Early childhood (1-5 years) obesity prevention: A systematic review of family-based multicomponent behavioral interventions

INTRODUCTION

Globally 38.9 million children under age 5 have overweight or obesity, leading to type 2 diabetes, cardiovascular complications, depression, and poor educational outcomes. Obesity is difficult to reverse and lifestyle behaviors (healthy or unhealthy) can persist from 1.5 years of age. Targeting caregivers to help address modifiable behaviors may offer a viable solution.

OBJECTIVE

Evaluate the impact of multicomponent family interventions on weight-based outcomes in early childhood and explore related secondary behavior outcomes.

METHODS

Four databases were searched (1/2017-6/2022) for randomized controlled trials (RCTs) of obesity-prevention interventions for children (1-5 years). Eligible studies included an objectively measured weight-based outcome, family interventions targeting the caregiver or family, and interventions including at least two behavioral components of nutrition, physical activity, or sleep.

RESULTS

Eleven interventions were identified consisting of four delivery modes: self-guided (n = 3), face-to-face group instruction (n = 3), face-to-face home visits (n = 2), and multiple levels of influence (n = 3). The reviewed studies reported almost no significant effects on child weight-based outcomes. Only two studies (one was an underpowered pilot study) resulted in significant positive child weight-management outcomes. Seven of the interventions significantly improved children's dietary intake.

CONCLUSION

Except for one, the reviewed studies reported that family based interventions had no significant effects on child weight-based outcomes. Future studies of this type should include measurements of age and sex-based body mass index (BMI) and trajectories, and also examine other important benefits to the children and families.

Stakeholder perspectives of family interventions for schizophrenia in Indonesia: a qualitative study

Mental illnesses comprise the single largest source of health-related economic burden globally and low-and middle-income countries (LMICs) are disproportionately affected. Many individuals with schizophrenia do not receive evidence-based, psychosocial interventions as these are largely unavailable, undeveloped, and under-researched in LMICs. Involving service-users and carers in the design of interventions is crucial to ensure stakeholder needs are adequately addressed by the intervention and to aid successful implementation. We aimed to explore the views and perspectives of different stakeholder groups about the delivery, format, and content of family interventions for people living with schizophrenia in Indonesia as a first step towards developing evidence-based, acceptable family interventions. This study used a qualitative design comprising single stakeholder focus groups. Data were analysed separately using the framework approach incorporating deductive and inductive coding within an existing heuristic framework. 51 participants consented to take part in this study comprising six stakeholder consultation groups including service-users (n = 15), caregivers (n = 15) and healthcare professionals (n = 21). Service users were diagnosed with schizophrenia. Caregivers comprised parents (n = 10, 67%), brothers (n = 2, 13%), sister (n = 1, 7%) and husbands (n = 2, 13%). Healthcare professionals were working as nurses (n = 6, 29%), doctors (n = 5, 23%) or cadre's (n = 10, 48%). Caregiver and service-user respondents had limited knowledge or experience of structured family interventions. There was strong support for such interventions, however, for effective delivery a number of challenges exist in terms of widespread stigmatised views, low expectations for involvement in sharing decisions about care and treatment, views that healthcare professionals are expert and have the authority to delegate tasks to families such as responsibility for ensuring medication adherence and understanding the need to balance the needs of both service-users and families when there are conflicting agendas for treatment. These findings can support the development of evidence-based family interventions for families of those with schizophrenia in Indonesia, as user-informed interventions enhance engagement, satisfaction, and adherence to family interventions.

[Current evidence for various inpatient psychotherapy programs in the treatment of psychoses-A narrative review article]

BACKGROUND

The analysis of the efficacy of evidence-based psychotherapy for patients with psychotic disorders has mostly been carried out in the outpatient field. In the inpatient field the efficacy is sometimes difficult to assess due to different healthcare systems.

OBJECTIVE

The aim of this narrative review is to summarize international guidelines and meta-analyses on the efficacy of inpatient psychotherapeutic treatment strategies for patients with psychotic disorders. Based on this, recommendations for disorder-specific ward concepts for acute and postacute fields are formulated.

METHODS

The German S3 guidelines, international guidelines, current meta-analyses and primary studies on psychological interventions in the treatment of psychotic disorders were included. Based on the results, recommendations for the inpatient psychotherapeutic treatment in various phases of treatment were formulated (acute phase and postacute phase).

RESULTS

In the acute phase a combination of cognitive behavioral therapy (CBTp) in the individual setting and family interventions in the group setting as well as metacognitive training (MCT acute) is effective and recommended. In the postacute phase, in addition to individual and group CBTp and family interventions, psychoeducation, social skills training and cognitive remediation have been shown to be effective and are recommended.

DISCUSSION

The suggested recommendations for concrete interventions in various treatment phases and the evidence base are critically discussed and recommendations for the structure of wards are presented.

Barriers and facilitators when implementing family involvement for persons with psychotic disorders in community mental health centres - a nested qualitative study

Background

The uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders.

Methods

We performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis.

Results

Organisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals.

Conclusions

Implementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families.

Trial registration

ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08489-y.

Family interventions for adults living with type 2 diabetes mellitus: A qualitative meta-synthesis

OBJECTIVE

Review and synthesize qualitative research on family interventions for adults living with type 2 diabetes.

METHODS

A qualitative metasynthesis was conducted. Analysis used imported concepts from realist evaluation - context, mechanisms, and outcomes.

RESULTS

Six studies met inclusion criteria in this qualitative systematic review. Powerful mechanisms were identified that occur outside the family intervention in the context of ethnic, racialized, and geographically defined groups. Many similarities were noted across contexts, such as low income. Mechanisms of interventions focused primarily on family member education. Outcomes were focused more on improving self-care behaviors, rather than family-oriented outcomes.

CONCLUSION

Systemic issues affecting social determinants of health set the context for family interventions for type 2 diabetes. When designing these interventions, intersectionality, scarcity, and family functioning may need to be considered.

PRACTICE IMPLICATIONS

Emphasis on education of family members may not be effective in improving diabetes outcomes, as many powerful mechanisms exist outside of these interventions.

"Ask Parents What They Want to Do" - Mothers Seeking Help with Parenting and Their Perspectives on Barriers and Potential Enablers for Help with Smoking Cessation: A Qualitative Study

PURPOSE

To describe parents' perceptions of opportunities and barriers to smoking cessation in early parenting and the support needed to achieve this.

DESIGN AND METHODS

A qualitative approach, using semi-structured interviews with mothers, and inductive thematic analysis.

RESULTS

Barriers to cessation intervention included readiness to quit, lack of knowledge, and the shame and stigma of seeking help. Mothers' perceived opportunities for support from early parenting services included approaches to effecting change, leveraging opportunities to explore smoking cessation, and tailoring interventions to family strengths, with a focus on promoting attachment.

CONCLUSIONS

Mothers may be struggling with parenting, but are also open to opportunities to explore smoking behaviours and intervention. Nurses and other health care professionals working in this setting may be well situated to support parents with their decisions to consider smoking cessation and avoid smoking relapse.

PRACTICE IMPLICATIONS

The findings can assist nurses and other early parenting service clinicians to consider their approach to parents who continue to smoke or are at risk of smoking relapse.

The New Patterns study: coordinated measures to combat child poverty

Background

Child poverty rates are rising in Norway with potential negative consequences for children. Services for families with low income are often fragmented and poorly integrated, and few coordinated initiatives have been implemented and evaluated in Norway.

Aims:

The aim of the current study is to evaluate how integrated and coordinated services provided over a prolonged period by a family coordinator are related to changes across a wide range of health, wellbeing and home environment indicators for the participants.

Methods:

The study uses a mixed methods approach utilising survey and register data, as well as information from interviews and shadowing, to document and evaluate outcomes associated with the intervention and the process of implementation. Data are gathered at baseline and annually throughout the duration of the study. Participants are identified to facilitate longer-term follow-up using register data.

Conclusions:

This project will develop important knowledge about the implementation of coordinated services to families with a low income, and how this way of organizing services influences important outcomes for the family members in the short and long term.

Reconnecting Homeless Adolescents and Their Families: Correlates of Participation in a Family Intervention

Behavioral family interventions are an effective way to intervene to prevent negative developmental outcomes for adolescents. Participation in family interventions encompasses behavioral and cognitive/attitudinal dimensions, among others, indicated by retention and engagement, respectively. Two dimensions of participation, retention and engagement, in a family intervention were examined in a sample of newly homeless adolescents and their parents or guardians. Correlates of participation included parents with more income and less perceived family conflict and adolescents with higher endorsement of depression, anxiety, somatization, obsessive-compulsive, phobic, and psychotic symptoms on the Brief Symptom Inventory (BSI). Stronger therapeutic alliance was correlated with being more distressed (i.e., lower income, more hostility), being a female adolescent participant, and having greater comfort discussing sex with parents. Furthermore, parents and adolescents with greater distress and thus greater need were more apt to finish the intervention. The finding that families who were experiencing more distress had higher alliance scores suggests that there is an additional need for development of interventions for families in crisis. Both participant and provider perceptions are also important in development of a strong therapeutic alliance. This study's findings have implications for further exploration of the development of cultural humility and improving mental health literacy among facilitators of behavioral interventions.

Behavioral Science and the Prevention of Adolescent Substance Abuse

This article reviews the evidence regarding behavioral science approaches to the prevention of substance use disorders. Prevention science grew out of research on family and school-based interventions that were designed to treat common behavioral problems of children and adolescents. That research showed that the amelioration of problems such as aggressive behavior could prevent the development of later problems including substance use, depression, and academic failure. We begin by reviewing evidence regarding the risk factors that contribute to the development of substance use disorders, as well as the protective factors that can reduce their likelihood. We then describe a variety of family, school, and community prevention programs that have been shown to prevent youthful use and abuse of substances. We conclude by describing the progress that has been made in getting these programs widely and effectively implemented, and the challenges we face in getting to the point where most communities are achieving considerable success in prevent substance use and the other common and costly behavioral and psychological problems of children and adolescents.

The Views of Mental Health Manager Towards the Use of a Family Work Model for Psychosis in Guangzhou, China

Family Interventions in Psychosis (FIP) have been promoted internationally but have been criticised for being based on western cultural models. This paper reports on a focus group study with 10 Integrated Mental Health Service Managers in Guangzhou, China using thematic analysis. Managers believed FIP might benefit families but identified potential difficulties due to (a) families avoiding services due to the 'shame' of mental illness (b) unrealistic expectations of services amongst families (c) deferral to 'key decision-makers' within families when discussing family issues with workers. The findings indicate that FIP work should focus on interaction between carers in the first instance with service users being introduced into sessions at a later date and that more attention needs to be given by the research community to how FIP may be adapted to cultural norms within China.

The forgotten parent: Fathers' representation in family interventions to prevent childhood obesity

Despite recognition that parents are critical stakeholders in childhood obesity prevention, obesity research has overwhelmingly focused on mothers. In a recent review, fathers represented only 17% of parent participants in >600 observational studies on parenting and childhood obesity. The current study examined the representation of fathers in family interventions to prevent childhood obesity and characteristics of interventions that include fathers compared with those that only include mothers. Eligible studies included family-based interventions for childhood obesity prevention published between 2008 and 2015 identified in a recent systematic review. Data on intervention characteristics were extracted from the original review. Using a standardized coding scheme, these data were augmented with new data on the number of participating fathers/male caregivers and mothers/female caregivers. Out of 85 eligible interventions, 31 (37%) included mothers and fathers, 29 (34%) included only mothers, 1 (1%) included only fathers, and 24 (28%) did not provide information on parent gender. Of the interventions that included fathers, half included 10 or fewer fathers. Across all interventions, fathers represented a mere 6% of parent participants. Father inclusion was more common in interventions targeting families with elementary school-aged children (6-10 years) and those grounded in Ecological Systems Theory, and was less common in interventions focused on very young children (0-1 years) or the prenatal period and those targeting the sleep environment. This study emphasizes the lack of fathers in childhood obesity interventions and highlights a particular need to recruit and engage fathers of young children in prevention efforts.

Guilt, shame and expressed emotion in carers of people with long-term mental health difficulties: A systematic review

Expressed emotion (EE) is a global index of familial emotional climate, whose primary components are emotional over-involvement (EOI) and critical comments (CC)/hostility. There is a strong theoretical rationale for hypothesising that carers' guilt and shame may be differentially associated with their EOI and CC/hostility respectively. This systematic review investigates the magnitude of these theorised associations in carers of people with long-term mental health difficulties. Electronic searches (conducted in May 2016 across Medline, CINAHL, Embase, PsycINFO and ProQuest) were supplemented with iterative hand searches. Ten papers, reporting data from eight studies, were included. Risk of bias was assessed using a standardised checklist. Relevant data were extracted and synthesised narratively. EOI was positively associated with both guilt and shame, whereas CC/hostility was positively associated with shame. The strength of associations varied depending on whether or not guilt and shame were assessed within the context of the caring relationship. Based on these data, an argument can be made for the refinement, development and evaluation of systemic and individual interventions designed to target carers' guilt and shame. However, more research is needed to clarify the strength of these associations and their direction of effect before firm conclusions can be drawn.

Brief Family-Based Intervention for Substance Abusing Adolescents

Research has shown that a lack of parental involvement in their children's activities predicts initiation and escalation of substance use. Parental monitoring and supervision, parent-child communication including communication regarding beliefs and disapproval of substance use, positive parenting, and family management strategies, have been shown to protect against adolescent substance abuse and related problems. Family and parenting approaches to preventing and intervening on adolescent substance abuse have received support in the literature. This article discusses the theoretical foundations as well as the application of the Family Check-up, a brief, family-based intervention for adolescent substance use.

Meaning of psychoses as perceived by patients, their relatives and clinicians

Making sense of psychoses supports insight and personal recovery. Relatives' and clinicians' different perspectives on psychoses might impede such processes e.g., in family interventions. This study compares the meaning of psychosis as perceived by patients, their relatives and clinicians and investigates factors associated with discrepancies between them. Meaning of psychosis was assessed in 70 interrelated patients, relatives and clinicians with the SUSE-questionnaire. Severity of disorder, therapeutic relationship and other clinical variables were analysed in patient groups with deviant SUSE-ratings compared to their relative or clinician respectively. The majority of patient-relative- and patient-clinician-dyads made equal ratings of meaning of psychosis. Relatives and clinicians tended to have a less optimistic view on long-term-effects than patients. Discrepancy in ratings between patients and relatives was best explained by the family relationship (i.e. not being a parent) and between patients and clinicians by the severity of positive symptoms. Strong consensus was found among patients, relatives and clinicians about a relatively positive, meaningful picture of psychosis. Sufficient opportunities to discuss experiences and understanding of psychosis help to make sense of it consensually. If clinicians' attitudes towards psychosis are negatively biased by symptomatology, they will struggle to see and support personal recovery.

Comparisons of HIV-Affected and Non-HIV-Affected Families Over Time

This study compares HIV-affected families and their non-HIV-affected neighbors' behavioral health outcomes and family conflict. To compare two groups from the same neighborhoods at four points over 18 months, mothers with HIV (MLH) (N=167) and their school-age children (age 6 to 20) were recruited from clinical care settings in Los Angeles, CA and neighborhood control mothers (NCM) without HIV (N=204) were recruited from modal neighborhoods. In addition, children living at home who were 12 years and older were recruited. We assessed parenting behaviors, family conflict, mental health, sexual behavior, substance use, and HIV-related health behaviors over time. MLH perceived greater economic insecurity at baseline, less employment, and involvement in romantic relationships. MLH reported more emotional distress and substance use than NCM. MLH, however, reported lowered HIV transmission risk. The random regressions indicated that MLH exhibited higher levels and became significantly less depressed and less anxious over time than their non-HIV-affected neighbors. MLH also reported less initial family violence and conflict reasoning than NCM; violence decreased and conflict increased over time for MLH relative to NCM. Children of MLH decreased their marijuana use but hard drug users of MLH increased their risk, over time, compared to children of NCM. Moreover, children of MLH reported more internalizing behaviors than children of NCM. Even when compared to other families living in the same economically disadvantaged communities, MLH and their children continue to face challenges surrounding family conflict, and key behavioral health outcomes, especially with respect to substance use and mental health outcomes. These families, however, show much resilience and MLH report lowered levels of HIV transmission risk, their children report no greater levels of HIV transmission risk and levels of family violence were lower than reported by families in the same neighborhoods.

Family interventions in schizophrenia: Issues of relevance for Asian countries

A growing body of research evidence has confirmed the efficacy of family-interventions as adjuncts to antipsychotics for the treatment of schizophrenia. Much of the recent evidence for such interventions derives from Asian, principally Chinese, studies. These trials have shown that relatively simple forms of family-interventions have wide ranging benefits, and can be implemented successfully in routine clinical settings. With the accumulation of this evidence in their favour, family-interventions for schizophrenia in Asia are poised to take the next critical step, that of wider implementation and improved accessibility for potential users. However, several issues merit consideration. Family-interventions need to be based on a culturally-informed theory, which incorporates cultural variables of relevance in these countries. While the ideal format for conducting family-interventions is still to be determined, it is quite evident that for such interventions to be useful they need to be simple, inexpensive, needs-based, and tailored to suit the socio-cultural realities of mental health systems in Asian countries. The evidence also suggests that delivery by non-specialist personnel is the best way to ensure that such services reach those who stand to benefit most from these treatments. However, there are several existing challenges to the process of dissemination of family-interventions. The major challenges include the achievement of a critical mass of trained professionals capable of delivering these interventions, and finding innovative solutions to make family-interventions more acceptable to families. If these hurdles are overcome, we could look forward to a genuine collaboration with families, who have always been the mainstay of care for the mentally ill in Asia.