Introduction

Childhood obesity has short and long-term consequences for physical and mental health [1, 2]. It is recognised by the World Health Organisation as one of the most serious public health challenges of the 21st century [3]. Despite more than a decade of policy attention, a high prevalence of childhood obesity persists in the UK [4]. For those children who are overweight, behavioural lifestyle interventions can result in clinically meaningful reductions in overweight in children and adolescents, compared to standard care or self-help [5,6,7].

In England, the National Institute for Health and Care Excellence (NICE) recommends that tailored clinical interventions should be considered for children with a body mass index (BMI) at or above the 91st centile [5,6,7,8]. Public Health teams, situated within local government, typically commission these services. Over 300 of these services are likely to be running in England [9]. NICE guidance does not specify who should identify and refer eligible children into provided services and these practices may vary.

Many eligible children do not benefit from existing services. This is partly due to attrition, where a child enters but does not complete a programme, reported to be between 27 and 90% [10]. However, many eligible children may not be referred to appropriate services, or may be referred but never initiate treatment. While there is a growing literature on attrition, research into barriers to referral to, and initiation of, childhood obesity treatment remains scant [11].

This qualitative study explores the challenge surrounding low referral and uptake rates into a community child weight management programme despite comparatively high retention, completion and service satisfaction of participants. The study objectives were to (a) describe current referral practices and pathways into the programme, (b) identify potential reasons for low uptake, and (c) make recommendations to improve service referral.

Main text

Methods

Intervention

The intervention “Eat Well Move More” (EWMM) combines healthy eating and cooking education with physical activity sessions. Three service offers exist: a school programme (4–16 years), community programme (7–11 years) and one-to-one sessions (12–16 years). The intervention was developed in Solihull, England using Public Health Outcome Framework guidance, and principles of behaviour change [12, 13]. Children may be referred to EWMM by general practitioners (GPs), school nurses, family support workers, paediatricians, or self-referral via the National Childhood Measurement Programme (NCMP). NCMP measures height and weight of school children in England. A letter is sent to families indicating the child’s weight status based on BMI [14]. Information on EWMM and healthy lifestyles is provided with the letter, and parents can self-refer into EWMM on this basis. EWMM allows rolling admissions, so families do not have to wait to join. It is free for referred children.

Data collection

Qualitative, semi-structured interviews and focus groups (FGs) were conducted with GPs and school nurses from November 2015 to March 2016, by two female researchers with previous interview experience and no previous relationship with participants (RJ/WR). Topic guides included questions about referral into EWMM and invited responses on any other aspect of EWMM. Interviews and FGs were audio recorded, and were an average length of 10 min per interview and 30 min per FG.

Purposive sampling was used to request participation. All GP practices within Solihull (N = 36) were contacted first by telephone, second by email if listed and third by fax. Targeted calls to practices where GPs were known to refer into EWMM were completed as a second wave of recruitment. Personalised emails from a Public Health Consultant were completed as a third wave of recruitment. Face-to-face or telephone interviews were offered to GPs to suit their schedules.

School nurses were recruited via email and telephone with all local area school nurse leads (N = 2); a request was sent to attend school nurse monthly meetings. FGs were conducted at school nurses’ monthly meetings to maximise the range of views collected. Nurses attended from schools in deprived and affluent areas of the community to reflect socio-economic disparity in the prevalence of child obesity [15, 16].

Data analysis

Data were transcribed verbatim and anonymised. Each dataset was analysed using a thematic analysis approach [17]. RJ coded all data initially and these codes were cross-checked and discussed with WR to ensure fit. Data were organised in NVivo [18]. Data were analysed deductively. Interviews and FG transcripts underwent initial and then axial coding. Categories were identified and themes emerged through an iterative process of refining and expanding emerging concepts and issues related to the research questions.

Results

Interviews and FGs completed or attempted are described in Table 1.

Table 1 Participant groups and numbers of evaluation participants
Full size table

Two FGs were conducted with School Nurses and Nursing assistants and four GPs completed interviews. Findings are detailed below.

School nurses’ views

Most school nurses described an awareness of EWMM, yet only three had made referrals into EWMM. Barriers to pupils being successfully referred to the EWMM programme emerged from school nurses’ experiences which are reflected in three themes (1) parent engagement; (2) children’s autonomy; (3) NCMP letter (Box 1).

Parent engagement

School nurses discussed how parents acted as barriers and facilitators to EWMM referrals. Nurses described scenarios where children sought out the school nurse to address their weight, ending with parent contact for permission to refer the child into EWMM. The referral would not then be made because the parent declined the referral. No further action would be taken on behalf of the child. Direct quotes reflect some of the issues Nurses expressed relating to this scenario (Box 1).

Child autonomy

Most school nurses shared that children presenting issues appeared highly motivated to make changes regarding their weight, but expressed concerns as to how to instigate and maintain changes within their family dynamic. Children’s right to make decisions about their own bodies was identified as an important inconsistency. Namely between a child’s right to challenge their parent’s refusal of receiving the human papilloma virus (HPV) vaccine (used as an example in one FG), versus their lack of right to challenge a weight referral.

The National Childhood Measurement Programme

School nurses recognised the importance of the NCMP, but expressed concern over negativity surrounding its implementation. They discussed how the NCMP could make conversations with parents difficult suggesting it acts as a barrier to optimal communication between parents, children and school nurses. Second, nurses reported that NCMP data were not optimally utilised locally. Nurses discussed the data currently ‘standing alone’ and that contextualising NCMP data locally could be used as a facilitator for engaging school nurses in ongoing referral-based services.

Closing the feedback loop

School nurses consistently expressed a need for feedback from EWMM. Nurses described how feedback might improve their knowledge of EWMM and what other children and parents can expect, which could increase the likelihood of parental engagement.

GPs views

Knowledge of childhood obesity and EWMM

Two GPs interviewed had not referred into EWMM recently but all were aware of its predecessor programmes (Box 2). GPs expressed the importance of services such as EWMM feeding back whether a referral was taken up and if that service was completed (echoing school nurses).

GPs suggested how they would like to receive information about EWMM that would increase the chance of referral into the service:

  • A visual prompt in the GP office such as a chart or characterisations of body shapes.

  • More frequent face-to-face information sessions at their practice to keep them up-to-date with what services are available.

  • Receipt of flyers and posters to put on practice notice boards or electronic screens in practices.

  • Regular follow up and feedback on patient attendance, completion, drop out and outcomes.

Talking about child weight

Two GPs did not see addressing obesity as a problem and felt that parents were generally receptive when child overweight was raised. The other GPs interviewed described a hesitance to have this ‘difficult conversation’ with parents and children. GPs offered approaches for addressing children’s weight which included both parent-focused and child-focused ‘tactics’. GPs felt this was a distinctly different conversation than one had with adults and they needed to do it “carefully and subtly” (Box 2).

Synthesis of findings

This study has identified two factors contributing to lower than expected referral rates into a community child weight management intervention, EWMM. First, a lack of knowledge exchange and feedback between service providers and referrers. Second, a resistance among health professionals to address child weight with parents and children, which we refer to as ‘the difficult conversation’.

The taboo of overweight (considered here as an avoidance of weight terminology and reluctance to engage individuals in conversations about weight) was observed in both school nurses and GPs. This is not a new or surprising finding given a recent emphasis on personal responsibility for weight management or the cultural politics regarding children’s weight [19,20,21,22,23]. Discussing overweight remains an issue fraught with emotional, psychological and physical risks, as well as benefits [24, 25].

For two GPs in this study, the taboo of discussing a child’s weight related to the hesitancy to have the difficult conversation between parents, health professionals, and children. Similarly, school nurses found that broaching the subject of obesity with parents was challenging and that they faced backlash from parents as a consequence. This difficult conversation has been identified in other populations as a barrier to referrals into weight management services [26,27,28,29].

Our study reflects a small set of health professionals’ views on the continued challenge of raising the issue of children’s weight, as well as how to manage that conversation between parents, children and health professionals [30,31,32,33]. Interventions which promote conversations between health professionals, children and families have shown some success [34,35,36,37]; suggesting improved confidence and skills among health professionals. However the most effective and sustainable interventions remain unclear [38]. A key insight from our conversation with school nurses suggested that children’s voice and autonomy merits greater consideration in approaches to accessing weight management among children and adolescents, particularly when their parents may hold different views to addressing their weight. This finding has been expressed elsewhere as important, illustrating a next step in maximising uptake of effective weight management interventions for children [32, 34, 38].

Conclusion

Our study identified a complicated network of practice-level communication and feedback challenges and facilitators for a community-based child weight management intervention. This study contributes to evidence that low intervention uptake may be related to health professionals’ hesitancy to have difficult conversations with children and families.

Recommendations for practice and research

Future research could identify the extent to which health professionals report ‘the difficult conversation’ as a barrier to referral into child weight management services, and develop related training and communication strategies if warranted. Examining optimal training and communication strategies between families and health professionals that are more inclusive of children’s voice and autonomy also seems warranted.

Limitations

This study was conducted among a small purposive sample of participants associated with a specific weight management service. It may not be applicable to services addressing child weight where intervention components or referral pathways differ substantially. Very few GPs responded to requests to discuss this topic, despite multiple attempts to contact them. This means data saturation may not have been reached and made it difficult to gauge the extent to which identified barriers are commonly perceived among the wider GP population in Solihull, and the UK.