Communication of children’s weight status to parents and children: What is effective and what are the children’s and parents’ experiences and preferences? A mixed methods systematic review
Systematic review
|Published
This review explores the most effective way to notify parents and children about their weight as well as their preferences for and experiences with weight notification.
Key message
Early intervention and conversation about a child’s weight may offer a greater chance of success in reducing weight and implementing a healthier lifestyle. This review explores the most effective way to notify parents and children about their weight as well as their preferences for and experiences with weight notification.
Studies of effect found that the format of feedback made little or no difference in parents attending further treatment, recognising their child as overweight or obese, reactions to the way the weight notification is given, motivation for lifestyle change, understanding how to reduce the risk of overweight, or taking any action. However, parents receiving feedback with motivational interviewing have somewhat greater satisfaction with the way the healthcare worker supports them.
Qualitative studies found that parents had clear preferences for the format, timing, content and amount of information they wanted to receive in relation to both the weighing process and weight notification. They also had clear preferences for how they wanted health care providers to interact and communicate with them and their children. Both parents and children often felt that they were not receiving enough information and worried about how their results would be kept private. Many parents experienced an emotional response when told about their child’s weight ranging from positive, disbelief and negative feelings. Those who reacted with disbelief or negatively were less likely to accept their child’s weight status and/or act upon the notification letter.
These qualitative results show that it is important that those working with weight assessment and notification programs take parents’ preferences into account when developing feedback formats, consider the mode of feedback they use and provide parents and children with tailored feedback and personalized follow up once a child is identified as underweight, overweight or obese.
Summary
Background
Childhood overweight/obesity is a serious threat to public health. Globally, the number of obese children and adolescents is ten times higher than 40 years ago, with accelerating trends particularly in low- and middle-income countries. Weight monitoring and notification is an integral part of early childhood and adolescent care. Early intervention and conversation about a child’s weight may offer a greater chance of success in reducing weight and implementing a healthier lifestyle. The Norwegian Directorate of Health commissioned this review to contribute to a guidelines process on routine weight screening and notification programs for children under the age of 18.
Objective
The first research objective was to assess the effect of different communication methods and information strategies delivered by health personnel to inform about weight status as compared to usual care or relative to another method/strategy. The second research objective was to explore parents’ and children’s preferences for and experiences with communication and information about weight issues as part of routine weight screening and notification programs.
Method
We conducted a mixed methods systematic review. We searched nine databases in October 2018. Two researchers screened all references from the searches, assessed the methodological quality of eligible studies, extracted data from the included studies, analysed the effect data (effect studies) and conducted a best fit framework synthesis on the qualitative data (qualitative studies). We also brought the data from both study types together using a best fit framework approach. We assessed our confidence in the findings using GRADE (effect studies) and GRADE-CERQual (qualitative studies).
Results
In total, we included four studies about effect and 23 studies about experiences with communication and information strategies to inform parents and/or the child about routine weight screening results.
Studies of effect
We included four studies of effect presented in nine publications comparing; (1) two different formats of face-to-face feedback of weight-screening results, (2) additional resources or follow up adjunct written feedback letters, (3) three different formats of written feedback letters.
We found that, parents receiving feedback with motivational interviewing, compared to “traffic lights”, probably have little or no difference in attendance of further treatment sessions; recognition of their child’s overweight or obesity; reaction (being upset) about the way information is given; motivation for lifestyle change. These parents have somewhat greater satisfaction with the way the healthcare worker supports them in the motivational interviewing condition. Parents receiving feedback letters and additional resources, compared to just standard feedback letters probably have little or no difference in perceiving they get information/resources that help them understand their child’s weight status or help to reduce the risk of overweight (for both findings we had moderate confidence). Finally, parents receiving different formats (phrasing) of written weight-screening feedback letters probably have little or no difference in taking any action or in their child’s subsequent body mass index (BMI) (for all of these findings we had moderate confidence in the estimate of effect).
Studies of experience and expectations
We included 25 qualitative references from 23 studies. Twelve of the studies looked at information received from elementary/middle schools or preschools, eleven at face-to-face communication with health care providers in primary health care centres and one explored parental preferences regarding communication and information. Parents were participants in twenty-one studies, ten year olds in two studies and children/adolescents in three studies.
We found that some parents felt that there was a lack of up to date information about when weighing was happening, the weighing process and the weight notifications. Children also wanted more information about these topics. Parents wanted more information about how to interpret the screening results and felt they were lacking knowledge on this. Health care providers were a trusted source of information about a child’s weight and could influence parental motivation to address weight issues. Parents wanted health care workers to intervene early, initiate conversations and tailor the weighing and communication process to each child (moderate confidence in the evidence).
Many parents approved of receiving a letter delivered by mail to inform of screening results but were concerned about the privacy and confidentiality of the weighing and notification process. Parents had clear preferences for the format, content, presentation, literacy level and tone of the weight notification letters they received, many feeling that the letter lacked necessary information. They also had clear preference for the terminology used in the letters and during face-to-face interactions as these could communicate respect or judgement (moderate confidence).
Some parents expected and accepted the results of the BMI letter and were not surprised. However, the majority of parents did not accept the results of the BMI letter not considering their child overweight. Many parents participated in an ‘othering’ process when receiving feedback about their child’s weight, contributing to the dismissal of overweight feedback they received, helping to define and separate them from the ‘other’ parents whom they perceived needed to be the target of obesity prevention (moderate confidence).
Many parents had an emotional response to being informed at all about their child’s weight, the person informing them about their child’s weight and their child’s actual weight. In some cases, parents said that receiving the letter had been a cue to action, other parents ignored, downplayed or dismissed the letters and took no action and a few parents said the letter had no impact as they had already implemented changes in their household before receiving it (moderate confidence). Many parents felt they lacked knowledge about how to communicate to their children about their weight or changing habits, causing distress, fear and frustration (high confidence).
Discussion
Our findings identified a number of areas that weight assessment and notification programs should take into consideration when planning and implementing BMI notification programs including; reflecting on the timing of information regarding the weighing process and notification about weight status, the format in which it is communicated, the content of the information and the way in which it is presented as well as information on how to interpret the results, the way in which face-to-face communication about weight is undertaken and support to parents about how to communicate with their children about their weight status and implementing changes within the family related to diet and exercise.
The findings, show that future effect studies could look at the impact of the timing of the information to parents, information availability, the amount of information stakeholders would like to receive as well as issues related to barriers to addressing weight issues in schools and feelings of self-efficacy. In general, studies could be carried out in a wider variety of geographic contexts. More studies are needed to explore the perceptions and experiences of children and youth regarding weight screening and notification as well as how to effectively communicate with and inform them. None of the included studies looked at outcomes or experiences related to underweight children.
Conclusion
In conclusion, studies of effect found that the format of feedback probably made little or no difference in parents attending further treatment, recognising their child as overweight or obese, reactions to the way the weight notification is given, motivation for lifestyle change, understanding how to reduce the risk of overweight, or taking any action. However, parents receiving feedback with motivational interviewing had somewhat greater satisfaction with the way the healthcare worker supports them. Qualitative studies found that parents had clear preferences for the format, timing, content and amount of information they wanted to receive. They also had clear preferences for how they wanted health care providers to communicate with them and their children. Both parents and children often felt that they were not receiving enough information and worried about how their results would be kept private. Many parents experienced an emotional response when told about their child’s weight. Those who reacted with disbelief or negatively were less likely to accept their child’s weight status and/or act upon the notification letter.
These qualitative results show that it is important that people working with weight assessment and notification programs consider parents’ preferences when developing feedback formats, considering the mode of feedback they are going to use and provide parents and children with tailored feedback and personalized follow up once a child is identified as underweight, overweight or obese.
