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RESEARCH ARTICLE Open Access
Enrolment of families with overweight children into a program aimed at reducing childhood obesity with and without a weight criterion: a natural experiment Emma Esdaile1* , Emely Hernandez1, Carly Jane Moores2 and Helen Anna Vidgen1
Abstract
Background: Difficulties engaging families with overweight children to enrol into programs aimed at reducing childhood obesity have been well documented. During the implementation of the Parenting, Eating and Activity for Child Health Program (PEACH
) over a large geographical area (Queensland (QLD), Australia), a natural experiment developed. This experiment provided an opportunity to observe if there was a difference in enrolment for families with overweight children with a weight criterion (referred to as the period with a Targeted Eligibility Criterion (TEC)) compared to when a weight criterion was removed (the period referred to as Universal Eligibility Criterion (UEC)). We also examined the eligibility criterion’s relationship with attendance, parental concern about their child’s weight, estimation of overweight and obesity from parent-reported data.
Methods: A secondary analysis of baseline data from 926 overweight/obese children from 817 families enrolled in PEACH QLD was performed. Analyses were adjusted to control for the presence of clustered data. Bivariate statistics were performed using Pearson chi-square test with the second-order Rao-Scott correction, and Mann–Whitney U-test for non-parametric continuous variables. Generalized Estimating Equations (GEE) explored the association between weight status-based eligibility criteria and enrolment of overweight children. GEE were adjusted for sex, age and socioeconomic index and stratified for weight category.
Results: Compared to obese children, overweight children were almost twice as likely to be enrolled when the program did not have weight status-based eligibility criteria (during UEC period) (OR = 1.90 (CI 95% 1.35–2.68, p < 0.001)). Parents of overweight children enrolled during the UEC period were more likely to regard their child’s weight as less of a concern than during the TEC period (UEC 67% vs. TEC 45%, p = 0.036). Children whose parent-reported data underestimated their weight category were more likely to be enrolled while the program did not have weight-related eligibility criteria OR = 2.27 (CI 1.38–3.70, p < 0.01). Program session attendance did not appear to be impacted by the changes in eligibility criteria.
Conclusions: The omission of weight criteria for healthy lifestyle programs is a consideration for health professionals and decision-makers alike when encouraging the enrolment of children who are overweight into healthy lifestyle programs.
Trial registration: ACTRN12617000315314. Retrospectively registered 28 February 2017.
Keywords: Childhood obesity, Primary school, Healthy lifestyle program, Engagement, Eligibility
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: emma.esdaile@gmail.com 1School of Exercise & Nutrition Sciences, Faculty of Health, Queensland University of Technology, Level 4, A Wing, O Block, Kelvin Grove, Brisbane, Queensland Qld 4059, Australia Full list of author information is available at the end of the article
Esdaile et al. BMC Public Health (2019) 19:756 https://doi.org/10.1186/s12889-019-6894-y
http://crossmark.crossref.org/dialog/?doi=10.1186/s12889-019-6894-y&domain=pdf
http://orcid.org/0000-0002-9166-1001
https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372258
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
mailto:emma.esdaile@gmail.com
Background Elevated obesity prevalence rates are an international phenomenon, and one in four Australian children aged 5– 17 years are overweight or obese [1]. Body Mass Index (BMI) categories of excess weight reflect the different levels of risk of chronic illness experienced by overweight and obese individuals. Obesity contributes to multiple co-morbidities in childhood and adulthood, as well as with all-cause mortality when compared to normal or over- weight status [2–5], and increases lifetime risk of develop- ing chronic disease [6]. As such, returning children to their healthy weight range is likely to have the greatest health benefits relative to the risks associated with lifelong excess weight. While childhood weight management pro- grams likely have benefits irrespective of the child’s weight status at enrolment, those who are overweight, rather than obese, are more likely to shift their weight status category into the healthy range [7], giving them the healthiest foun- dation for adulthood [8, 9]. This reinforces the importance of early identification and intervention. The Parenting, Eating and Activity for Child Health
(PEACH) Program is an evidence-based [7, 10] healthy lifestyle program that was scaled up and delivered state- wide in Queensland (a geographically large state of Australia) to parents of primary school-aged children who were above their healthy weight range. In Queensland, the prevalence of overweight in children aged 5–17 years is 19%, while the obesity prevalence is 7% [11]. Despite the higher proportion of overweight compared to obese chil- dren in the general population, the children who enrolled into PEACH Queensland (PEACH QLD) and were above a healthy weight were predominantly obese (79%) rather than overweight (21%) [10]. Other studies show dif- ficulties in recruiting families with overweight children into weight management programs in Australia; when par- ents enrol, their children tend to be disproportionately obese, rather than overweight [10, 12]. Despite these diffi- culties PEACH QLD was interested in increasing enrol- ments among children who were overweight, in order to better reflect the target population. From a public health perspective weight loss among
obese and overweight children is significant. However, the probability of returning to a healthy weight is higher [7] while avoiding the development of co-morbidities is lower [13] for children who are overweight (compared to obese) and so maximising their enrolments into healthy lifestyle programs is a key prevention strategy. Early qualitative re- search undertaken among parents who enrolled into PEACH QLD identified that parents sought out a range of other methods to act on their child’s weight before they considered enrolling into a weight management program [14], suggesting there are factors which delay enrolment as children continue to gain excess weight. Continuous quality improvement during the scaling up of PEACH
QLD (described in detail elsewhere [15]) provided the op- portunity for a retrospective natural experiment to explore whether parents of overweight children were more likely to enrol into the program when the weight status eligibil- ity criterion was removed. Our research aim was to investigate if a weight criterion
acts as a barrier to enrolment into healthy lifestyle pro- grams aimed at reducing childhood obesity. Three key themes emerge from the literature as the primary barriers for parents of overweight children not enrolling into a weight management program. These barriers include per- ceived stigma [16–18], inability of parents to recognise their child is above their healthy weight [19, 20] and par- ents not considering weight to be an immediate health issue [20, 21]. While stigma was not measured, our evalu- ation framework collected data that relates to the other identified barriers. These were the extent of agreement be- tween parent-reported and facilitator-measured anthropo- metric data and the extent to which parents were concerned about the seriousness of obesity for their child. We hypothesised that the removal of a weight criterion
would lower barriers to entry and proportionately more parents with overweight children would enrol, rather than delaying seeking external support for their child. To ex- plore this, we compared the proportion of overweight and obese children enrolled into the program before and after the removal of weight status-based eligibility criterion to be above a healthy weight. We compared factors that re- lated to identified barriers to enrolment, where data were available. We also compared enrolment and attendance before and after the weight-status eligibility criterion to observe if there was a difference in these characteristics in order to inform recruitment for future programs.
Methods PEACH Queensland The Queensland Government contracted Queensland University of Technology to deliver the PEACH Program using a license from its creators [10], this project is re- ferred to as PEACH QLD [15]. We have previously de- scribed implementation learnings [15], evaluation [22] and program outcomes [7] of PEACH QLD elsewhere. Briefly, PEACH consists of ten 90-min group-based face- to-face sessions delivered by a trained facilitator over a six-month period. The parent group sessions focus on parenting skills training to improve the healthy lifestyle behaviours (diet, physical activity and sedentary behaviour including screen time) of children [23]. Consistent with clinical practice guidelines [24], PEACH QLD focused on healthy lifestyle messages using whole-of-population mes- sages from the Australian Dietary Guidelines [25] and Australia’s Physical Activity & Sedentary Behaviour Guide- lines for…
