI) standard deviation score (BMI z-value) of the child, and by BMI of the study parent (obese/not obese).

SETTING

General practices across Bristol, North Somerset and South Gloucestershire primary care trusts.

PARTICIPANTS

Children (BMI ≥ 95th percentile) aged 5-11 years and their families.

INTERVENTION

Standard care comprised dietary and activity advice by trained practice nurses. Adjunctive Mandolean training (the intervention) educated participants to eat meals more slowly and to rate levels of fullness (satiety). Mandolean is a small computer device attached to a weighing scale that provides visual and oral feedback during meals while generating a visual representation of levels of satiety during the meal. Participants were encouraged to eat their main meal each day from the Mandolean. One parent was also given a Mandolean to use when eating with the child.

OUTCOME MEASURES

Outcomes for the pilot were recruitment of 36 families to the trial in the 9-month pilot phase, that meals would be eaten at least five times a week off a Mandolean by 90% of patients randomised to the intervention arm, that 80% of patients in both arms would attend the weight management clinic appointment 3 months post randomisation and that > 60% of children using Mandolean would demonstrate a reduction in speed of eating from baseline within 3 months of randomisation.

RESULTS

None of the criteria for progression to the main trial were reached. Despite numerous pathways being available for referral, only 21 (13 to standard care, eight to intervention arm; 58%) of the target 36 families were recruited in the pilot phase. Less than 20% of those randomised to Mandolean used the device at least five times a week. The > 60% target for slowing down of eating speed by 3 months was unmet. Attendance at the weight management clinic in general practice hubs for both arms of the study at 3 months was 44% against a target of 80%.

CONCLUSIONS

This pilot trial failed to meet its objectives in terms of recruitment, treatment adherence, demonstration of a reduction in speed of eating in sufficient numbers of children, and attendance at follow-up appointments. Despite a high prevalence of childhood obesity in the geographical area and practices signing up for the trial, this study, like many others, demonstrates a failure of families to engage with and respond to primary care weight management interventions. We need to understand why the target population seems inured to the health message that childhood obesity is a significant health-care issue and identify the barriers to seeking help and then acting on positive health behaviour retraining. Only when we have fully understood the general public's perceptions of childhood obesity and have identified ways of engaging target populations can we hope to develop interventions that can work in a primary or community-based setting.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN90561114.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 47. See the NIHR Journals Library website for further project information.

Qualitative studies among obese children and adolescents: a systematic review of the literature

Childhood obesity is a complex condition involving medical, social, moral and cultural issues. Qualitative approaches are of great value in understanding this complexity. This meta-synthesis of 45 qualitative studies deals specifically with the issue of obesity in children and adolescents from different perspectives--those of obese children and adolescents, of parents, and of health professionals providing support to the family. Our aim was to obtain a coherent view of child and adolescent obesity, focused on clinical and personal experience. The themes derived from the synthesis process fall under three main axes: 'Seeing others, seeing oneself', 'Understanding others, understanding oneself', and 'Treating others, treating oneself'. It emerges that participants in all three groups had equal difficulty in perceiving and labelling obesity, mainly because of their lack of any real common ground. The insufficiency of shared representations destabilizes the therapeutic relationship and its construction: an important issue in the doctor-child-parent relationship in this context is the need to exchange their viewpoints of obesity. Health workers may also expand their understanding of obesity by incorporating the personal experiences of obese children and their parents in order to match treatment plans to their needs and expectations.

Parents' views and experiences of childhood obesity management in primary care: a qualitative study

BACKGROUND

Primary care has been viewed as an appropriate setting for childhood obesity management. Little is known about parents' views and experiences of obesity management within this clinical setting. These views and experiences need to be explored, as they could affect treatment success.

OBJECTIVE

To explore parents' views and experiences of primary care as a treatment setting for childhood obesity.

METHODS

In-depth interviews were held with 15 parents of obese children aged 5-10 years, to explore their views and experiences of primary care childhood obesity management. Parents were contacted via a hospital-based childhood obesity clinic, general practices and Mind, Exercise, Nutrition … Do it! (MEND) groups based in Bristol, England. The interviews were audio-taped transcribed verbatim and analysed thematically.

RESULTS

Parents viewed primary care as an appropriate setting in which to treat childhood obesity but were reluctant to consult due to a fear of being blamed for their child's weight and a concern about their child's mental well-being. They also questioned whether practitioners had the knowledge, time and resources to effectively manage childhood obesity. Parents varied in the extent to which they had found consulting a practitioner helpful, and their accounts suggested that GPs and school nurses offer different types of support.

CONCLUSIONS

Parents need to be reassured that practitioners will address their child's weight in a non-judgemental sensitive manner and are able to treat childhood obesity effectively. A multidisciplinary team approach might benefit a child, as different practitioners may vary in the type of care they provide.

Recognition and management of overweight and obese children: a questionnaire survey of general practitioners and parents in England

AIMS

To (i) compare the views of general practitioners (GPs) and parents about the causes, consequences and management of childhood overweight/obesity; and (ii) explore the extent to which they can identify overweight/obesity in children.

METHODS

A questionnaire was mailed to all GPs in one Primary Care Trust and all parents in one primary school in southern England, 2008. Information was gathered on socio-demographic background, views about causes, consequences and management of childhood overweight/obesity; judgements about the weight status of 14 images of children (seven boys, seven girls) in the Children's Body Image Scale (CBIS). Comparisons were made between GP and parents' responses using unpaired bivariate tests.

RESULTS

The response rate was 33%. Differences exist between the views of GPs and parents about childhood weight management: 86.4% of parents felt GPs should be involved, compared to 73.3% of GPs (P < 0.001). Parents thought GPs should be more proactive than the GPs stated they would be. GPs were significantly more likely than parents to see a role for school nurses and dieticians. One third of respondents thought GPs lacked expertise in child weight management. Most GPs and parents correctly identified obese children from the images, but inaccuracies occurred at category margins.

CONCLUSIONS

Childhood overweight/obesity is a serious public health concern, and primary care has a role to play in tackling it. GPs in England need more training in childhood overweight/obesity management. Their role needs to be clarified in the context of multiagency approaches.

Lessons learned from a family-focused weight management intervention for obese and overweight children

Objective

Treatment for childhood obesity is characterised by high attrition rates and failure to achieve weight maintenance. It is therefore important to develop more effective programmes. The aim of the present qualitative study was to explore the views of parents, children and health trainers to identify issues which can inform the development of more effective programmes.

Design

A qualitative study combining in-depth interviews and focus groups. Participants were selected purposively from current and past attendees.

Setting

WATCH-IT, a UK-based community child weight management programme.

Subjects

Twenty-three families who had previously attended (or were currently attending) WATCH-IT were interviewed. Focus groups with ten trainers explored their views of the intervention.

Results

Parents and children had different goals for involvement, with parents focusing on psychological benefits, while children concentrated on goals relating to weight loss and physical fitness. Parents were found to struggle to provide consistent support to their children and this was exacerbated by family dynamics. The child's commitment to lose weight, support from their family and a good relationship between the child and their trainer were viewed as important keys to successful weight management.

Conclusions

The study will guide the design of existing and future programmes by providing insights into issues that challenge successful engagement. It highlights the possible value of exploring the therapeutic relationship between trainers and participants.

Obese young people's accounts of intervention impact

OBJECTIVE

To uncover in-depth qualitative accounts of intervention impact from obese young people during a period of lifestyle change after attending a residential weight-loss camp.

METHODS

An innovative, progressively focused process of (1) single end-of-stay interviews, (2) interviews repeated in the home environment at 3 months and (3) 9 months. Comprehensive data were collected from five information-rich cases who contributed at each stage. Verbatim transcripts were analysed to identify issues associated with camp impact.

RESULTS

Reporting positive in-camp experiences, there were also anxieties about returning home and successfully translating knowledge and behaviors into longer term strategies. Inductive analysis suggested cognitive ambiguity in relation to positive camp impact. This developed and intensified over the 9 months of post-camp experience, despite the help of supportive others.

CONCLUSION

Young people described a positive post-camp impact that continued into the home environment. Unexpectedly, though it was also an ambiguous experience. Cognitive ambiguity created behavioral conflict which undermined motivation for sustained healthy living.

PRACTICE IMPLICATIONS

These unique accounts enable service providers to better understand post-camp experiences and use them to work with young people towards more positive outcomes. Even after intensive and successful intervention young people may still require ongoing support for continued lifestyle change.