Practical Lessons Learned from Adolescent and Parent Experiences Immediately and 12 Months following a Family-Based Healthy Lifestyle Intervention

Abstract

Background:

Adolescence is a critical time to intervene and establish healthy long-term behaviors to decrease the impact of adult obesity in the future. The purpose of this study was to identify key intervention strategies and techniques for community interventions by analyzing the short-term and longer-term shared experiences of both adolescents with overweight or obesity and their parents involved in a community-based, healthy lifestyle intervention.

Methods:

Qualitative interviews and focus groups were conducted with teens (aged 12–16 years with a BMI above the 85th percentile) and their parents immediately following the 8-week intervention (n = 37 teens, n = 33 parents) and at 12 months follow-up (n = 23 teens, n = 20 parents). Results were analyzed thematically.

Results:

Both teens and parents reported high satisfaction with the program. Immediately following the 8-week intervention, teens reported enjoying participating in exercise with similar peers. Parents described inaccurate expectations from the program. After the 12-month follow-up, teens reported struggling with a cyclical pattern of health behaviors, and parents described a sense of loss following the intensive program and improved communication skills with their adolescent.

Conclusions:

Several practical strategies emerged for use in future community programs for adolescents with overweight or obesity. Future programs should consider management of expectations, perceptions vs. outcomes, and the cyclical nature of behavior change in adolescents. Strategies for future health behavior change interventions with overweight adolescents should address time management, translation of knowledge into behavior change, successful implementation of practical goal-setting strategies, and increasing intrinsic motivation.

Introduction

Adolescents with obesity are more likely to have obesity as adults,¹ thus interventions to treat adolescent obesity are greatly needed. While there have been several interventions using physical activity, dietary and cognitive changes,^2,3 inclusion of parents,^4,5 goal setting, and self-monitoring of progress^5–7 to decrease adolescent obesity in the short-term,⁸ long-term changes in behaviors are needed to reduce the impact of adult obesity on society.^9,10 However, little is currently known on effective long-term strategies to reduce obesity among adolescents.

Adolescence in a unique transitionary period where children gain independence, navigate changing relationships with parents, and build habits for life.¹¹ Thus, factors influencing long-term behavior change in this population may be different than those for younger children and adults. Unfortunately, there is limited evaluation of the specific issues for adolescents engaged in family-based interventions, including barriers and enablers to sustain healthy lifestyle behaviors postintervention.¹² A better understanding of these factors is critical among adolescents as they are at a high risk of dropping out of programs and interventions.^3,6,13,14

The purposes of this in-depth mixed-methods study were to identify practical strategies for practitioners implementing interventions in community settings by exploring the shared experiences of adolescents with overweight or obesity and their parents during a community-based, healthy lifestyle intervention. Importantly, experiences were explored both immediately following the 8-week intensive intervention (short-term behavior change) and 12 months following completion of the intervention (longer-term behavior change).

The current study builds on the Curtin University Activity, Food and Attitudes Program (CAFAP) that aimed to use a family-based approach to assist adolescents who are overweight or obese to help improve their health. CAFAP was recently evaluated using a multiple cohort staggered-entry, waitlist period-controlled clinical trial study design.¹⁵ Following the 8-week program, participants had modest improvements in serves of fruit (1.1 serves per day) and junk food (3.2 serves per day), increased moderate physical activity (monthly rate of change of 1.8 minutes per day), and decreased sedentary time (monthly rate of change of −5.1 minutes per day).¹⁵

Methods

Study Design

Qualitative research methods were used to obtain a greater understanding of the experiences of teens and parents¹⁶ immediately after the 8-week program and 12 months postprogram.

CAFAP was based on the self-determination theory¹⁷ and goal-setting theory,¹⁸ with the aim of enhancing intrinsic motivation for behavior change.^17–19 Theoretical underpinnings, program rationale, and results of the waitlist period-controlled clinical trial of CAFAP are reported elsewhere.^15,19–21 In short, CAFAP included an 8-week program involving twice weekly 2-hour sessions at local venues, followed by 12 months of maintenance during which participants received tapered telephone and SMS contact. The phone calls and messages were based on self-determination and goal-setting theories, semitailored in a positive tone, and included options for behaviors and testimonials from other teens. A complete description of the SMS protocol can be found elsewhere.²² At least one parent (or adult caregiver) of the adolescent (hereafter termed teen) who was primarily responsible for household food selection and physical activity support had to also attend CAFAP. The majority of regularly attending parents were mothers. Program sessions did not focus on weight, but rather covered healthy eating, increasing physical activity, reducing sedentary behavior, and goal setting, which together aimed at improving overall health through intrinsically motivated behavior change.^15,21 The complete program is available to researchers and practitioners by contacting the authors or through the website http://healthsciences.curtin.edu.au/schools-and-departments/physiotherapy-exercise-science/cafap. Ethics approval was granted by the Curtin University Human Ethics Committee (HR1095/2011)

Study Participants

Participants were recruited from the community through community newspapers, radio, health professionals, and distribution of flyers. Participants were aged from 11 to 16 years at baseline with a BMI above the 85th percentile on the Centers for Disease Control BMI-for-age growth charts²³ and recruited from two lower socioeconomic communities in the Perth metropolitan area during 2012. A total of 37 teens (n = 34 with BMI percentile ≥95th percentile) who completed the 8-week intervention were invited through flyers, e-mails, and text messages to attend a focus group or interview immediately following the program. Once a teen agreed to participate, the attending parent(s) was also invited to participate. All 37 teens agreed to participate immediately postprogram and 23 participated at 12 months postprogram. In addition, 33 parents participated immediately postprogram and 18 parents participated at 12 months postprogram.

Focus Group and Interview Content

A combination of focus group and interviews was conducted by trained facilitators and a standardized question schedule was provided as described below. Two focus groups were conducted with parents and teens together (one from each location) and all other parents and teens were interviewed individually. The number of participants completing interviews and focus groups can be seen in Table 1. All the postprogram feedback was conducted in focus groups as this mimicked the intervention session structure and the group was present for the postprogram assessment and catch-up. At 12 months postprogram, mostly interviews were conducted with the teens as assessments were conducted individually and there was limited interest from participants in attending a group session. Focus groups were conducted with parents when two or more researchers were available: one to do the individual teen assessments and one to conduct a parent focus group.

Table 1.

Teens and Parents Who Completed CAFAP Postprogram Qualitative Assessments in Two Local Communities, Number Conducted (Number of Total Participants)

		Postprogram		12 months postprogram
Sample	Data collection method	Community 1	Community 2	Community 1	Community 2
Teen (12–16 years)	Focus groups	3 (n = 21)	3 (n = 16)	—	—
	Interview	—	—	12 (n = 12)	11 (n = 11)
Parent	Focus group	3 (n = 19)	3 (n = 14)	1 (n = 3)	1 (n = 3)
	Interview	—	—	5 (n = 5)	7 (n = 7)
Total participants		n = 70		n = 41

CAFAP, Curtin University Activity, Food and Attitudes Program.

Immediately Postprogram

Teens and parents were asked to discuss what they liked about CAFAP and how it could be improved. Parents were asked a number of additional questions relating to why they participated in the program; their expectations; and how CAFAP helped their child.

12 Months Postprogram Completion

Teens and parents were asked similar questions as immediately postprogram, such as what they liked about CAFAP, with additional questions about what changes did they continue 12 months post-CAFAP; what were the barriers and enablers to change; was the postprogram support provided by the program team helpful; and any overall comments about the program.

Analysis of Qualitative Data

Discussions were audiotaped for accuracy of transcription. Audiotapes were transcribed by facilitators within 48 hours and analyzed thematically using an inductive approach. Transcripts were coded independently by three researchers (K.L.S., A.M., A.A.F.) using thematic analysis methods.²⁴ Themes were then compared between the three researchers, with discussion of inconsistencies facilitated by a fourth researcher (E.K.H.) until agreement on the themes was reached. Quotes from participants are included in Tables 2 and 3 to support findings.

Table 2.

Quotes from Teens and Parents Immediately Postprogram

	Teens	Parents
Liked about CAFAP	“The first hour of physical activity was really good.”	“I really liked the fact that [participant] wasn't made to feel, ‘Why is it me? Why am I the only fat person in the world?’ … So, it made her feel that it wasn't an impossible task. So that it actually made her feel better in that she wasn't alone.”
	“The cooking was fun.”
	“Exercising and meeting new people.”	“We've all realized that we're in the same boat, when we go home, we're all fighting the same battles. So, it's been really really good to know that we're not alone. You know, we're not the only ones who have to say no all the time and who get treated like crap back, it just makes you feel more positive about coming back each week and taking in more information. Not every week is a success, but the fact is that we're back here every week and we're still learning more and more. And that's slowly having an effect.”
		“I think it has made me and my daughter a lot closer. We're a lot more involved together doing stuff at CAFAP, and afterward too.”
		“My son has become more secure in himself. Like, he's carrying himself better. He hasn't lost weight, but he's actually becoming more confident.”
How could CAFAP be improved	“Less writing.”	“It would have been good for (participant's name) to see me getting up a sweat as well.
	“If they taught us to set goals with games, it would be fun.”	“I think they just get a bit overwhelmed with us leaning over them saying ‘what are you writing, what are you writing’ Because it's a lot about them being independent and making these choices and making their own goals.”
	“More cooking sessions.”
	“More physical activity sessions.”
Didn't like about CAFAP: “Goal setting is probably the most hated thing.”		Why you joined CAFAP: “When I saw it in the local rag I thought this is someone sending me a sign about how to help my daughter. Because I was trying.”
“I don't like cutting gym short with the goals.”		“Daughter came and approached us and said ‘Can we get onto this, can we try it?’ I recognized that my daughter had a weight problem and we wanted to support her in any way that we can.”
“Its location, too many people I know. [it would be better] at University or something. So, there's no bullies from school, they're very judgmental, and we come here not to be judged, but we are. They know what we're doing, they laugh at you and stuff.”		What kept you going to CAFAP: “The child really wanted to come.”
		“She didn't want to come the first two weeks, but now she looks forward to coming.”
Skills learned: “I think it really made us think about things that we don't normally think about. I found just reading the labels was something, I mean you know that they're there, but when you start looking at it, it makes such a huge impact on the serves and how much. I actually enjoyed all the nutritional bits.”		Expectations for CAFAP: “My immediate reaction was that it will help with weight loss. So, to be quite honest, I don't think I realized how comprehensive it was in terms of the discussions. There's nothing that could have prepared me for the stuff that I've learnt for myself, like in terms of the goal setting, I just thought I'm accompanying him, he's going to do fitness and I'm just going to be chatting as parents waiting for our kids. But, when I got here and realized ‘Wow! There's actually much more to it.’”

Table 3.

Quotes from Teens and Parents 12 Months Postprogram

	Teens	Parents
Enablers	“Mum and Dad helping.”	“It made us more aware of our lifestyle. Trying to sort of put everybody on the right track I suppose…You become more aware of what you are buying when you are shopping and all that sort of stuff.”
	“Mum doesn't buy like really bad stuff anymore.”
	“I think honestly I am just a little more confident to just go in and give it a go.”
	“Goal setting was a thing I'd never actually done before. Like never really thought it was even that useful. But, like I tried it, and like once you read over what you kind of wanted to do at the end of the year, you're just like, ‘Oh, I actually did some of that.’ It's kind of amazing how you can actually do that even though you don't even know you did it until like heaps after. Then you're like, ‘Oh wow! cool.’”	“Well, one of the biggest things is that I felt I had to be a role model for (participant's name), and this sort of taught me a lot about my behaviors and how that influences (participant's name) and her choices”
		“The fact that the mentors or the coordinators were really young and could come down to the teenagers' level was fantastic.”
Barriers	“Like it is hard when I go out with my friends and that. Like last time I went out, they all got ice creams and I didn't, so yah, it's been hard.”	“And I think because she doesn't have the reflective skills to be able to do the self-reflection. She just wants to change, but doesn't like recognize that she has the power to change. That she is still looking for someone else to do it for her.”
		“I would have liked to do a lot more, but she doesn't want to do it.”
	“I started volleyball, but I didn't have the time to do it because we have a whole lot of homework suddenly dropped on top of us.”	“I dread to think what it will be like now that there isn't going to be any contact sort of thing.”
	“I would say like if it was like my ideal program I would have the program longer. Because 8 weeks seems a long time, but it goes quite fast, and quickly, but I was more motivated when I was like, ‘Oh, I'm seeing them on Monday, or the next day.’ So, I would say longer.”
CAFAP content and support	“That doing little by little really does help a lot.”	“We don't want the focus to be actually on any weight, we want it to be on her health and well-being and her strength.”
	“There isn't one way to lose weight and that there's like better ways, or more fun ways and easier ways to maintain type of thing.”
	“I kind of think about [goals] more than I look at them. I've got the goals in my head like all the time.”	“I think what has come out of it I think is the support I have to give my teen.”
		“I think the hardest change was I think for me was for me feeling that I was a bit of a failure for allowing (participant's name) to get to where she was. So the hardest thing for me was to bring it up and, in fact, this was really good for bringing it up and finding ways to be constructive with our discussions, not destructive. Because it is that teenage age where I didn't want to disempower her, I didn't want her to feel negative about anything and I wanted it to be empowering, but it was trying to find that balance.”

Quantitative Satisfaction Survey

All participants completed an anonymous satisfaction survey immediately postprogram and 12 months postprogram and descriptive analyses were conducted. The survey consisted of 10 questions rated on a Likert scale (1: strongly disagree-low satisfaction to 5: strongly agree-high satisfaction) that related to the self-determination theory constructs of intrinsic motivation and need supportive behaviors,¹⁷ goal setting,¹⁸ and general satisfaction with the program.

Results

As the same questions were discussed in the focus groups and interviews, the results have been combined, with parent and teen results reported separately. Participant quotes are attributed generically to preserve confidentially and can be seen in Tables 2 and 3.

Immediate Postprogram Findings—Teens

Liked about CAFAP

Teens enjoyed meeting new people who had the same issues as them and liked practical aspects such as cooking and exercise. However, they did not like writing their goals down.

Did not like about CAFAP

The process of goal setting was not liked by most teens. Some found it boring, repetitive, or time-consuming. They did not want to come to a program after school where they had to sit down and write. They wanted to be active and spend time on things they enjoyed such as exercise.

How could CAFAP be improved?

There were a number of difficulties with venues. There were several complaints about the level of noise from others using the same venue that impacted on the teens' ability to hear during CAFAP sessions. There was also some concern by one group about being seen by peers who were not CAFAP participants, but were at the venue.

Reducing the time spent in goal setting was a common theme. One suggestion was that goal setting could be more fun if combined with a variety of games or exercises they could choose.

Skills learned

Learning about portion size, cooking, and reading food labels were skills that teens valued and enjoyed practicing.

Immediate Postprogram Findings—Parents

Why CAFAP and how they found out about the program

Parents found out about CAFAP from a variety of sources, including health professionals, flyers, community newspapers, school newsletters, or word of mouth. Most parents were hoping CAFAP would help their child lose weight in a supportive environment.

Expectations

Some parents did not expect to have direct involvement in CAFAP; however, most enjoyed interacting with their child and were surprised how much they learned. One of the key expectations of most parents was that their child would lose weight through regular exercise and changing their diet.

Another key expectation was that the teens would have one-on-one counseling with a psychologist on a regular basis. It was felt that a psychologist would help teens deal with underlying issues related to their overweight status and help motivate them to become healthier.

Liked about CAFAP

Most parents liked the fact that CAFAP was specifically tailored to overweight teens and their families or others who were in the same boat. Parents reported that CAFAP opened the lines of communication between themselves and teens. Parents were appreciative of not having to nag their teen to engage with CAFAP activities at home, but they were able to reinforce messages delivered within the program by a health professional. They also felt that CAFAP empowered their child to believe they could change.

All parents endorsed CAFAP and reported something positive about its effect on their teen's behavior, their own behavior, or both. The approachable and knowledgeable staff, supportive environment, and understanding of small achievable steps were also reported.

Suggestions for improvement

Most suggestions related to wanting more exercise included in the program and having more time together as teen and parent in sessions. Others thought they needed less time together, where teens could discuss content without pressure from parents.

Barriers

Time, poor weather, traffic, and having other children who were not attending the program were the main barriers to regular attendance noted by parents. There were a couple of negative comments about the program content with one parent suggesting the content was too basic and the other that it was over the child's head.

What got them there and what kept them there?

Parents reported that their primary reason for attending the program was wanting to help their child. Many found that the inclusion of family provided a supportive environment for all family members to improve their health.

12 Months Postprogram Findings—Teens

Changes that continued 12 months postprogram

When asked 12 months postprogram what changes they had made during the program that were still maintained, teens reported reducing or eliminating junk food; reading food labels; adhering to portion sizes; exercising at the gym, with others, or a personal trainer; walking the dog; reducing sedentary behavior (e.g., TV); and engaged in school or community sporting teams.

Barriers

The main barriers to maintaining healthy behaviors noted were resisting junk food and not being able to exercise (or not taking the opportunity to) on a regular basis. Junk food was difficult to avoid for some teens, particularly if they were out with their friends or at a social event. However, they were aware of eating the wrong or too much food. This self-awareness did not always translate into intrinsic motivation or strategies to maintain their healthy behaviors.

Other barriers included time constraints (e.g., school, homework, exams), going out with friends instead of exercising, lack of motivation, and too young to join a gym.

Some teens reported reverting back to their pre-CAFAP unhealthy routines when under additional pressure (e.g., examinations); however, it was common for those who did not maintain behavior changes to mention how they managed to get back on track (e.g., common cyclical behaviors).

Enablers

The teens mentioned a number of key enablers to behavior change. Although teens said they did not like goal setting immediately postprogram, this was one of the most common enablers reported. A high level of awareness regarding healthy behaviors was evident. Teens did not always maintain changes, but often brought themselves back into line. Equally strong was the reported high level of self-confidence in sourcing healthy enjoyable activities.

Support and encouragement from parents was a major theme that teens said facilitated change, helped maintain healthy behaviors, and assisted them to get back on track if they did not maintain their behavior changes.

CAFAP content and support

When asked about the main messages of CAFAP, only one teen mentioned losing weight (which was the main reason given for joining CAFAP). Teens saw the main messages as being active, healthy eating (portion sizes, food labels), and reducing sedentary behaviors.

Contact from CAFAP staff during the 12-month postprogram period had a major effect on many of the teens. Although not all comments about text messages were positive, they achieved the aim of prompting teens to reassess goals and behaviors. Phone calls from CAFAP staff were looked upon positively with many saying they enjoyed the personal contact.

Seeing other teens and CAFAP staff from the program at the assessments was a strong motivator as both a reminder and social interaction.

12 Months Postprogram Findings—Parents

Changes that continued 12 months postprogram

Parents generally noted that they were more aware of what they needed to do to support their teen's healthy lifestyle. Common changes reported within the family were more exercise particularly walking, more fruit and vegetables in their diet, eating breakfast, developing meal plans in advance, and using the skills learned during CAFAP to assist their teen (role model, intrinsically motivate, encourage).

Some parents had enrolled their teen or themselves in a gym, enlisted the aid of personal trainers, or joined another healthy lifestyle program to support their efforts.

Barriers

One of the major barriers that parents noted was the difficulty in getting their teen motivated to change. This lack of motivation seen in teens was dealt with in two main ways: either parents saw their teen as the problem with little control as the parent or they saw their role as an active participant in assisting their teen to make changes using the strategies and skills learned through CAFAP.

Two of the barriers mentioned immediately postprogram were also noted at 12 months: time and family commitments. Time was an issue for all families.

There was a sense of loss when the program finished. Some parents were particularly concerned that positive changes made during the program could be lost by no longer having the support of CAFAP staff and regular sessions with other parents and teens.

Enablers

There were a number of key enablers that parents had implemented to support their teens. Providing opportunities for their teens to engage in healthy lifestyle behaviors was commonly noted. Opportunities were considered to include both parent involvement as role models and tangible provision of goods, such as healthy foods and access to gym memberships.

Learning about nutrition was commonly noted by parents as important to facilitate change.

Other common enablers were teens joining school physical activities and support from the CAFAP team to help review goals to keep teens motivated.

CAFAP content and support

Most parents had no trouble recalling the main messages of CAFAP being healthy eating, more exercise, less sedentary behaviors, and goal setting. They mentioned the program had made a difference in their lives and that of their teens. Overall, parents felt the program improved communication with their teen, increased their motivation to be healthier, and made them more aware of the consequences of their decisions.

Support from the CAFAP team was considered an additional motivation to maintain change. There was, however, some disappointment that there was not more one-to-one counseling for teens to help them set goals, build self-confidence, and support them when they lose their way.

Satisfaction Survey Results

In addition to the qualitative interviews and focus groups with parents and teens, both teens and parents reported they were satisfied with CAFAP immediately postprogram and 12 months postprogram in the satisfaction survey. Teens' overall satisfaction was 4.2 (SD 0.8) immediately postprogram and 4.0 (SD 0.5) 12 months postprogram. Parents' overall satisfaction was 4.0 (SD 0.9) immediately postprogram and 4.1 (SD 0.4) 12 months postprogram. The individual items and scores can be seen in Table 4.

Table 4.

Satisfaction of Teens and Parents with CAFAP Immediately Post the 8-Week Intervention and 12 Months of Maintenance

	Teens (SD)		Parents (SD)
Survey item	Post	12 months	Post	12 months
CAFAP covered areas relevant to my needs	4.2 (0.8)	4.0 (0.6)	4.0 (1.0)	4.1 (0.6)
I learned valuable new skills and knowledge	4.3 (0.9)	4.2 (0.6)	4.0 (1.1)	4.1 (0.6)
I received enough individualized help or attention	4.1 (0.9)	4.0 (0.6)	3.7 (1.1)	3.8 (0.8)
I had confidence in the facilitators' knowledge and skills	4.3 (1.0)	4.2 (0.7)	4.2 (1.1)	4.5 (0.6)
I can now deal more effectively with my (my child's) physical activity, sedentary, and healthy eating behaviors	4.2 (0.9)	3.9 (0.9)	3.9 (1.0)	3.8 (0.7)
I am now able to deal more effectively with my (my child's) weight	3.9 (1.0)	3.9 (0.7)	3.6 (0.8)	3.7 (0.7)
I am sure about how to continue to work on my goals	4.1 (0.9)	3.9 (0.7)	3.7 (1.0)	3.9 (0.4)
I feel confident to apply what I learned in my daily life	4.2 (0.8)	3.9 (0.7)	4.1 (0.8)	4.1 (0.5)
I would recommend CAFAP to a friend with similar problems	4.4 (0.9)	3.8 (0.9)	4.5 (1.1)	4.4 (0.6)
Overall, I was completely satisfied with CAFAP	4.3 (1.0)	4.1 (0.7)	4.3 (1.0)	4.2 (0.7)

1: strongly agree, 2: disagree, 3: neutral, 4: agree, 5: strongly agree.

SD, standard deviation.

Discussion

This mixed-methods study identified unique and similar barriers and enablers for teens and parents, discrepancies between perceptions and measured behavioral outcomes, and application of the theoretical framework for teens and parents participating in CAFAP.

Teen and Parent Perceptions

Both teens and parents described positive experiences with CAFAP and an increase in knowledge about healthy behaviors. Consistent with program messages, both teens and parents positively reiterated that CAFAP was about healthy behaviors and not just losing weight. As enablers for participation in CAFAP, teens discussed the social aspect, while parents overwhelmingly reported continuing CAFAP because their teen enjoyed it. It has been reported that children and adolescents enjoy the socialization²⁵ and participate because they find activities fun and enjoyable.⁵ Little is known on parents' motivation for enrolling and supporting their children's participation in a healthy behavior change intervention.²⁶

Managing Expectations

Following participation in CAFAP, many parents reported that they had not expected to be as involved in the program as they were. Program facilitators described some difficulties with parent engagement in early sessions, potentially because the parents were not prepared to be actively involved. Furthermore, parents may not have been ready to address feelings of responsibility and guilt that are common in parents of adolescents with obesity.²⁷ In the current study, CAFAP parents described enjoying the time spent with their teen in a supportive environment once they understood their role and knew how to better support their teen's goals.

Perceptions vs. Outcomes

The majority of teens and parents reported that they had made positive behavioral changes. At 1-year postprogram, both parents and teens reported maintenance of some positive changes. However, these reports of positive changes were not consistent with measured outcomes of objective measures of physical activity, nutrition, and body composition. Only small improvements were seen, including an increase in fruit consumption and reduction in junk food (−1.6 serves per day, range −9.5, 6.9), sedentary time, and body composition, not all of which were maintained for 12 months.¹⁵ There were large interindividual variations in changes from pre to post 8-week intervention. For example, the mean change in MVPA was 5.2 minutes per day, but ranged between −14.8 minutes per day to 27.7 minutes per day, and the mean change in serves of junk food per day was −1.7, but ranged from −14.8 to 27.7. Similarly, the mean change in BMI was 0.2 kg/m² and not statistically significant; however, the range between individuals was −3.4 to 3.1. Some teens described an increased knowledge of healthy behaviors, but were unable to translate the knowledge into changes in behaviors. Additionally, both parents and teens described difficulty in maintaining behaviors once the intensive program finished. This knowledge-to-behavior gap is consistent with previous research.²⁸ However, while knowledge acquisition did not lead to immediate changes in behaviors, it is possible that the teens may apply these skills as independent young adults, but longer follow-up is needed to detect any long-term changes.

Theoretical Constructs—Goal Setting

Almost all teens mentioned their dislike for goal setting immediately following program completion. Goal setting was described as difficult and opposed due to taking time away from other enjoyable activities in the program. Yet, at 12 months postprogram, many reported using goal-setting strategies. There were a number of difficulties associated with teaching the goal-setting process, which required extra time in the sessions to address. Often multiple facilitators needed to be involved to give parents and teens sufficient support. While reviews and meta-analyses have reviewed the effectiveness of goal setting,^29,30 no studies have reported on the practicality and participant burden of regular goal setting.

Theoretical Constructs—Motivation

Both teens and parents cited a lack of motivation as a barrier to behavior change, which is consistent with previous studies.³¹ CAFAP was based on the self-determination theory and aimed to increase teens' intrinsic motivation for healthy behaviors and parents' intrinsic motivation to support these behaviors.¹⁹ Several teens discussed the extrinsic causes of behavior change, such as CAFAP staff reminders. In contrast, teens who reported maintaining behavior change cited intrinsic motivations, such as enjoyment of healthy lifestyle behaviors. Parents were also divided when describing motivation underlying support of teens' behavior changes. Overall, parents appreciated that CAFAP lessened the need to extrinsically motivate or nag teens, yet some parents blamed the teens for lack of success, while others saw it as their role to help teens make changes using what they learned in CAFAP. The latter of these was consistent with the aims of the intervention.

Strengths and Limitations

A major strength of the study was the collection of both teen and parent perspectives who both participated in a family-based program. This strategy provided greater insight into how parents could effectively support their teen to uptake a healthier lifestyle. Only half of the CAFAP participants were involved in the 12-month postassessment. The interviews and surveys were anonymous; therefore, we were unable to analyze the responses by individual characteristics such as age. Results therefore cannot be generalized to the whole group. Additionally, a small number of focus groups were conducted with the parents and teens together, which may have influenced their responses. However, the structure of the intervention sessions was focused on teens expressing opinions and parents supporting teens. Anecdotally, the researchers conducting these groups perceived limited biases and the themes were consistent between groups conducted both separately and with parents and teens mixed.

Practical Implications

This study guides future health behavior change interventions with overweight teens to explore strategies to address time management, translating knowledge into behavior change, successful implementation of practical goal-setting strategies, and increasing intrinsic motivation. Based on these in-depth analyses of teen and parent experiences of CAFAP, there are several practical implications for future interventions and community programs. When designing interventions, we recommend that future programs focus on healthy behaviors and not weight as this was positively received by teens and parents, and teen enjoyment was important for both teen and parent involvement. When selecting a theoretical framework and strategies, it is important to balance the time costs and benefits of regular goal-setting practices. If complex behavior change strategies are used (such as goal setting for adolescents), adequate time during the intervention must be allocated to build participant capacity to successfully engage in these strategies. It is also critical to consider the length of time and amount of support needed to meaningfully change theoretical constructs, such as developing intrinsic motivation. Eight weeks of in-person contact may not be sufficient to change motivation and behaviors among teens. During recruitment for a family-based program, the parent role should be clearly explained to parents, with an opportunity for program staff to check with parents to assess their understanding of their role from the outset.

In the assessment of programs, it is essential to use objective measures of targeted outcomes as teen and parent perceptions may not be a true reflection of behavior change.

Conclusions

This study provides insights into the barriers and enablers to sustained behavior change in teens from both teens' and parents' perspectives, immediately post and 12 months postprogram completion. While CAFAP was based on best practice evidence and the participants were highly satisfied with the overall program, there were minimal sustained behavior changes. Thus, future interventions among adolescents with overweight and obesity may need to explore alternatives and enhancements to traditional, short-term community-based programs. This may include longer durations of personal and peer contact through interactive technology to support face-to-face contact and more involved roles for parents and families, such as exercising together and additional skill building in navigating barriers.

Footnotes

Acknowledgments

The authors would like to thank the adolescents and parents who participated in CAFAP; the CAFAP facilitators and the research staff; and Curtin University colleagues. This trial was funded by a Healthway Health Promotion Research Project Grant #19938. Professor Leon Straker was supported by a National Health and Medical Research Council senior research fellowship #APP1019980.

Author Disclosure Statement

No competing financial interests exist.

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