Predictors of Engagement in a Pediatric Weight Management Clinic after Referral

Parental Factors Associated With Intentions to Initiate a Family-Based Pediatric Weight Management Program

Background: Childhood obesity can be addressed through family-based pediatric weight management; however, treatment enrollment in the United States is low. This study aimed to identify parental factors associated with intentions to initiate a family-based pediatric weight management program. Methods: Cross-sectional survey data were collected from an online panel of US parents with at least one 5- to 11-year-old child identified as likely to have overweight or obesity. Participants viewed a video about a hypothetical family-based pediatric weight management program, rated their 30-day initiation intentions for that program, and answered additional related questionnaires. Results: Participants (n = 158) identified as White/Caucasian (53%) or Black/African American (47%), were primarily female (61.4%) and married/cohabitating (81.6%) with children who were predominantly girls (53.2%) and, on average, 9-year-olds. Higher parents' perception of program effectiveness predicted initiation intentions (p < 0.001), while concern for their child's weight and parent depression and anxiety levels did not. Higher initiation intentions and perceived program effectiveness were reported by Black/African American participants (p < 0.01) and those with at least a bachelor's degree (p < 0.01) compared to White/Caucasian participants and those without a bachelor's degree, respectively. Initiation intentions were higher for those with greater financial security (p = 0.020) and fewer than three children in the home (p = 0.026). Participants endorsed initiation barriers of time constraints (25%), possible lack of enjoyment for the child (16.9%), and lack of family support (15%). Conclusions: Future program enrollment efforts may need to focus on strategies to increase perceived program effectiveness, although further research is needed that measures actual enrollment in real-world contexts.

The Use of Electronic Health Record Data to Identify Variation in Referral, Consent, and Engagement in a Pediatric Intervention for Overweight and Obesity: A Cross-Sectional Study

Clinical weight management programs face low participation. The authors assessed whether using electronic health record (EHR) data can identify variation in referral, consent, and engagement in a pediatric overweight and obesity (OW/OB) intervention. Using Epic EHR data collected between August 2020 and April 2021, sociodemographic and clinical diagnostic data (ie, International Classification of Disease [ICD] codes from visit and problem list [PL]) were analyzed to determine their association with referral, consent, and engagement in an OW/OB intervention. Bivariate analyses and multivariable logistic regression modeling were performed, with Bayesian inclusion criterion score used for model selection. Compared with the 581 eligible patients, referred patients were more likely to be boys (60% vs. 54%, respectively; P = 0.04) and have a higher %BMIp95 (119% vs. 112%, respectively; P < 0.01); consented patients were more likely to have a higher %BMIp95 (120% vs. 112%, respectively; P < 0.01) and speak Spanish (71% vs. 59%, respectively; P = 0.02); and engaged patients were more likely to have a higher %BMIp95 (117% vs. 112%, respectively; P = 0.03) and speak Spanish (78% vs. 59%, respectively; P < 0.01). The regression model without either ICD codes or PL diagnoses was the best fit across all outcomes, which were associated with baseline %BMIp95 and health clinic location. Neither visit nor PL diagnoses helped to identify variation in referral, consent, and engagement in a pediatric OW/OB intervention, and their role in understanding participation in such interventions remains unclear. However, additional efforts are needed to refer and engage younger girls with less extreme cases of OW/OB, and to support non-Hispanic families to consent.

Attrition from paediatric weight management impacts anthropometric outcomes at 2 years, but not health-related quality of life

The study objective is to evaluate the influence of attrition from a paediatric weight management program (PWM) on health indicators over a 2-year period. In this observational study, children and youth with obesity were recruited at entry into a family-based behaviour modification PWM and had four research study visits, independent of clinic visits, over 2 years. Participants were divided into attrition groups based on length of clinic enrolment. Body composition, cardiometabolic health and health-related quality of life (HRQoL) were assessed. Among 269 children enrolled, 19% had no clinic treatment visit, 16% had treatment visits only up to 6 months, 23% up to 1 year and 42% had at least one clinic visit after 1 year (No Attrition). Greater declines in BMI z-score and body fat were seen at 2 years in children with No Attrition, while improvements in HRQoL were similar for all attrition groups. Children who attended at least one treatment visit reported improved HRQoL up to 2 years, regardless of duration in clinic. In contrast, declines in body fat and BMI z-score were greater at 2 years for those with at least one visit after 1 year. Continued efforts to reduce attrition are likely to improve anthropometric health outcomes during PWM.

Factors predicting parent engagement in a family-based childhood obesity prevention and control program

BACKGROUND

Family-based interventions are efficacious at preventing and controlling childhood overweight and obesity; however, implementation is often hindered by low parent engagement. The purpose of this study was to evaluate predictors of parent engagement in a family-based childhood obesity prevention and control intervention.

METHODS

Predictors were assessed in a clinic-based community health worker (CHW)-led Family Wellness Program consisting of in-person educational workshops attended by parents and children. This program was part of a larger effort known as the Childhood Obesity Research Demonstration projects. Participants included 128 adult caretakers of children ages 2-11 (98% female). Predictors of parent engagement (e.g., anthropometric, sociodemographic, psychosocial variables) were assessed prior to the intervention. Attendance at intervention activities was recorded by the CHW. Zero-inflated Poisson regression was used to determine predictors of non-attendance and degree of attendance.

RESULTS

Parents' lower readiness to make behavioral and parenting changes related to their child's health was the sole predictor of non-attendance at planned intervention activities in adjusted models (OR = 0.41, p < .05). Higher levels of family functioning predicted degree of attendance (RR = 1.25, p < .01).

CONCLUSIONS

To improve engagement in family-based childhood obesity prevention interventions, researchers should consider assessing and tailoring intervention strategies to align with the family's readiness to change and promote family functioning.

TRIAL REGISTRATION

NCT02197390, 22/07/2014.

Family-reported barriers and predictors of short-term attendance in a multidisciplinary intervention for managing childhood obesity: A psycho-family-system based randomised controlled trial (ENTREN-F)

OBJECTIVE

This study was aimed to examine patient enrolment in the pre-intervention stage, family-reported barriers, attendance rates and underlying predictors of short-term attendance in a family-system-based randomised controlled trial for managing childhood obesity in children aged 8-12-years-old (ENTREN-F).

METHOD

Psychosocial and anthropometric measures were collected through primary health referral. The data were used for descriptive analyses of sample characteristics and linear regression analyses.

RESULTS

Low enrolment rates and several family-reported barriers were observed in the pre-intervention stage. Logistical barriers were the most frequent family-reported reason for attrition in the different stages of the study. Having a first face-to-face orientation session with the families and the use of motivational interviewing helped to improve adherence in the initial phases of the study. After 6 months of intervention, family based treatments (FBTs) under consideration achieve greater adherence compared with the standard intervention. Moreover, family involvement was a predictor of success for better treatment adherence rates. By contrast, participants who attended a brief standard intervention, mothers with primary education, greater body mass index, higher levels of depressive symptomatology and more critical comments towards their children, children with higher weight status and lower levels of self-reported depressive symptoms at baseline attended interventions less frequently.

CONCLUSIONS

In future programmes a comprehensive screening of modifiable factors related to family and their setting characteristics is paramount prior to intervention, identifying key barriers related to drop-out, especially in the case of less-advantaged families.

Re-referring Children for Multidisciplinary Obesity Management

OBJECTIVES

To examine characteristics of children referred for obesity management based on referral frequency, child- and referrer-related variables associated with re-referral, and determine whether re-referral increased treatment initiation.

STUDY DESIGN

This population-level, retrospective analysis included all 2- to 17-year-olds referred for obesity management to 1 of 3 multidisciplinary clinics in Alberta, Canada between April 2013 and December 2017. Children were dichotomized based on referral frequency, specifically once only or more than once (re-referred). Data were retrieved from standardized referral forms and patient registries. Analyses included logistic regression and generalized estimating equations models.

RESULT

We analyzed data from 2745 children (47.2% female; mean age: 11.4 years; mean body mass index z score: 3.03) and 2705 physicians (60.2% female; 65.6% pediatricians). Overall, 300 (10.2%) children were re-referred with most (n = 276; 92.0%) being referred twice. Children were less likely to be re-referred if they were referred by a family physician (vs pediatrician) (aOR 0.62; 95% CI 0.46-0.84; P = .0018) or scheduled a clinic appointment following their index referral (aOR: 0.29; 95% CI 0.21-0.4; P < .001). Treatment initiation was higher in children who were referred once only (42.1%) vs their re-referred peers (18.0%; P < .0001); however, for children who were re-referred, they were more likely to initiate treatment following their second referral (aOR 2.3; 95% CI 1.22-4.31; P = .01). This improvement was not sustained on subsequent referrals (aOR 0.44; 95% CI 0.17-1.12; P = .08).

CONCLUSIONS

Few children were re-referred for pediatric obesity management; however, for those children who were re-referred, being re-referred once only increased the likelihood of treatment initiation.

A Mixed-Methods Examination of Referral Processes to Clinic-Community Partnership Programs for the Treatment of Childhood Obesity

Background: Partnerships with community programs have been used to improve access to obesity care and address clinical barriers to childhood obesity management; however, little is known about the program referral process. The objective of this study was to identify factors that affect the referral from clinics to community-based programs. Methods: Active Recreation through Community-Healthcare Engagement Study (ARCHES) is a mixed-method, implementation study designed to test the feasibility of establishing clinic-community partnerships to treat childhood obesity. We collected clinical referral and program attendance data from the six ARCHES clinic-community partnerships and conducted semistructured interviews (n = 19) with key stakeholders. Logistic regression models were used to identify referral characteristics associated with ever attending a community program. We used deductive thematic analysis to examine contextual factors affecting the clinical referral and subsequent attendance at the community programs. Results: Patients referred from individual providers [odds ratio (OR): 3.20, 95% confidence interval (CI): 1.08-9.48], specialty clinics (OR: 2.73, 95% CI: 1.48-5.05), and community wellness clinics (OR: 3.42, 95% CI: 1.05-11.13), had greater odds of ever attending the programs compared with patients from primary care clinics. Patients referred to cohort-based programs compared with open enrollment programs had greater odds of ever attending the programs. Stakeholders emphasized the value of communication within the partnership and with patients in clinical settings. Effective provider communication with patients involved engaging and program endorsing conversations to explain the value of the program. Conclusions: We identified factors that may improve the referral process in clinic-community partnerships to provide resources to primary care providers looking to address childhood obesity. Clinical Trial Registration number: NCT03246763.

Waitlist management in a pediatric weight management clinic: implementing an orientation session

Background

This study evaluates implementation of an orientation session to address a waitlist of more than 2000 referrals to a pediatric weight management clinic in the Mid-South United States.

Methods

An hour-long group-based orientation to the pediatric weight management clinic was implemented to provide information about the structure and expectations of the clinic as well as education on healthy lifestyle recommendations. Families were contacted from the waitlist by telephone and invited to attend an orientation session prior to scheduling a clinic appointment.

Results

Of 2251 patients contacted from the waitlist, 768 scheduled an orientation session, of which 264 (34 %) attended. Of the 264 orientation participants, 246 (93 %) scheduled a clinic appointment. Of those, 193 (79 %) completed a clinic visit. Waitlist times decreased from 297.8 ± 219.4 days prior to implementation of orientation sessions to 104.1 ± 219.4 days after.

Conclusions

Orientation has been an effective and efficient way to triage patient referrals while maximizing attendance in limited clinic slots for patients and families demonstrating interest and motivation. Elements of this approach are likely generalizable to other pediatric clinical settings that must strategically manage a large volume of patient referrals.

Assets and Challenges to Recruiting and Engaging Families in a Childhood Obesity Treatment Research Trial: Insights From Academic Partners, Community Partners, and Study Participants

Background: There is need for the childhood obesity treatment literature to identify effective recruitment and engagement strategies for rural communities that are more likely to lack supportive infrastructure for healthy lifestyles and clinical research relative to their urban counterparts. This community case study examines recruitment and engagement strategies from a comparative effectiveness research (CER) trial of two family-based childhood obesity (FBCO) treatment interventions conducted in a medically underserved, rural region. Guided by a Community Based Participatory Research (CBPR) and systems-based approach, the primary aim was to analyze interviews from academic partners, community partners, and parent study participants for recruitment and engagement assets, challenges, and lessons learned. Methods: Over the 3-year lifespan of the study, researchers conducted 288 interviews with Community Advisory Board members (n = 14), Parent Advisory Team members (n = 7), and study participants (n = 100). Using an inductive-deductive approach, interviews were broadly coded for recruitment and engagement assets, challenges, and recommendations; analyzed for descriptive sub-coding; and organized into stakeholder/organization and participant level themes. Codes were analyzed aggregately across time and examined for differences among stakeholders and parent study participants. Results: Adherence to CBPR principles and development of strong community partnerships facilitated recruitment and engagement; however, variability in recruitment and engagement success impacted partner confidence, threatened outcome validity, and required additional resources. Specifically, assets and challenges emerged around eight key needs. Three were at the stakeholder/organization level: (1) readiness of stakeholders to conduct CBPR research, (2) development of sustainable referral protocols, and (3) development of participant engagement systems. The remaining five were at the participant level: (1) comfort and trust with research, (2) awareness and understanding of the study, (3) intervention accessibility, (4) intervention acceptability, and (5) target population readiness. Future recommendations included conducting readiness assessments and awareness campaigns, piloting and evaluating recruitment and engagement strategies, identifying participant barriers to engagement and finding a priori solutions, and fostering stakeholder leadership to develop sustainable protocols. Conclusion: Collective findings from multiple perspectives demonstrate the need for multi-leveled approaches focusing on infrastructure supports and strategies to improve stakeholder and participant awareness of, and capacity for, recruiting and engaging medically underserved, rural families in a FBCO CER trial.