Developing health messages: Qualitative studies with children, parents, and teachers help identify communications opportunities for healthful lifestyles and the prevention of obesity
Childhood overweight is at an all-time high in the United States. In an effort to better understand children's, parents', and teachers' attitudes, perceptions, and behaviors about preventing overweight in childhood and to explore potential avenues for communicating overweight prevention messages, we conducted qualitative research with these three groups in 2000. Our research consisted of three progressive phases, each building on information obtained from the previous phase: Phase 1, 16 focus groups (N = 112); Phase 2, in-home observations, in-depth interviews, and diaries (N = 6 families); Phase 3, 10 qualitative interview sessions (N = 46). Both parents and children indicated that encouragement and ″small victories” to sustain involvement in getting more fit were critical to success. The findings also suggest that children need direct messages to motivate them to change their exercise and eating habits, as well as tips on cooperating with their parents to achieve fitness goals. Parents need to learn how to talk about eating and exercise habits with their children in positive and encouraging ways and to learn how to help their children maintain efforts to get fit. Teachers consider it essential that parents support healthful lifestyles at home. Parents and children need positive, realistic approaches to getting fit, such as answers to questions about healthful lifestyles; ideas for physical games and activities the family can enjoy together; attainable goals and small steps to healthful eating; healthful meal, snack, and recipe suggestions; incentive ideas for getting kids active; and referral services for local support groups. Parents and children need to work together in addressing the overweight prevention issue and need effective tools to facilitate this cooperative effort. J Am Diet Assoc. 2003;103:721-728.
Section snippets
Overview of plan components and participants
The qualitative research described here consisted of three phases, with the results of each phase serving as the foundation for the next (see Figure 2). Open-ended questions were presented to gauge reactions to and attitudes about a variety of issues related to childhood overweight. The methodology for all three phases was designed to be exploratory and directional in nature, using a nonrandom sample of consumers.
Specifically, our research assessed issues children view as most relevant and
Methods
Separate focus groups composed of children, parents, or teachers examined eating and activity habits of preteen children and the influences on their behavior, attitudes and perceptions related to healthful lifestyles and overweight, and perceived barriers to maintaining a healthful weight.
Sixteen focus groups (N = 112) were conducted in January and February 2000 in Chicago, IL, and Baltimore, MD: 8 groups of children, 6 groups of parents, and 2 groups of teachers. The children were divided into
Methods
Using findings from Phase 1, an in-depth observational study of children perceived to be above ″normal” weight for their age was undertaken to more fully understand eating, activity, and lifestyle behaviors and to gain insight into the most credible communications and messages to deliver healthful lifestyle information to families.
The research included in-home observations, interviews, and food-activity diaries of six families (two families per city), from April 24 to May 2, 2000, in Atlanta,
Methods
Utilizing the previous research, a series of concepts were created and presented to participants to determine how to best target and develop messages. The research focused on two aspects: understanding which concepts audiences preferred so that healthful lifestyle messages would be relevant to and motivational for ″unfit” children and their parents, and eliciting initial reactions to strategies under consideration for a communications and education project aimed at preventing overweight among
Discussion
The results from all three phases of our research suggest parent/child cooperation is essential to address physical activity and nutrition concerns. Children appear to lack the parental guidance, role models, and emotional support they desire to help them prevent overweight. Program elements and delivery strategies should incorporate the concepts ″Need attainable goals” and ″Self-esteem” to maximize reach and impact. Self-esteem issues could be used to motivate children to improve eating and
Limitations and recommendations
Due to the qualitative nature of our studies, results cannot be generalized to the general population. However, qualitative research is useful because it provides an in-depth view of attitudes and perceptions, as well as possible solutions. In future studies, it will be useful to develop a survey tool to assess the strength and distribution of the attitudes and perceptions related to overweight and healthful weight using statistically valid quantitative techniques. Other socioeconomic and
In previous studies conducted by the author's team, parents of children with overweight and obesity reported in focus groups and surveys that checking for weight-related health problems was the single most important thing a pediatrician could do to help their children improve their weight.3,16 Thus, past studies have supported the hypothesis that increasing pediatrician communication about a child's unhealthy weight and risk for or presence of obesity comorbidities would be expected to increase parental motivation to make behavioral changes.10,33,34 The present findings build on past work, showing that a clinician's attention to high BMI in combination with medical risk is associated with significant improvement in children's relative weight.
This study uses clinical practice data to determine whether recommended weight management clinician behaviors are associated with weight status improvement in children aged 6–12 years who are overweight or obese.
Electronic health record data (2009–2014) from 52 clinics were used. Weight status was examined from 1 visit to the next as dichotomous improvement (versus worsening or no change) and change in percentage overweight (over sex/age-specific BMI95). The primary predictor was a clinician behavior variable denoting attention to high BMI alone or with assessment of medical risk/comorbidities and was defined using combinations of diagnostic codes and electronic health record orders. Covariates included time between visits and medications associated with weight gain or loss. Adjusted multilevel regression models examined the association of the clinician behavior variable with weight status improvement. Analyses were conducted from 2015 to 2018.
Children (n=7,205) had a mean age of 8.9 years; 45.5% were overweight, 54.5% obese, and 81.1% publicly insured. For 62% of overweight children, and 38%, 21%, and 11% of those in obesity classes 1–3, respectively, no attention to high BMI/medical risk assessment at any visit was identified. Children with evidence of clinician attention to high BMI alone and who underwent a medical risk assessment had significantly greater AOR of improvement in percentage of BMI95 and percentage of BMI95 change: BMI alone, AOR=1.2 (p<0.001) and β= −0.3 (p>0.05); BMI/medical risk, AOR=1.2 and β= −0.5 (both p<0.001). Other factors associated with weight status improvement included prescription medications (1 or more prescriptions associated with either weight loss or none associated with weight gain) and fewer months between visits.
This is the first study to use electronic health record data to demonstrate that widely recommended clinician behaviors are associated with weight status improvement in children aged 6–12 years who are overweight or obese.
However, while effort is put into informing parents of their children's weight status and attempting to initiate treatment with obese children, there is little holistic understanding of how parents should communicate with their children once they themselves are aware that their child's weight is a concern. Many parents worry that raising the issue of weight and engaging their child in weight-management activities risks harming their child's physical self-perceptions, wellbeing and could trigger eating disorders (Young et al., 2008; Park et al., 2014; Gillison et al., 2014; Syrad et al., 2014; Taylor et al., 2013; Statham et al., 2011; Pocock et al., 2010; Borra et al., 2003; Falconer et al., 2014). That is, the negative impact of tackling weight on a child's wellbeing, or simply raising their child's awareness of their weight, is perceived to be more of a threat to their health than their being overweight.
Many parents express concern that raising the issue of weight risks harming their child's physical self-perceptions and wellbeing. Such concerns can deter families from engaging with weight management services. This systematic review aimed to investigate the evidence behind these concerns by analysing the association between parent-child weight-talk and child wellbeing. A systematic search of eight databases identified four intervention studies and 38 associative studies. Meta-analysis was only possible for the associative studies; to facilitate more meaningful comparisons, weight-talk was categorized into four communication types and effect size estimates for the association between these and wellbeing indicators were calculated through a random effects model. Encouraging children to lose weight and criticizing weight were associated with poorer physical self-perceptions and greater dieting and dysfunctional eating (effect sizes: 0.20 to 0.47). Conversely, parental encouragement of healthy lifestyles without explicit reference to weight was associated with better wellbeing, but this was only measured in two studies. Of the four intervention studies, only one isolated the effects of parents' communication on wellbeing outcomes, reporting a positive effect. There was no effect of age on the strength of associations, but dysfunctional eating was more strongly associated with parent communication for girls than boys. The findings indicate that some forms of parent-child weight-talk are associated with poor wellbeing, but suggest that this is not inevitable. Encouraging healthy behaviours without reference to weight-control, and positive parental involvement in acknowledging and addressing weight-concern may avoid such outcomes. More longitudinal research is needed to analyse the direction of these effects.
