Why don't families initiate treatment? A qualitative multicentre study investigating parents' reasons for declining paediatric weight management

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.

Perceived barriers in family-based behavioural treatment of paediatric obesity - Results from the FABO study

BACKGROUND

To date, few studies have investigated perceived barriers among those who participate in and drop out of family-based behavioural treatment (FBT) for paediatric obesity. Examining experienced barriers during treatment, and their role in participation and completion of treatment has important implications for clinical practice.

OBJECTIVES

To compare perceived barriers to participating in a family-based behavioural social facilitation treatment (FBSFT) for obesity among families who completed and did not complete treatment.

METHODS

Data were analysed from 90 families of children and adolescents (mean (M) age = 12.8 years, standard deviation (SD) = 3.05) with severe obesity enrolled in a 17-session FBSFT program. After completing 12 sessions or at the time of dropout, parents and therapists completed the Barriers to Treatment Participation Scale (BTPS), a 5-point Likert scale (1 = never a problem, 5 = very often a problem) which includes four subscales: 1. Stressors and obstacles that compete with treatment, 2. Treatment demands and issues, 3. Perceived relevance of treatment, 4. Relationship with the therapist.

RESULTS

Families who did not complete treatment scored significantly higher on the BTPS subscales stressors and obstacles that compete with treatment (M = 2.03, SD = 0.53 vs. M = 1.70, SD = 0.42), p = 0.010 and perceived relevance of treatment (M = 2.27, SD = 0.48 vs. M = 1.80, SD = 0.50), p < 0.001 than families who completed treatment. No other significant differences between groups were observed.

CONCLUSION

Families are more likely to drop out of FBSFT when experiencing a high burden from life stressors or when treatment is not meeting the expectations and perceived needs of the family.

Materials and Methods for Recruiting Systematically Marginalized Youth and Families for Weight-Management Intervention Trials: Community Stakeholders' Perspectives

Rates of overweight and obesity are problematic among systematically marginalized youth; however, these youth and their families are a hard-to-reach research population. The purpose of our study was to identify facilitators and barriers for recruiting systematically marginalized families in youth weight-management intervention research. This study built upon existing evidence through involvement of youth, parents, community agency workers, and school nurses, and an exploration of both recruitment materials and processes. Seven focus groups were conducted with 48 participants from 4 stakeholder groups (youth, parents, school nurses, and community agency workers). A codebook approach to thematic analysis was used to identify key facilitator and barrier themes related to recruitment materials and processes across the stakeholder groups. Ecological systems theory was applied to contextualize the facilitators and barriers identified. Participants reported the need to actively recruit youth in the study through engaging, fun recruitment materials and processes. Participants reported greater interest in recruitment at community-based events, as compared to recruitment through health care providers, underscoring the depth of distrust that this sample group has for the health care system. Recommendations for recruitment materials and processes for weight-management intervention research with systematically marginalized families are proposed.

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.

Parents' perception of health promotion: What do parents think of a healthy lifestyle in parenting and the impact of the school environment? A qualitative research in the Netherlands

PURPOSE

This study aimed at gaining insight into parents' perceptions towards health behaviour in parenting and the impact of the school environment. Healthcare professionals experience barriers to discuss health behaviour in families where levels of overweight and obesity are elevated. There is a need to understand parents' perception and perceived significance of health behaviour.

DESIGN AND METHODS

Sixty-three semi-structured interviews were conducted with parents of children from three primary schools located in two different neighbourhoods in Zwolle, the Netherlands. Parents were asked to formulate their top three priority goals in parenting, additionally supplemented with 15 predetermined goals, including a health behaviour related goal. Parents ranked the goals in order of importance and gave an explanation. Finally, parents shared their opinions regarding the school environment in promoting health behaviour, according to the EnrG framework.

RESULTS

In 8 out of 63 interviews, health was reported in the top three self-formulated goals. Other goals considered important were happiness and being respectful to others. When health was ranked as less important in parenting, routine of health behaviour, own beliefs and religion were given as explanations. The physical school environment and teachers were mentioned as important factors in promoting health behaviour.

CONCLUSIONS

Parents indicate health behaviour as a key-element in parenting, even when health behaviour is not considered as the most important priority.

PRACTICE IMPLICATIONS

Since school is perceived as a logical and powerful environment, healthcare professionals should collaborate with school staff to empower their own, teachers' and parents' roles to address health promotion.

Physician-related predictors of referral for multidisciplinary paediatric obesity management: a population-based study

BACKGROUND

It is recommended that primary care-based physicians refer children with overweight and obesity to multidisciplinary paediatric obesity management, which can help to improve weight and health.

OBJECTIVE

To determine predictors of referral to multidisciplinary paediatric obesity management.

METHODS

This retrospective, population-level study included physicians who could refer 2-17 years old with a body mass index ≥85th percentile to one of three multidisciplinary paediatric obesity management clinics in Alberta, Canada. Physician demographic and procedural data were obtained from Practitioner Claims and Provider Registry maintained by Alberta Health from January 2014 to December 2017. Physician characteristics were compared based on whether they did or did not refer children for obesity management. Univariable and multivariable logistic regression models analysed associations between physician characteristics and referral making.

RESULTS

Of the 3863 physicians (3468 family physicians, 395 paediatricians; 56% male; 49.3 ± 12.2 years old; 22.3 ± 12.6 years since graduation) practicing during the study period, 1358 (35.2%) referred at least one child for multidisciplinary paediatric obesity management. Multivariable regression revealed that female physicians (versus males) [odds ratio (OR): 1.68, 95% confidence interval (CI): 1.46-1.93; P < 0.0001], paediatricians (versus family physicians) (OR: 4.89, 95% CI: 3.85-6.21; P < 0.0001) and urban-based physicians (versus non-urban-based physicians) (OR: 2.17, 95% CI: 1.79-2.65; P < 0.0001) were more likely to refer children for multidisciplinary paediatric obesity management.

CONCLUSIONS

Approximately one-third of family physicians and paediatricians referred children for multidisciplinary paediatric obesity management. Strategies are needed to improve referral practices for managing paediatric obesity, especially among male physicians, family physicians and non-urban-based physicians as they were less likely to refer children.

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.

Paediatric teams in front of childhood obesity: A qualitative study within the STOP project

INTRODUCTION

Understanding the underlying factors that influence the approach to overweight and obesity in children is basic to best support families searching a solution to this important public health problem.

OBJECTIVE

To assess attitudes and feelings of paediatric staff in addressing overweight and childhood obesity to parents, exploring perceived barriers and facilitators, for an effective care.

PARTICIPANTS AND METHOD

Qualitative study by means of individual semi-structured questionnaires of paediatric staff (paediatricians and paediatrician nurses; n = 57; 68% female) of primary health care centres and hospitals in Mallorca. Thematic analysis was done.

RESULTS

Three themes emerged from the data: "Parents' attitude in childhood obesity" (sub-themes "The conscience of parents", "The parents ask for help"), "Paediatric staff and childhood obesity" (sub-themes "Approaching to the problem: The interview with parents", "Looking together for the solution"), and "System barriers" (sub-themes "Improving teamwork and health policy", "Family participation in addressing childhood obesity").

CONCLUSIONS

Paediatric staffs know how to treat childhood obesity, but demand training on motivation. Effectivity on therapy of childhood obesity will be obtained after parents/carers recognize the problem and establish a trustful relationship with paediatric staff. The health system is still a barrier to the activity of paediatric personnel.

Determinants of attrition in a pediatric healthy lifestyle intervention: The CIRCUIT program experience

INTRODUCTION

Attrition in pediatric weight management programs is notoriously high. Greater understanding of its determinants is needed to inform retention strategies. We identified determinants of attrition in CIRCUIT, a healthy lifestyle intervention program for youth at risk of cardiovascular disease.

METHODS

A one-arm intervention study of children aged 4-18 years who initiated the CIRCUIT program in the first five years of its existence (N = 403). We defined attrition as attending the baseline visit but ceasing attendance prior to the 1-year follow-up. Potential determinants of dropout included the child's age, sex, ethnicity, body mass index (BMI) z-score, family socio-demographic characteristics, and estimated driving time to the program, all measured at baseline. Associations were estimated bivariately, using chi-squared- and t-tests, and simultaneously in a multivariable logistic regression model.

RESULTS

Of the 403 participants who started the program, 198 (49%) dropped out within 12 months of enrollment. Youth who dropped out were older (mean age 12.8y vs. 11.3y; p < 0.01), were less likely to live with both parents (62% vs. 71%; p = 0.05), and to have mothers who had completed high school (79% vs. 88%; p = 0.01). No group differences were observed for sex, ethnicity, baseline BMI z-score, fathers' education, or driving time to the program. In multivariate models, only older age at initiation of the intervention (OR: 1.2; CI: 1.1,1.3) and lower maternal education (OR: 2.0; CI: 1.0,3.8) were associated with dropout.

CONCLUSION

Improved tailoring of interventions to older pediatric participants and to families of lower maternal education may help reduce attrition in CIRCUIT and similar lifestyle intervention programs.

[Paediatric teams in front of childhood obesity: a qualitative study within the STOP project]

INTRODUCTION

Understanding the underlying factors that influence the approach to overweight and obesity in children is basic to best support families searching a solution to this important public health problem.

OBJECTIVE

To assess attitudes and feelings of paediatric staff in addressing overweight and childhood obesity to parents, exploring perceived barriers and facilitators, for an effective care.

PARTICIPANTS AND METHOD

Qualitative study by means of individual semi-structured questionnaires of paediatric staff (paediatricians and paediatrician nurses; n=57; 68% female) of primary health care centres and hospitals in Mallorca. Thematic analysis was done.

RESULTS

Three themes emerged from the data: «Parents' attitude in childhood obesity» (sub-themes «The conscience of parents», «The parents ask for help»), «Paediatric staff and childhood obesity» (sub-themes «Approaching to the problem: The interview with parents», «Looking together for the solution»), and «System barriers» (sub-themes «Improving teamwork and health policy», «Family participation in addressing childhood obesity»).

CONCLUSIONS

Paediatric staffs know how to treat childhood obesity, but demand training on motivation. Effectivity on therapy of childhood obesity will be obtained after parents/carers recognize the problem and establish a trustful relationship with paediatric staff. The health system is still a barrier to the activity of paediatric personnel.

Public health nurse referrals for paediatric weight management: A nested mixed-methods study

AIMS AND OBJECTIVES

To (a) characterise and determine proportions of referred and enrolled children and (b) explore public health nurses' (PHNs) experiences, perspectives and recommendations regarding a new nurse-led referral pathway for paediatric weight management.

BACKGROUND

Children with obesity and their families in Canada access specialised services for obesity management through physician referral. Since this requirement can prevent timely access to health services, we established and tested a referral pathway whereby PHNs directly refer children to specialised care for obesity management.

DESIGN

Nested mixed-methods study reported using GRAMMS.

METHOD

Our research study included children (2-17 years of age; body mass index ≥85th percentile) referred by a PHN to the Pediatric Centre for Weight and Health (PCWH; Stollery Children's Hospital, Edmonton, Alberta, Canada) from April 2017-September 2018. We summarised referral and enrolment data using descriptive statistics and conducted one-on-one, semi-structured telephone interviews with PHNs; interviews were audio-recorded, transcribed verbatim, managed using NVivo 12 and analysed by two independent reviewers using content analysis.

RESULTS

Our sample included 79 referred children (4.4 ± 1.8 years old; 3.4 ± 1.3 BMI z-score; 52.7% male), of which 47 (59.5%) enrolled in care. PHNs' (n = 11) experiences, perspectives and recommendations regarding the new referral pathway were grouped into four categories: (a) practicality of the referral pathway (e.g., simple and straightforward), (b) utility of the referral pathway (e.g., economic and timesaving), (c) uptake of the referral pathway (e.g., physician's influence) and (d) recommendations to improve the referral pathway (e.g., having electronic access to the referral form).

CONCLUSIONS

A PHN-specific referral pathway led most children and families to enrol in paediatric weight management and overall was perceived as acceptable and appropriate among PHNs.

RELEVANCE TO CLINICAL PRACTICE

Our results highlight the valuable role that PHNs can play in directly referring children to specialised services for weight management. This pathway has the potential to reduce wait times and enhance treatment enrolment.

Planting a seed - child health care nurses' perceptions of speaking to parents about overweight and obesity: a qualitative study within the STOP project

BACKGROUND

Nurses in child health care (CHC) centers in Sweden play a key role in the early detection and management of childhood overweight/obesity, through meeting families early, regularly and over many years. However, research focusing on CHC nurses' perceptions of their role in childhood overweight/obesity management is scarce. As part of the EU-funded project "Science and Technology in childhood Obesity Policy" (STOP), this study examines CHC nurses' perceptions of speaking to parents about children's overweight/obesity and of their role in referring children to treatment for overweight/obesity.

METHODS

All registered CHC nurses in Stockholm County (n = 442) received an email invitation letter explaining the study. Individual face-to-face visits (n = 15) in selected centers, and phone calls (n = 24) to nurses working in these centres were also conducted. In total, 17 CHC nurses (all female, average work experience 6.7 years (SD ± 4.9 years)) from 10 municipalities (including four of the top five municipalities with the highest prevalence of overweight and obesity) in Stockholm County were interviewed. The interviews were conducted by phone, transcribed and analyzed using thematic analysis.

RESULTS

Two main themes were developed through the analysis: 1) The relationship between the nurse and the parent and 2) Glitch in the system. Under the first theme, nurses reported that weight-related discussions were facilitated by building and maintaining trust with parents. However, nurses also said they were reluctant to address children's weights if this could compromise parents' trust. Under the second theme, nurses highlighted several organizational barriers to addressing a child's weight with parents, including insufficient cooperation with other healthcare providers and limited time for visits. Nurses also identified lack of sufficient knowledge about what to offer the family and lack of confidence in their communication skills as additional barriers.

CONCLUSIONS

We found that pediatric nurses perceive relational and organizational factors as barriers to address childhood obesity with parents. To improve care, it is necessary to provide nurses with continuing education about obesity and communication skills and organizational support to improve communication within the healthcare system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03800823; 11 Jan 2019, prospectively registered.

Access to Multidisciplinary Care for Pediatric Weight Management: Exploring Perspectives of the Health Care Team within Canada and the United States

Background: In Canada and the United States, most families referred for pediatric weight management services do not start treatment. Of families who initiate care, many discontinue before the program ends. Parents and youth have reported difficulties in accessing services as an important barrier to starting or completing programming. The purpose of this study was to understand barriers and identify potential solutions related to access to care from the perspective of health care team members from Canada and the United States. Methods: Qualitative description method guided the study design. Participants were health care team members, purposefully recruited through Canadian and US-based pediatric weight management program registries. Telephone interviews were conducted with participants between February and May 2017. Interviews were transcribed verbatim and analyzed using content analysis. Results: Eighteen individuals from 16 sites participated (n = 8 Canada, n = 8 United States). Access barriers and potential solutions were related to: (1) referral and eligibility, (2) wait lists and program capacity, (3) logistics and costs, and (4) stigma and weight bias. Barriers were similar between Canadian and US sites, with the exception of cost-related barriers. Conclusions: Health care providers from Canada and the United States reported multiple societal, organizational, service, and family-level barriers to accessing multidisciplinary pediatric weight management care. Proposed solutions suggest that service providers can play a key role alongside families to improve access to appropriate care. Further research is needed to demonstrate the feasibility and effectiveness of proposed solutions.

Participant experiences in a paraprofessional-led weight management program for children and families

Background:

Pediatric obesity is a serious and widespread medical condition that is increasing in the United States. Unfortunately, family-based programming to address the disorder fails to successfully reach and engage many children, particularly in low-income communities. To provide more affordable, accessible, and scalable programming options, researchers partnered with pediatricians and the Cooperative Extension Service (Extension) in a Midwestern state to develop a collaborative intervention. Partnering pediatricians referred children and families to a weight management program delivered by a trained Extension paraprofessional. The current study describes family experiences with the program.

Methods:

Researchers conducted a focus group or family interview with 13 program completers to elicit program perceptions, experiences with paraprofessionals, and motivators to continue. The focus group and family interviews were audio recorded and transcribed verbatim for textual analysis. Using thematic analysis, researchers examined patterns across transcripts and formulated emerging themes.

Results:

Key themes that emerged included (1) nutrition guidance, (2) interaction, (3) child influence, and (4) family engagement. Families viewed paraprofessionals as compassionate and competent educators who were instrumental in helping families modify health-related behaviors.

Conclusions:

Results of the current study are important to efforts focused on addressing childhood obesity, particularly in underserved communities where access to healthcare services is limited.

Continued attendance for paediatric weight management: A multicentre, qualitative study of parents' reasons and facilitators

Although prolonged engagement in paediatric weight management (PWM) is associated with positive treatment outcomes, little is currently known about enablers of long-term programme attendance. The purpose of our study was to explore families' reasons for and facilitators of their continued attendance at health services for PWM. Semi-structured, individual interviews were conducted with parents of children (10-17 year old; body mass index ≥85th percentile) who completed the active phase of treatment in one of four Canadian multidisciplinary clinics for PWM. Interview data were recorded digitally, transcribed verbatim and analysed thematically. Parents' (n = 40) reasons for continued clinic attendance included ongoing concerns (eg, parental concern about their child's health), actual and expected benefits from treatment (eg, lifestyle improvements) and perceived quality of care (eg, structured, comprehensive, tailored health services). Several logistical and motivational factors contributed to continued attendance, including flexible work schedules, flexible appointment times, financial resources and children's motivation for treatment. Helping families address treatment barriers and ensuring that weight management services meet families' treatment expectations are promising strategies to enhance retention in PWM to optimize health outcomes.

Tackling Childhood Overweight: Parental Perceptions of Stakeholders' Roles in a Community-Based Intervention

Introduction. Collaborative efforts among communities, schools, parents, and health professionals are needed to prevent childhood obesity, which touches one third of Canadian youth. The purpose of this case study was to obtain parents’ experience and perceptions about stakeholder roles in a multidisciplinary community-based intervention aiming to tackle childhood overweight. Methods. Data were collected from semistructured interviews with 10 parents following their participation in a community-based program designed to help families with overweight children adopt a healthier lifestyle. Results and Discussion. All parents preferred a multidisciplinary health team to monitor their children’s health. They expect that a physician or a pediatrician could diagnose overweight, explain results to parents, and refer families to resources. The team could also include professionals from health and education such as nutritionists/dietitians, nurses, physical education teachers, psychologists, kinesiologists, and social workers. Parents’ own perceived role would consist of instructing and reinforcing their children about healthy behaviors, role modeling for a healthy lifestyle, and seeking for professional help when needed. Conclusion. Parents involved in a support group with overweight child consider their own role as crucial to help changing their family lifestyle. They also prefer a multidisciplinary team that can address different aspects of overweight/obesity. However, the physician was perceived as having the central role in mobilizing a group of stakeholders around youth with overweight/obese, including the parents. A further step would be to understand barriers and facilitators to collaboration among health professionals in childhood overweight prevention and treatment.

Development and use of an index for measuring implementation of a weight management program in children in primary care clinics in Texas

BACKGROUND

The Texas Childhood Obesity Research Demonstration study was an integrated, systems-oriented intervention that incorporated primary and secondary obesity prevention approaches targeting multiple sectors, including primary care clinics, to address childhood obesity. The primary care clinic component included the American Academy of Pediatrics' Next Steps weight management counseling materials that support brief healthy lifestyle-focused visits. The current study describes the methodology and assesses the implementation of the Next Steps program in the participating primary care clinics, as well as the association of implementation with enrollment of children with overweight and obesity in the secondary prevention intervention.

METHODS

The study used a serial cross-sectional study design to collect data from 11 primary care clinics in Houston (n = 5) and Austin (n = 6), Texas, in 2013-2014. Responses of primary care providers on 42 self-reported survey questions assessing acceptability, adoption, appropriateness, and feasibility of the program were utilized to create a mean standardized clinic implementation index score. Provider scores were aggregated to represent Next Steps implementation scores at the clinic level. A mixed effects logistic regression test was conducted to determine the association between program implementation and the enrollment of children in the secondary prevention.

RESULTS

Mean implementation index score was lower at Year 2 of implementation (2014) than Year 1 (2013) although the decrease was not significant [63.2% (12.2%) in 2013 vs. 55.3% (16.5%) in 2014]. There were no significant associations between levels of implementation of Next Steps and enrollment into TX CORD secondary prevention study.

CONCLUSIONS

The development of an index using process evaluation measures can be used to assess the implementation and evaluation of provider-based obesity prevention tools in primary care clinics.

Predicting Enrollment in Multidisciplinary Clinical Care for Pediatric Weight Management

OBJECTIVES

To characterize the children who were referred, determine the proportion of referred children who enrolled, and examine factors associated with enrollment in multidisciplinary clinical care for pediatric weight management.

STUDY DESIGN

This cross-sectional study included the population of children (2-17 years of age; body mass index of ≥85th percentile) referred to 1 of 3 hospital-based multidisciplinary weight management clinics in Alberta, Canada, from April 2013 to April 2016. Referral and enrollment data were obtained from Alberta Health Services databases. Bivariate and multivariable logistic regression models were used to determine the independent and combined effects of predictors of enrollment.

RESULTS

Of the 2014 children (51.8% male; mean body mass index z-score: 3.42 ± 0.03) referred to multidisciplinary clinical care, 757 (37.6%) enrolled in care. Most referred children had severe obesity and were referred by physicians. Several factors independently predicted enrollment; however, in our most parsimonious multivariable model, only the time gap (OR, 0.94; 95% CI, 0.88-0.99; P = .03) between the attendance date of the orientation session and the booking date of initial appointment predicted enrollment for all children. Body mass index z-score (OR, 0.81; 95% CI, 0.67-0.98; P = .03) and time gap (OR, 0.92; 95% CI, 0.85-0.99; P = .02) predicted enrollment in children with severe obesity exclusively.

CONCLUSIONS

Fewer than 40% of referred children enrolled in multidisciplinary clinical care. Reducing the duration of enrollment and providing additional support for treatment initiation to children with severe obesity may enhance treatment uptake for pediatric weight management.

Helping children and families to enrol in weight management: What can stakeholders do?

Many children and their families do not benefit from multidisciplinary clinical care (MCC) for paediatric weight management because they do not enrol in (initiate) treatment. The purpose of this report was to highlight practical recommendations to enhance the enrolment of Canadian children in MCC, which were drawn from multisite Canadian studies (quantitative and qualitative) that we completed recently. Recommendations to stakeholders, including primary care providers, MCC providers and decisions makers, were organized according to opportunities, motivation and barriers to enrol. Findings from our research suggested that enrolment in MCC can be improved by increasing opportunities and motivation to enrol as well as reducing the impact of enrolment barriers.

The engagement pathway: A conceptual framework of engagement-related terms in weight management

Engagement denotes the extent to which, and how, individuals participate in weight management (WM) services. Effective WM services should generate meaningful outcomes and promote high participant engagement; however, research is predominantly focused on the former. Given that engagement is a poorly understood phenomenon, and that engagement-related concepts are often used synonymously (e.g., dropout and attrition), the engagement pathway is hereby introduced. This pathway defines key concepts (e.g., recruitment, adherence, attrition) and their relationships in the enrolment, intervention, and maintenance stages of treatment. The pathway will help researchers and practitioners better understand engagement-related concepts whilst encouraging greater conceptual consistency between studies.

Parent Recommendations to Enhance Enrollment in Multidisciplinary Clinical Care for Pediatric Weight Management

OBJECTIVE

To explore parents' recommendations to enhance enrollment in multidisciplinary clinical care for managing pediatric obesity.

STUDY DESIGN

Data for this interpretative description study were collected through individual, semistructured interviews that were audiorecorded, transcribed verbatim, and analyzed thematically. Parents (n = 79) were recruited from 4 multidisciplinary weight management clinics in Canada located in Edmonton, Hamilton, Montreal, and Vancouver.

RESULTS

Most interviewed parents had children with obesity (body mass index ≥95th percentile; 84.2%), were female (87.3%), had postsecondary education (69.6%), and were white (75.9%). Parents' recommendations referred to enrollment opportunities, information about obesity services, motivation for treatment, and accessibility to obesity services. Specifically, parents recommended to increase referral options and follow-up contacts with families during the enrollment process, inform referring physicians and families about the availability and characteristics of obesity services, enhance families' motivation for treatment, prevent families from getting discouraged, make services more appealing to families, and address accessibility issues (eg, offering multiple options for appointment times, providing support for transportation).

CONCLUSIONS

Parents' recommendations support the need for family-centered approaches to enhance enrollment; however, their feasibility, acceptability, and effectiveness remain to be tested empirically.

Strategies to Recruit a Diverse Low-Income Population to Child Weight Management Programs From Primary Care Practices

Purpose and Objectives

Primary care practices can be used to engage children and families in weight management programs. The Texas Childhood Obesity Research Demonstration (TX CORD) study targeted patients at 12 primary care practices in diverse and low-income areas of Houston, Texas, and Austin, Texas for recruitment to a trial of weight management programs. This article describes recruitment strategies developed to benefit both families and health care practices and the modification of electronic health records (EHRs) to reflect recruitment outcomes.

Intervention Approach

To facilitate family participation, materials and programs were provided in English and Spanish, and programs were conducted in convenient locations. To support health care practices, EHRs and print materials were provided to facilitate obesity recognition, screening, and study referral. We provided brief training for providers and their office staffs that covered screening patients for obesity, empathetic communication, obesity billing coding, and use of counseling materials.

Evaluation Methods

We collected EHR data from 2012 through 2014, including demographics, weight, and height, for all patients aged 2 to 12 years who were seen in the 12 provider practices during the study’s recruitment phase. The data of patients with a body mass index (BMI) at or above the 85th percentile were compared with the same data for patients who were referred to the study and patients who enrolled in the study. We also examined reasons that patients referred to the study declined to participate.

Results

Overall, 26% of 7,845 patients with a BMI at or above the 85th percentile were referred to the study, and 27% of referred patients enrolled. Enrollment among patients with a BMI at or above the 85th percentile was associated with being Hispanic and with more severe obesity than with patients of other races/ethnicities or less severe obesity, respectively. Among families of children aged 2 to 5 years who were referred, 20% enrolled, compared with 30% of families of older children (>5 y to 12 y). Referral rates varied widely among the 12 primary care practices, and referral rates were not associated with EHR modifications.

Implications for Public Health

Engagement and recruitment strategies for enrolling families in primary care practice in weight management programs should be strengthened. Further study of factors associated with referral and enrollment, better systems for EHR tools, and data on provider and office adherence to study protocols should be examined. EHRs can track referral and enrollment to capture outcomes of recruitment efforts.

Access to primary care child weight management programs: Urban parent barriers and facilitators to participation

The prevalence and comorbidities of childhood obesity among low-income urban children are a significant health issue in the United States. Programs designed to assist families are underutilized. The aim of this study is to describe barriers and facilitators relevant to intervention program participation from the perspective of parents who have children who are overweight or obese. Systematic thematic analysis of focus groups and semi-structured interviews with parents from multiple urban pediatrics and family medicine practices were used to gather data. A framework analysis approach was used and a codebook of themes was developed. Transcripts were coded independently by the research team and consensus among researchers was reached. Forty-eight parents participated in the study. Perceived barriers to participation included (1) varied referral process (lack of follow-up or varying referral experience), (2) costs (time and program fee), (3) logistics (location and program schedule), and (4) child motivation. Perceived facilitators to participation included (1) systematic referral process (in-office referral and timely follow-up), (2) program content and organization, and (3) no cost. Multiple barriers and facilitators affect weight management program participation among families, which should be specifically targeted in future obesity interventions in order to effectively reach urban, minority parents and children.

The Team to Address Bariatric Care in Canadian Children (Team ABC3): Team Grant Research Proposal

BACKGROUND

Severe obesity (SO) in Canadian children remains poorly understood. However, based on international data, the prevalence of SO appears to be increasing and is associated with a number of psychosocial, bio-mechanical, and cardiometabolic health risks. The purpose of our national Team to Address Bariatric Care in Canadian Children (Team ABC3) is to develop and lead a series of inter-related studies to enhance the understanding and management of SO in Canadian children and adolescents (0-18 years).

METHODS/DESIGN

From 2015 to 2019, Team ABC3 will conduct a series of projects at the regional, provincial, and national levels using multiple methods and study designs to respond to key knowledge gaps by (i) generating evidence on the prevalence of SO and its impact on health services utilization in children using existing Canadian data sources from primary care settings, (ii) exploring contemporary definitions of SO that link with health outcomes, (iii) comparing and contrasting health risks across the continuum of SO, (iv) understanding potential barriers to and facilitators of treatment success in children with SO, and (v) examining innovative lifestyle and behavioral interventions designed to successfully manage SO in children and their families. Furthermore, to examine the impact of innovative interventions on the management SO, we will (vi) evaluate whether adding a health coach, who provides support via text, email, and/or phone, improves children's ability to adhere to a web-based weight management program and (vii) test the feasibility and impact of a community-based weight management program for pre-school children with SO and their parents that combines group-based parenting sessions with in-home visits.

DISCUSSION

Our research aligns with national priorities in obesity research, brings together leading scientists, clinicians, and stakeholders from across Canada, and will inform health services delivery throughout the country to provide the best care possible for children with SO and their families.

Following Suit: Using Conversation Cards for Priority Setting in Pediatric Weight Management

OBJECTIVE

To describe families' selections of Conversation Cards (CCs), a priority-setting tool in pediatric weight management, and examine CC-related differences based on families' anthropometric and sociodemographic characteristics.

METHODS

A retrospective medical record review was conducted of 2- to 17-year-olds with obesity and their families who enrolled in a pediatric weight management clinic between January, 2012 and September, 2016.

RESULTS

Medical records of 146 children were included. On average, families selected 10 ± 6 CCs (range, 3-32 CCs); only 50% of families (n = 73) indicated perceived readiness to make healthy changes. Adolescents (vs children) revealed less healthy eating behaviors (P = .001) and physical activity habits (P = .002). Goal setting was perceived to be a motivator across several sociodemographic characteristics (all P < .05).

CONCLUSIONS AND IMPLICATIONS

The CCs were useful in describing families' priorities. The diversity of issues identified by families highlighted the importance of multidisciplinary expertise in pediatric weight management.

Barriers and facilitators to initial and continued attendance at community-based lifestyle programmes among families of overweight and obese children: a systematic review

The success of childhood weight management programmes relies on family engagement. While attendance offers many benefits including the support to make positive lifestyle changes, the majority of families referred to treatment decline. Moreover, for those who do attend, benefits are often compromised by high programme attrition. This systematic review investigated factors influencing attendance at community-based lifestyle programmes among families of overweight or obese children. A narrative synthesis approach was used to allow for the inclusion of quantitative, qualitative and mixed-method study designs. Thirteen studies met the inclusion criteria. Results suggest that parents provided the impetus for programme initiation, and this was driven largely by a concern for their child's psychological health and wellbeing. More often than not, children went along without any real reason or interest in attending. Over the course of the programme, however, children's positive social experiences such as having fun and making friends fostered the desire to continue. The stigma surrounding excess weight and the denial of the issue amongst some parents presented barriers to enrolment and warrant further study. This study provides practical recommendations to guide future policy makers, programme delivery teams and researchers in developing strategies to boost recruitment and minimise attrition.

Role of Health Coaches in Pediatric Weight Management

This study aims to describe patients' and families' perspectives regarding the ideal role and responsibilities of a health coach to facilitate pediatric weight management in the primary care setting. Systematic thematic analysis of semistructured interviews with overweight children and their parents was performed. The majority of participants self-identified as racial/ethnic minorities and were Medicaid eligible. Desired health coaching elements included ( a) customized support and encouragement, including goal setting and maintenance, cultural sensitivity, and consideration of budget and lifestyle; ( b) nutritional guidance, including meal planning, assistance obtaining healthy food, and education and counseling; and ( c) linkage to resources, including social services, physical activity support, and programs for children with special health care needs. We conclude that families' specific needs should be holistically considered in the design of health coaching programs targeting pediatric obesity. Such support may help overcome social and financial barriers to changing health behaviors related to weight management.

Facilitators and Barriers to the Achievement of Healthy Lifestyle Goals: Qualitative Findings From Australian Parents Enrolled in the PEACH Child Weight Management Program

OBJECTIVES

To describe the qualitative research methods used in the Parenting Eating and Activity for Child Health (PEACH) randomized controlled trial and to examine parent-reported facilitators and barriers to the achievement of program goals.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Parents enrolled in the Australian PEACH randomized controlled trial, a family-focused child weight management program conducted blinded for review.

PARTICIPANTS

A total of 95 parents of overweight children aged 5-10 years participated in face-to-face semistructured interviews.

PHENOMENON OF INTEREST

Factors external to the PEACH intervention that facilitated or inhibited their success.

ANALYSIS

Interviews were recorded, transcribed, and analyzed using thematic analysis techniques.

RESULTS

Three facilitator themes were identified: (1) internal locus of parental control, (2) external locus of parental control, and (3) child factors. Six barrier themes were identified: (1) internal locus of parental control, (2) external locus of parental control, and (3) child factors; (4) maintenance and managing special occasions; (5) time management challenges; and (6) inconsistencies or lack of support.

CONCLUSIONS AND IMPLICATIONS

The social and environmental barriers and time pressures identified by parents are a common feature of Western family life such that many parents are raising families in stressful situations. Insights provided by this qualitative research provide an important understanding of these experiences. Consideration of such issues in the design and implementation of future child weight management interventions may help to increase the acceptability and effectiveness of such programs.

Recommendations From Parents to Improve Health Services for Managing Pediatric Obesity in Canada

OBJECTIVE

Although parents are uniquely positioned to offer first-hand insights that can be used to improve health services for managing pediatric obesity, their perspective is underexplored. Our objective was to characterize parents' recommendations for enhancing tertiary-level health services for managing pediatric obesity in Canada.

METHODS

Semistructured, one-on-one interviews were conducted with parents of children who initiated treatment at 1 of 4 Canadian tertiary-level, multidisciplinary weight management clinics. Parent perspectives were elicited regarding the strengths and weaknesses of the health services they received as well as areas for potential improvement. Interviews were audio-recorded and transcribed verbatim. We used qualitative description as the methodological framework and manifest content analysis as the analytical strategy.

RESULTS

Parents (n = 65; 88% female; 72% Caucasian; 74% with at least some postsecondary education; 52% >$50,000 CDN household income) provided a range of recommendations that were organized according to health care: 1) accessibility, 2) content, and 3) delivery. The most common recommendations included increasing scheduling options (44%; n = 29), tailoring services to families' needs and circumstances (29%; n = 19), placing greater emphasis on physical activity (29%; n = 19), altering program duration (29%; n = 19), incorporating interactive elements (25%; n = 16), information provision (25%; n = 16), and providing services at sites closer to participants' homes (24%; n = 15).

CONCLUSIONS

Parents' recommendations to enhance health services for managing pediatric obesity concerned modifiable factors related to accessibility, content, and delivery of care. Further research is needed to evaluate whether implementing suggested recommendations improves clinically relevant outcomes including attrition, quality of care, and success in weight management.

Design programmes to maximise participant engagement: a predictive study of programme and participant characteristics associated with engagement in paediatric weight management

BACKGROUND

Approximately 50% of paediatric weight management (WM) programme attendees do not complete their respective programmes. High attrition rates compromise both programme effectiveness and cost-efficiency. Past research has examined pre-intervention participant characteristics associated with programme (non-)completion, however study samples are often small and not representative of multiple demographics. Moreover, the association between programme characteristics and participant engagement is not well known. This study examined participant and programme characteristics associated with engagement in a large, government funded, paediatric WM programme. Engagement was defined as the family's level of participation in the WM programme.

METHODS

Secondary data analysis of 2948 participants (Age: 10.44 ± 2.80 years, BMI: 25.99 ± 5.79 kg/m(2), Standardised BMI [BMI SDS]: 2.48 ± 0.87 units, White Ethnicity: 70.52%) was undertaken. Participants attended a MoreLife programme (nationwide WM provider) between 2009 and 2014. Participants were classified into one of five engagement groups: Initiators, Late Dropouts, Low- or High- Sporadic Attenders, or Completers. Five binary multivariable logistic regression models were performed to identify participant (n = 11) and programmatic (n = 6) characteristics associated with an engagement group. Programme completion was classified as ≥70% attendance.

RESULTS

Programme characteristics were stronger predictors of programme engagement than participant characteristics; particularly small group size, winter/autumn delivery periods and earlier programme years (proxy for scalability). Conversely, participant characteristics were weak predictors of programme engagement. Predictors varied between engagement groups (e.g. Completers, Initiators, Sporadic Attenders). 47.1% of participants completed the MoreLife programme (mean attendance: 59.4 ± 26.7%, mean BMI SDS change: -0.15 ± 0.22 units), and 21% of those who signed onto the programme did not attend a session.

CONCLUSIONS

As WM services scale up, the efficacy and fidelity of programmes may be reduced due to increased demand and lower financial resource. Further, limiting WM programme groups to no more than 20 participants could result in greater engagement. Baseline participant characteristics are poor and inconsistent predictors of programme engagement. Thus, future research should evaluate participant motives, expectations, and barriers to attending a WM programme to enhance our understanding of participant WM engagement. Finally, we suggest that session-by-session attendance is recorded as a minimum requirement to improve reporting transparency and enhance external validity of study findings.

Addressing Pediatric Obesity in Ambulatory Care: Where Are We and Where Are We Going?

Since the "2007 summary report of child and adolescent overweight and obesity treatment" published by Barlow, many obesity intervention studies have been conducted in pediatric ambulatory care. Although several meta-analyses have been published in the interim, many studies were excluded because of the focus and criteria of these meta-analyses. Therefore, the primary goal of this article was to identify randomized case-control trials conducted in the primary care setting and to report on treatment approaches, challenges, and successes. We have developed four themes for our discussion and provide a brief summary of our findings. Finally, we identified major gaps and potential solutions and describe several urgent key action items.

Factors Associated with Attendance after Referral to a Pediatric Weight Management Program

OBJECTIVE

To evaluate factors affecting attendance or nonattendance at an initial interprofessional pediatric weight management visit after referral. We hypothesized that increased severity of obesity, farther distance from the program, lower education level of the primary caregiver, public insurance or no insurance, and lower socioeconomic status would all decrease likelihood of attending initial visit after referral.

STUDY DESIGN

We examined referral and visit data over 4 years and 5 months. We used geocoding and multivariable logistic regression to analyze links between attendance and demographic factors, baseline body mass index, insurance type, and distance from patients' homes to the program site.

RESULTS

Over the study period, 41.2% of the 4783 children referred to the pediatric weight management clinic attended at least 1 visit. A total of 4086 children were included in the full analyses. Factors associated with attendance were female sex, higher body mass index severity class, private health insurance, residence in areas with higher median income, and residence in areas with a higher prevalence of high school completion.

CONCLUSIONS

The current project expands our understanding of factors linked to children's attendance at an initial pediatric weight management visit. Despite limitations including missing data, results have important implications for pediatric weight management clinics, referring providers, and policymakers to target populations with low attendance and optimize use of these evidence-based programs.

Why do families enrol in paediatric weight management? A parental perspective of reasons and facilitators

BACKGROUND

Few children with obesity who are referred for weight management end up enroled in treatment. Factors enabling enrolment are poorly understood. Our purpose was to explore reasons for and facilitators of enrolment in paediatric weight management from the parental perspective.

METHODS

Semi-structured interviews were conducted with parents of 10- to 17-year-olds who were referred to one of four Canadian weight management clinics and enroled in treatment. Interviews were audio-recorded and transcribed verbatim. Manifest/inductive content analysis was used to analyse the data, which included the frequency with which parents referred to reasons for and facilitators of enrolment.

RESULTS

In total, 65 parents were interviewed. Most had a child with a BMI ≥95th percentile (n = 59; 91%), were mothers (n = 55; 85%) and had completed some post-secondary education (n = 43; 66%). Reasons for enrolment were related to concerns about the child, recommended care and expected benefits. Most common reasons included weight concern, weight loss expectation, lifestyle improvement, health concern and need for external support. Facilitators concerned the referral initiator, treatment motivation and barrier control. Most common facilitators included the absence of major barriers, parental control over the decision to enrol, referring physicians stressing the need for specialized care and parents' ability to overcome enrolment challenges.

CONCLUSIONS

Healthcare providers might optimize enrolment in paediatric weight management by being proactive in referring families, discussing the advantages of the recommended care to meet treatment expectations and providing support to overcome enrolment barriers.

The Future of Pediatric Obesity

The National Health and Nutrition Examination Survey from the Centers for Disease Control and Prevention reports a steady increase in obesity over the last 30 years. The greatest increase was seen in 15 to 19 year olds, whose obesity prevalence almost doubled from 10.5% to 19.4%. The solution to pediatric obesity requires a multidisciplinary approach addressing cultural norms, technologic advances, and family engagement. Future treatment strategies to combat the obesity epidemic will have to extend beyond the health care provider's office. Behavior modification remains the key component to pediatric obesity prevention and treatment.