Acceptability of Hospital-Based Pediatric Weight Management Services among Patients and Families: A Narrative Synthesis

Abstract

High rates of attrition from pediatric weight management services are well documented in the literature; however, studies reporting on acceptability of “real-world” services have not previously been reviewed. This narrative synthesis aimed to summarize quantitative and qualitative research reporting on satisfaction of families who attended a secondary or tertiary pediatric weight management service. Electronic databases were searched for studies of family and/or patient satisfaction with hospital-based pediatric weight management services. Included articles were scored on their methodological quality. Searches returned 4509 articles of which 17 were eligible. Education, practical strategies to assist behavior change and the approach of staff were reported as the most valued service aspects. Practical, organizational, and service content issues were reported as the primary reasons for poor engagement or discontinuation of treatment. The majority of recommendations for service improvement related to service content, with the following subthemes: program content, delivery of the weight management intervention, individualized treatment, and treatment expectations. Potential strategies for reducing attrition and improving consumer satisfaction include assessment of families' readiness to change at the outset of treatment and implementation of treatment non-negotiables. Development of a standardized measure of patient satisfaction for use in pediatric weight management service development, evaluation, and comparison is recommended.

Introduction

Childhood obesity is a significant public health concern internationally. Family-based lifestyle interventions incorporating behavior modification around eating and activity are effective and considered first-line treatment for pediatric obesity,^1–3 especially in younger children.⁴ The longer the intervention duration and the greater the intensity of the intervention, the more likely patients will have better weight outcomes.^5–7 Depending on the degree of severity, children and adolescents with obesity may be managed in a primary, secondary, or tertiary level health care setting. In this context, primary-level care refers to a patient's first contact within the health system, not including hospital services, and secondary-level care refers to specialist services in either a hospital or nonhospital setting who do not have first contact with a patient (e.g., pediatrician).^8,9 Tertiary services are considered highly specialized services for patients referred from a secondary care clinician.^8,9

High rates of attrition from pediatric weight management programs have been well documented in a previous systematic review by Skelton et al.¹⁰ and more recently by Kelleher et al.,¹¹ with up to 75% of patients and their families who enroll in treatment programs discontinuing treatment before completing the intervention. When patients discontinue treatment, their weight status and comorbidities may worsen, placing them at further increased risk of adverse physical and emotional health consequences.¹² Previous reviews regarding attrition from hospital- and community-based pediatric weight management services and pediatric weight management clinical trials have found that practical issues such as transport, scheduling conflicts, and changes in family circumstances were frequently cited by families as reasons for discontinuing treatment.^10,11,13 Studies exploring families' experiences of pediatric weight management services have also found that mismatched clinician and consumer expectations of treatment, impacts on school attendance, treatment costs, communication issues between clinicians and families, parenting challenges, and the age and “life experience” of clinicians contribute to poor engagement in treatment and attrition.^12,14–20

A key consideration in addressing poor engagement and attrition in health services is consumers' satisfaction with, and acceptability of, the service they are attending. Consideration of consumers' feedback on a health care service has the potential to improve the quality of care, accessibility, and outcomes of the health service with benefits extending to the health system, health professionals, and consumers themselves.^21,22

Although previous reviews of studies regarding consumer satisfaction and attrition in pediatric weight management exist,^10,11,13,23 these reviews have considered settings such as primary-level services and weight management clinical trials as well as studies focused on prevention of obesity. Papers reporting on the acceptability of secondary- and tertiary-level “real-world” services (i.e., established weight management services as opposed to research settings) have not previously been reviewed systematically. This narrative synthesis aimed to summarize quantitative, qualitative, and mixed-methods research reporting on satisfaction of parents/carers and patients up to 18 years of age who have attended a secondary or tertiary pediatric weight management service. In addition, authors aimed to ascertain barriers to continued engagement in weight management services and examine what measures of patient satisfaction have been utilized in recent literature. The results from this study will provide recommendations for present and future pediatric weight management services from both a clinical and a service evaluation and development perspective.

Methods

The methods for this narrative synthesis were guided by recommendations given in Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.²⁴

Literature Search

Systematic searches of Medline through OvidSP; PsychINFO through OvidSP; CINAHL through Ebsco; AMED through OvidSP; and Embase through OvidSP were conducted in November 2018 for English-language studies of family and/or patient satisfaction with pediatric weight management services. Search terms included (child* OR adolescen* OR paediatric OR pediatric); (weight management OR obes* OR overweight; treat* OR program* OR clinic OR service); (view* OR evaluat* OR experience* OR satisf* OR perspective* OR feedback); (parent* OR famil* OR carer*). The full search strategy is presented in Supplementary Table S1.

Study Selection

Studies were included if they reported on the experiences of patients aged ≤18 years and/or their family who attended an established secondary- or tertiary-level pediatric weight management service for treatment of obesity. Studies were excluded if they reported on the experiences of (1) patients over the age of 18 and/or their families; (2) participants receiving treatment as part of a pediatric weight management clinical trial; (3) patients receiving an intervention aimed at preventing, not treating, overweight or obesity; (4) patients who were referred to a pediatric weight management service but did not attend; or (5) patients receiving treatment as part of a primary-level service.

After removal of duplicates, all titles and abstracts were screened by two reviewers (C.M. and M.G.). Disagreements were resolved by a third reviewer (R.N.). Full text papers were retrieved for all records that appeared to meet all inclusion criteria and screened for eligibility by C.M. and M.G., with conflicts resolved by a third reviewer (R.N.).

Data Extraction and Synthesis

Qualitative and quantitative data were extracted by two reviewers (C.M. and R.N., respectively) and checked by a third reviewer (M.G.). Extraction was completed using a data extraction table developed by the authors based on other mixed-methods systematic reviews undertaken in the field of obesity.^25,26 Extracted data included details about each study's interventions, populations, study methods, and outcomes as relevant to the aims of the review. Qualitative research findings were pooled by examining results from each of the qualitative papers and categorizing them based on similarity of meaning. These categories were then synthesized to generate a set of themes.

Quantitative and qualitative data were synthesized using triangulation, that is, quantitative and qualitative data sets were analyzed separately and compared to consider whether findings from each method agreed (convergence), offered complementary information on the same issue (complementarity), or appeared to contradict each other (discrepancy or dissonance).²⁷

Assessment of Methodological Quality

Methodological validity was assessed using the Mixed-Methods Appraisal Tool (MMAT).²⁸ Qualitative and quantitative studies were assessed by authors C.M. and R.N., respectively, and all studies were evaluated independently by a third reviewer (M.G.). The MMAT includes questions for various study designs, and each subset includes four to six questions. An overall score for quality was calculated by counting the number of “Yes” scores for each category. If the study scored >4, it was considered “high quality,” three to four was “moderate quality,” and <3 was “low quality.”

Results

The literature search identified 4509 publications, of which 143 were retrieved for full text review (Fig. 1). Seventeen of these were included in the narrative synthesis—six quantitative and 11 qualitative studies (Fig. 1). Descriptive details of included articles are summarized in Table 1.

Figure 1.

PRISMA flow diagram of search and study selection process.

Table 1.

Characteristics of Included Quantitative and Qualitative Studies

			Details of weight management service			Study characteristics
	Author, year, country	Methods/study design	Level of care	Clinicians involved	Description of weight management intervention	Participant group	n	Patient weight status at presentation	Time point of satisfaction data collection	Data collection tool/method
Quantitative	Bejarano et al., 2017, USA	Cohort study	Secondary	NR	NR	Parents/carers	50	Mean (SD) BMI z score = 2.31 (0.34)	At 3, 6 and 9 month review appointments	Press-Ganey Medical Practice Survey
	Braet et al., 2010, Belgium	Cohort study	Tertiary	Dietitian, pediatrician, psychologist	Dietary and exercise intervention focused on healthy eating habits, moderate exercise, food and activity monitoring, goal setting, and behavior modification techniques. 12 week intervention +/− 4–8 month follow-up	Parents/carers	72	Mean (SD) %BMI over IBW = 163.89 (23.43)	After initial appointment booked; during two intake sessions; at each of the 6 treatment sessions; 1 year after admission	Reasons for Eating Treatment Questionnaire, Barriers to Treatment Participation Scale
	Cote et al., 2004, USA	Quality improvement study	Tertiary	Physician, psychologist, dietitian, nurse, exercise physiologist	Emphasis on diet modifications, promotion of an active lifestyle, behavior therapy, supportive parental involvement, comprehensive clinical evaluation, individual nutrition counseling, group exercise sessions, and group parental education. 12 week intervention followed by 6 and 12 month integrated after-care programs	Parents/carers	120	Treatment completers mean (SD) %BMI over IBW = 100.2 (37.23); treatment noncompleters mean (SD) %BMI over IBW = 109.85 (50.36)	Postintervention	CAHPS 2.0 survey
	Grimes-Robison, 2013, USA	Quality improvement study	Secondary	Pediatrician, nurse practitioner, dietitian, physical therapist, psychologist	Nutritional education and fitness recommendations. Duration of intervention not predetermined	Parents/carers	35	NR	At patient's second visit	Pediatric Weight Management Survey adapted from the CAHPS survey
	Hampl et al., 2013, USA	Quality improvement study	Tertiary	NR	NR; several different sites with various interventions involved	Parents/carers	147	Mean (SD) BMI percentile = 99.2 (1.9); mean (SD) BMI z score = 2.4 (0.5)	Postintervention	Semistructured survey including list of factors that may contribute to attrition with Likert scale for participants to rank factors from a lot to not at all with two additional options of don't know and not applicable
	Mulgrew et al., 2011, USA	Case control study	Tertiary	Pediatrician, dietitian, rural health care provider	Consultations conducted by pediatrician and dietitian face to face or through telemedicine with rural health care provider present at rural/remote clinics. Duration NR	Parents/carers	25	NR	For face-to-face consultations, 53% at first visit, 29% at third visit, 13% at fourth visit, and 13% at fifth visit. For telemedicine, 70% at first visit and 30% at visits 2 to 9	Questionnaires adapted from “Promoting Healthy Development Survey” from the Child and Adolescent Health Measurement Initiative and “Outcomes of the Kaiser Permanente Tele-Home Health Research Project”
Qualitative	Fjone, 2016, USA	Grounded theory	Secondary	Physicians, nurses, nutritionists, nursing assistants	NR	Children/adolescents aged 10–14 years and their parents and siblings	20	NR	NR	One-on-one interview
	García et al., 2017, Chile	Grounded theory	Secondary	Nutritionist, medical professional	NR	Parents/carers	9	NR	When parents/carers had attended three or more consecutive medical evaluations	One-on-one interview
	Kitscha et al., 2009, Canada	Grounded theory	Secondary	Dietitian	Dietary intervention comprising assessment; food and exercise records; goal setting; family-centered counseling. Intervention lasting up to 2 years	Parents/carers who attended 1–2 visits and did not return for follow-up within a 4 month period	21	Mean (SD) BMI z score = 2.32 (0.74)	Time elapsed between discontinuing treatment and data collection NR	Phone interview
	Nogueira et al., 2013, Brazil	Quality improvement study	Secondary	Pediatricians, nutritionist, physical educator, psychologist, physiotherapist. Duration NR	NR	Parents of children/adolescents who abandoned treatment, did not receive discharge from care or who did not attend for >6 months	41	Mean (SD) BMI z score = 2.4 (0.53)	Average of 3.6 years after abandonment of treatment	Phone interview
	Owen et al., 2009, UK	Quality improvement study	Secondary	Clinician, dietitian, exercise specialist	Assessments of progress held every 3 months. Other details NR	Children/adolescents aged 5–18 years and their parents/carers. Included children/adolescents who had and had not lost weight and families who did and did not attend follow-up appointments	32 (21 parents/carers; 11 children/adolescents)	NR	NR	One-on-one interview in hospital or in patient's home; phone interview (n = 1)
	Sallinen Gaffka et al., 2013, USA	Quality improvement study	Secondary and tertiary	Medical and nutrition professionals	Length of intervention varied across 13 sites involved; details NR	Parents/carers of children/adolescents aged 2–18 years who did not complete 25% of scheduled visits; did not return for a follow-up appointment within 6 months of initial visit or were not scheduled to return to the program/clinic	147	Mean (SD) BMI percentile = 99.2 (1.9)	NR	Phone interview
	Skelton et al., 2016, USA	Quality improvement study	Tertiary	Pediatrician, family counselor, dietitian, physical therapy, exercise/activity specialist	Physician assessment and review; biweekly appointment with family counselor and dietitian for first 4 months focusing on goal setting, education, and behavioral counseling; physical therapist/exercise specialist appointments scheduled as needed. Four-month intervention with physician follow-up (duration NR)	Parent–child dyads where children aged between 7 and 18 years. Families identified as having “dropped out” if they had not attended a clinic visit within the previous 4 weeks or had not responded to repeated requests for a follow-up appointment	87 (57 parents/carers; 30 children/adolescents)	Mean (SD) BMI = 34 (8.35); Mean (SD) BMI z score = 2.36 (0.355)	Parents and children interviewed within 4–6 weeks of completing 4 months of treatment or upon dropping out	Phone interview
	Stewart et al., 2008, UK	Quality improvement study	Secondary	Dietitian	Focus on behavior change rather than weight change using “Traffic Light Diet” and advice to increase physical activity. Eight appointments over 6 month period	Principal carers of primary school-age children	17	NR	12 months after commencing treatment	One-on-one interview
	Tremblay et al., 2016, Canada	Quality improvement study	Tertiary	Four study sites involved:1. PCWH: medical, nursing, psychology, nutrition, physical activity staff2. Shapedown BC: GP, dietitian, psychologist3. Growing Health program: medical, nursing, psychology, nutrition, exercise physiology staff4. Healthy Weight Clinic: disciplines NR	1. PCWH: multidisciplinary support with option for parents to participate in group-based intervention2. Shapedown BC: behavioral weight management program3. Growing Health program: individual counseling augmented with group sessions4. Healthy Weight Clinic: lifestyle guidance for children who have comorbidities related to obesity, supplemented by community-based lifestyle modification program	Primary carers of children/adolescents aged 10–17 years who attended at least one clinic appointment within the past 6 months	65	Mean (SD) BMI = 32 (6.7); Mean (SD) BMI z score = 2.58 (0.7); Mean (SD) BMI percentile = 98.2 (2.4)	NR	One-on-one interview
	Woolford et al., 2012, USA	Quality improvement study	Secondary	Pediatrician, psychologist, dietitian, social worker, exercise physiologist	Weekly nutrition education group and weekly exercise group for adolescents. 6 month intervention	Adolescents aged 12–18 years and their parents	63	NR	NR	Phone interview
	Zenlea et al., 2017, Canada	Quality improvement study	Secondary	Pediatric endocrinologist, nurse, mental health provider (social worker/child psychologist), dietitian, activity therapist	Group intervention with focus on teaching healthy lifestyle strategies, including healthy eating, physical activity, coping with stress, and parenting; families with more complex needs offered individual sessions. Initial group program 4–12 weeks with follow-up for up to 2 years	Parents/caregivers of patients aged 2–17 years	32	NR	Parents had completed 4 week pilot group-based program or were enrolled in more structured group-based program	Focus group

BC, British Columbia; BMI, body mass index; CAHPS, Consumer Assessment of Health Plan Study; GP, general practitioner; IBW, ideal body weight; NR, not reported; PCWH, Pediatric Center for Weight and Health; SD, standard deviation.

The sample size of included studies ranged from 9 to 147. A total of 449 and 534 participants were involved in quantitative and qualitative studies, respectively. Eleven studies were conducted in secondary-level services and six in tertiary-level services. Thirteen of the weight management services reported upon were multidisciplinary; two were dietitian-led services; and two studies did not report the disciplines of clinicians involved in the service. The majority of studies took place in the United States (n = 9) with the remaining in the United Kingdom (n = 2), Canada (n = 3), South America (n = 2), and Europe (n = 1).

Each of the studies reported on feedback from parents/carers, with five studies also including input from the enrolled children and adolescents. Nine studies^{12,16,29–35} reported clinical characteristics of patients attending the weight management service at presentation; however, only one study²⁹ discussed the relationship between patients' clinical outcomes and satisfaction with treatment, reporting that lower satisfaction was associated with greater weight loss. While Stewart et al.³⁶ categorized participating parents as having children who met their treatment goal (lost or maintained weight) or did not meet their treatment goal (gained weight), differences in feedback from these two groups were not discussed. Therefore, interpretation of patients' and families' satisfaction with the weight management service in light of patients' response to treatment was not possible.

All included papers were deemed to be of “high quality”; that is, receiving a score of >4 using the MMAT.

Patient and Family Satisfaction with Pediatric Weight Management Services

Findings from included studies regarding valued aspects of pediatric weight management services and facilitators of treatment engagement are summarized in Table 2. Bejarano et al.²⁹ reported that satisfaction with weight management service treatment contributed positively to parent self-efficacy and self-reported treatment adherence. In addition, they proposed that imperfect treatment alliance and service satisfaction increased the probability of weight loss. The most valued aspects of pediatric weight management services were education provided by the clinicians, strategies to facilitate behavior change, and the weight management service staff. Specifically, both parents and children and adolescents valued education regarding health impacts of obesity and aspects of nutrition and physical activity relevant to weight management. Working with weight management service staff who were supportive, nonjudgmental, and endeavored to develop a therapeutic relationship with both the patient and family was also strongly endorsed.

Table 2.

Findings from Included Studies Regarding Valued Aspects of Pediatric Weight Management Services and Facilitators of Treatment Engagement

Quantitative	Treatment alliance and satisfaction with weight management service contribute positively to self-efficacy and self-reported treatment adherence²⁹
	Imperfect treatment alliance and visit satisfaction increase probability of weight loss²⁹
	No significant difference in parent satisfaction between subspecialty consultations for weight management delivered by telemedicine and face-to-face visits³⁸
Qualitative	1. Aspects of weight management service	a. Education—Nutrition recommendations, that is, tangible nutrition recommendations that could be readily adopted⁴²; information about diet, exercise, and the long-term effects of obesity¹⁷; healthy lifestyle messages being delivered and reinforced (caregivers' own messaging about health and wellness to their children had greater impact if reinforced by health care providers, caregivers felt supported and validated by educational content presented in sessions, combination of positive messaging and communication skills sessions helped caregivers to feel more confident in their parenting approach)³⁹
		b. Strategies to facilitate behavior change—Interactive demonstrations and visual activities, parents valued home visits, adolescents valued weekly weight checks, tips/tools that helped incorporate healthy practices into routines, peer support⁴²; regular clinic contact¹⁷; children/adolescents valued increased time together as a family, for example, cooking and meal planning³⁴
		c. Weight management service staff—Supportive, nonjudgmental environment that emphasized health, support from team members⁴²; clinic staff, “no nonsense” attitude to obesity¹⁷; relationship between caregiver–health team and relationship between health team–child⁴⁰; supportive forum for sharing experiences related to caring for children with obesity³⁹
		d. Service delivery—Telemedicine effective in providing quality care to rural populations facing geographic barriers to access to care³⁸
	2. Outcomes of attending weight management service	a. Health outcomes—Weight outcome³⁶
		b. Psychological outcomes—Self-esteem (child more confident and happier)^34,36; self confidence³⁴

Barriers to Weight Management Service Attendance and Behavior Change

A summary of patient- and family-reported barriers to attending pediatric weight management services and patient's behavior change is shown in Table 3. Barriers were categorized into three main themes based on qualitative data:

Table 3.

Findings from Included Studies Regarding Barriers to Pediatric Weight Management Service Attendance and Behavior Change

Quantitative	1. Braet et al.³⁰	a. Predictors of dropout from treatment included age of patient (noncompleters older compared with completers), lower parental motivation at intake, and child psychopathology
	1. Braet et al.³⁰	b. No difference between completers and noncompleters on Barriers to Treatment Participation Scale
	2. Cote et al.¹⁶	a. Reasons for attrition are multifactorial and not captured sufficiently using demographic or health-related parameters in isolation
		b. Process-level measures are the predominant factors that influence families' retention in a program. Disease morbidity and caregiver's perception of their child's overall health status appears to be of lesser importance
		c. Perceived quality of care associated with withdrawal from weight management service even when sociodemographic and health parameters are accounted for
	3. Grimes-Robison³⁷	No significant relationship between retention and accessibility, program effectiveness, patient- and family-centered care, and outcome expectations
	4. Hampl, et al.¹²	Despite geographic diversity, parents of children who prematurely discontinued treatment endorsed similar reasons for attrition, mainly scheduling, transportation and barriers to implementing treatment recommendations
Qualitative	1. Reasons for attrition	a. Practical barriers—Physical barriers (scheduling, parking, location, time), organizational barriers (clinic environment)³¹; logistical issues (flexibility in hours and location)^33,34; scheduling, transportation¹²; difficulty adjusting schedules of consultations with activities of parents and patients, difficulty in scheduling a return appointment, long waiting hours³²
		b. Content and results of program—Program educational content³¹; content and/or delivery of the intervention¹²; unsuccessful treatment/could not lose weight, performance of new treatment at another health service³²
		c. Patient/family motivation—Family readiness to change/motivation³¹; barriers to implementation of recommendations¹²
		d. Mismatched expectations of treatment/treatment outcomes—Mismatched expectations between parents, their child, and clinic program/staff for the outcome¹²; parents expecting greater weight loss³⁴
		e. Families choosing not to return to treatment—Family perceived no need for follow-up visit³¹; most families who discontinued treatment did so on their own, without discussion of decision with member of treatment team³³; refusal to return to treatment by children³²; unforeseen circumstances³¹
	2. Barriers to behavior change	a. Perceived inadequate support from weight management service—Lack of health care provider support³⁶; need for ongoing support to maintain lifestyle changes³⁹; difficulty identifying specific lifestyle changes and needed practical ideas to do so, parental anxieties¹⁷
		b. Perceived inadequate support from wider family—Lack of support from nucleus family and/or extended family, families experienced extended family as unsupportive³⁶; more regular and practical support to deal with issues of interfering extended families¹⁷; family congruence (overt and covert), continuous negotiation (parents negotiating choices such as physical activity, nutrition, homework, dinner and family chores, making school lunches with children)⁴¹
		c. Under-recognition/underestimation of problem—Parents were either aware of a weight problem (seekers/avoiders of treatment) or unaware of weight problem (deniers)³⁶
	3. Burden and stigma	a. Shared burden—Shared burden between parents and children; that is, burden of shame, guilt, and failure to stick to a diet or exercise plan⁴¹
	3. Burden and stigma	b. Guilt and blame—Parents felt fear, anger, guilt, confusion around their child's weight problem³⁶; caregiver experiences of feeling blamed for causing their children's obesity (i.e., “courtesy stigma” in which a person is stigmatized because of close association with another person with a stigmatizing feature)³⁹

(1)

Reasons for attrition, with subthemes of practical barriers; content and results of the program; patient/family motivation; mismatched expectations of treatment/treatment outcomes; and families choosing not to return to treatment;

(2)

barriers to behavior change, with subthemes of perceived inadequate support from the weight management service; perceived inadequate support from wider family; and under-recognition/underestimation of problem, and;

(3)

burden and stigma, with subthemes of shared burden and guilt and blame.

Quantitative data showed differing results in regard to predictors of, and reasons for, attrition. Braet et al.³⁰ reported older patients, lower parental motivation at intake, and presence of patient psychopathology as predictors of dropout, whereas Cote et al.¹⁶ concluded that participants' reasons for attrition were multifactorial and do not appear to be sufficiently explained using demographic or health-related parameters in isolation. Furthermore, Grimes-Robison³⁷ showed that outcome expectations did not differ between those who dropped out of treatment and those who completed treatment, whereas Hampl et al.¹² reported that parents of patients who discontinued treatment endorsed mismatched expectations between them, or their child, and treating clinicians.

Methods and Measures of Weight Management Service Satisfaction

Across the 17 studies included in this narrative synthesis, no two studies used the same measure of service satisfaction. Of the six studies that measured service satisfaction quantitatively, three used existing measures of general treatment satisfaction and quality^16,29,30 and three created questionnaires for the purposes of their research.^12,37,38 For the 11 qualitative studies, one study conducted a focus group,³⁹ four studies conducted one-on-one, face-to-face interviews,^35,36,40,41 five studies conducted phone interviews,^31–34,42 and one study conducted both one-on-one interviews and a phone interview.¹⁷ All qualitative studies used questionnaires/discussion guides developed by the authors for the purposes of their study.

Recommendations to Improve Weight Management Services

A summary of patients' and families' recommendations for improvements to pediatric weight management services from the included studies is reported in Table 4. Most recommendations pertained to the content of the weight management service, with subthemes of program content (e.g., greater focus on aspects such as physical activity, parenting strategies, and nutrition education), delivery of the weight management intervention (e.g., group versus individual delivery, use of parent-only sessions), individualized treatment (e.g., adolescent-specific service), and treatment expectations. Recommendations were also made regarding clinician communication and therapeutic relationships and organizational factors such as clinic hours and accessibility.

Table 4.

Findings from Included Studies Regarding Patient and Parent/Carer Recommendations to Improve Pediatric Weight Management Services

1. Service content	a. Program content—Greater emphasis on physical activity, disease-specific information to increase children's responsibility/accountability for their health while providing coaching techniques for parents; general parenting and child psychology information to enable parents to redirect their children to make appropriate diet choices³⁷; nutrition education, exercise and behavior education or support³⁹; higher frequency of medical examination³³; physical activity, information provision, weight and progress tracking, psychological services³⁵
	b. Delivery of weight management intervention—Interactive elements, peer contact³⁵; family-centered approach that emphasizes family lifestyle changes rather than just child's, interactive learning environment that incorporates video games and demonstrations, appointments focused around a playgroup or a group setting to allow children to interact, develop friendships, and motivate each other, a child-friendly and inviting environment with games/entertainment to keep the child busy, allowing the parent to focus on counseling session³⁷; breaking recommendations down into manageable goals¹¹;
	c. Individualized treatment—Development of an adolescent-specific program⁴¹; individualized care³⁵; tailored treatments³⁹; diverse menu of treatment recommendations¹¹
	d. Treatment expectations—Ensuring that parental/child expectations are assessed early in the treatment process and that clinic/program features are discussed alongside these expectations¹¹
2. Communication and therapeutic relationship	a. Enhance family participation; motivate the child to encourage therapeutic alliance³³b. Keeping patients and parents actively engaged in weight management may require a delicate balance between maintaining positive rapport and challenging them to make meaningful behavioral changes²⁸
3. Organizational	a. Clinic hours—Expanded clinic hours⁴¹; staff and supporting hospital administration should consider scheduling alternative times for visits, assessing families' transportation and financial needs¹¹b. Clinic accessibility—Additional clinic locations in the community, assistance with transportation to clinic, free or reduced price parking⁴¹; access to care, that is, scheduling, program location, transportation³⁵

Discussion

This narrative synthesis aimed to summarize quantitative and qualitative research reporting parent and patient satisfaction and acceptability of hospital-based pediatric weight management services. Findings regarding participants' satisfaction were dominated by positive feedback, with a focus on valued components of the service and valued health outcomes as a result of attending the service. Overall, practical, organizational, and service content issues were the most heavily endorsed reasons for poor engagement or attrition.

Aspects reported as most valued by patients and families were consistent with a previous review of consumer satisfaction of childhood obesity prevention and primary-, secondary-, and tertiary-level treatment programs.²³ The most commonly cited reasons for families discontinuing treatment were organizational/logistical.^12,31–34 This has also been described in previous reviews of reasons for attrition in pediatric weight management services and clinical trials.^10,11,13 With the exception of Hampl et al.¹² who reported mismatched expectations of treatment outcomes as a reason for attrition, these findings are in contrast to clinicians' perceptions.⁴³ Semistructured interviews conducted with clinicians working in pediatric weight management found that the most common perceived reasons for attrition included family characteristics, patients' past experiences with obesity treatment, families' understanding of obesity treatment, and how much families valued treatment.⁴³

A possible explanation for this discrepancy between parent and clinician views is parents may report scheduling and accessibility issues as the causes for attrition in instances where lack of motivation to undertake and maintain behavior change was the underlying reason for discontinuation of treatment. This hypothesis is supported by the results of this review where, despite a high prevalence of families citing organizational factors as the reason for attrition (Table 3), relatively few recommendations were offered as to how this could be addressed by the service (Table 4). It has also been suggested that treatment centers that assess pediatric patients' motivation levels have greater treatment success⁴⁴ and lower rates of attrition.³⁰ In instances when clinicians overestimate patients' and their families' motivation, clinicians are working in a perceived “action” mode of behavior change⁴⁵ when the patient or family is not yet at the point of deciding to change.⁴⁶ Jumping ahead in this way can cause patients to feel misunderstood and badgered, and increase their resistance to change.⁴⁶ This in turn increases the likelihood of families disengaging from treatment.

In the future, pediatric weight management services may need to include an assessment of motivation at the outset of treatment as a way to decrease attrition in pediatric weight management services. Specifically, assessment of motivation to change eating and exercise behaviors is recommended as a patient's or families' goal of decreasing weight may not always correspond with a willingness to alter dietary and exercise behaviors.^1,47–50

Another key barrier to behavior change identified was the discrepancy between patients', families', and clinicians' expectations of treatment and treatment outcomes.^12,34 Adult patients who leave their medical visits with unmet expectations fare more poorly, reporting less symptom improvement and more postvisit health system contacts than patients whose treatment expectations are met.⁵¹ In studies conducted in adults with obesity, patients tended to greatly overestimate how much weight they would lose when attending a weight management service,^52–55 with higher weight loss expectations being associated with greater attrition.^55–57

It is unclear what role patients' and families' expectations of what treatment will encompass and the associated outcomes play in satisfaction with pediatric weight management services and attrition. One explanation may be that treatment attrition or lack of behavior change is a result of inadequate explanation or poor understanding of what is involved in weight management treatment for the patient and their family and what outcomes are realistic. Specifically, this could relate to (1) practical and organizational barriers, that is, the patient/family did not understand the level of commitment required or treatment outcomes were not matched to the families' capacity to engage in treatment; (2) issues with program content, that is, the patient/family did not understand the role of each member of the treating team and the aims of treatment provided by each member of the team; or (3) the level of support and communication, that is, the patient/family did not understand the capacity of the treating team to support and communicate with the family throughout their treatment.

One approach to ensuring that treatment expectations are clear to patients and families is the concept of treatment non-negotiables. Non-negotiables are a way to communicate aspects of treatment that a treating team consider to be mandatory and aim to help clinicians and patients balance the principles of patient safety, autonomy, and respect.⁵⁸ To the best of our knowledge, the use of this approach as part of an adult or pediatric weight management service has not previously been reported in the scientific literature.

Of the 17 papers reviewed, no consistent quantitative measure (e.g., questionnaire) of satisfaction or standardized qualitative guide (e.g., interview or focus group discussion guide) was used. The majority of the tools used to measure satisfaction were either (1) developed by clinicians or researchers working in the area of pediatric weight management; or (2) designed to evaluate health care services generally, not modified for use in pediatric weight management. As noted by Van Cleave et al.,⁵⁹ explanatory research comparing different models of health care can be limited when standardized measures are not used. Hence, the current lack of standardized measures of service acceptability in pediatric weight management makes the comparison of service acceptability and participants' satisfaction with weight management services with differing models of care difficult.

Limitations

There are a number of limitations of this review. First, only English-language articles were considered and despite all studies being rated as “high quality” using the MMAT, study sample sizes were relatively small. Smaller sample sizes are more limiting in quantitative studies as qualitative research with a small sample size and can still allow for exploration of a broad range of participant experiences.⁶⁰ Second, only two studies^29,30 repeated quantitative measures of patient satisfaction. However, these studies did not explore the impact of changes in clinical practice on patient satisfaction. Therefore it was not possible to comment on the application of the study findings, and how this influenced service delivery and acceptability. It is important to keep in mind that satisfaction surveys capture patients' recollections and perceptions of care, which may not necessarily correspond with events that occurred.⁶¹ Furthermore, none of the studies reviewed used the same measure of service satisfaction. Although addressing patient's perceptions of treatment remains essential to addressing patient satisfaction and improving service delivery, it should be acknowledged that patient's perceptions of treatment may not align with what clinicians believe is being delivered and may be limited by the method used to collect data from patients and their families. Finally, the lack of clinical outcome data meant that it was not possible to assess the extent to which treatment response impacted patients' and families' satisfaction with a weight management service.

Conclusion and Recommendations

The results of this narrative synthesis demonstrate that use of patient and family education, practical strategies to assist behavior change, and the approach of weight management service staff were the most valued aspects of pediatric weight management services. Potential strategies for reducing attrition and increasing patient satisfaction to improve outcomes include measuring families' readiness to change at the outset of treatment and matching treatment interventions to this, and implementing treatment non-negotiables so treatment expectations are clear to the patient and family.

To enhance the clinical effectiveness and retention of patients in pediatric weight management services, future research should focus on the development of a standardized measure of patient satisfaction. It is also recommended that research exploring consumer satisfaction with pediatric weight management services involves consideration of quantifiable patient outcomes to better interpret data regarding acceptability. Furthermore, consideration of research regarding both patient/family satisfaction and reasons for attrition, and clinicians' perceived reasons for patient attrition should be involved in the planning and development of pediatric weight management services.

Funding Information

This research was undertaken as part of the CHild and Adolescent weight Management Pathways (CHAMP) Study funded by a NSW Translational Research Grant.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

References

Oude Luttikhuis

, Baur

, Jansen

, et al. Cochrane review: Interventions for treating obesity in children. Evid Based Child Health, 2009; 4:1571–1729.

Baur

, Hazelton

, Shrewsbury

. Assessment and management of obesity in childhood and adolescence. Nat Rev Gastroenterol Hepatol, 2011; 8:635–645.

Loveman

, Al-Khudairy

, Johnson

, et al. Parent-only interventions for childhood overweight or obesity in children aged 5 to 11 years. Cochrane Database Syst Rev, 2015. [Epub ahead of print; DOI: 10.1002/14651858.CDOI2008.]

Mead

, Brown

, Rees

, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. Cochrane Database Syst Rev, 2017; 6:CD012651.

Janicke

, Steele

, Gayes

, et al. Systematic review and meta-analysis of comprehensive behavioral family lifestyle interventions addressing pediatric obesity. J Pediatr Psychol, 2014; 39:809–825.

Whitlock

, O'Connor

, Williams

, et al. Effectiveness of weight management interventions in children: A targeted systematic review for the USPSTF. Pediatrics, 2010; 125:e396–e418.

Wilfley

, Tibbs

, Buren

DJV

, et al. Lifestyle interventions in the treatment of childhood overweight: A meta-analytic review of randomized controlled trials. Health Psychol, 2007; 26:521–532.

Cohen

, Alexander

, Critekos

, et al. The acceptability, effectiveness, and impact of different models of care for pediatric weight management services: Protocol for a concurrent mixed-methods study. BMC Health Serv Res, 2018; 18.

Cohen

, Brennan

, Alexander

, et al. Assessment of clinicians' views for managing children with obesity in the primary, secondary, and tertiary settings. Child Obes, 2019 [Epub ahead of print; DOI: 10.1089/chi.2019.0106.]

10.

Skelton

, Beech

. Attrition in paediatric weight management: A review of the literature and new directions. Obes Rev, 2011; 12:e273–e281.

11.

Kelleher

, Harrington

, Shiely

, et al. Barriers and facilitators to the implementation of a community-based, multidisciplinary, family-focused childhood weight management programme in Ireland: A qualitative study. BMJ Open, 2017; 7:e016459.

12.

Hampl

, Demeule

, Eneli

, et al. Parent perspectives on attrition from tertiary care pediatric weight management programs. Clin Pediatr, 2013; 52:513–519.

13.

Dhaliwal

, Nosworthy

NMI

, Holt

, et al. Attrition and the management of pediatric obesity: An integrative review. Child Obes, 2014; 10:461–473.

14.

Barlow

, Ohlemeyer

. Parent reasons for nonreturn to a pediatric weight management program. Clin Pediatr, 2006; 45:355–360.

15.

Cason-Wilkerson

, Goldberg

, Albright

, et al. Factors influencing healthy lifestyle changes: A qualitative look at low-income families engaged in treatment for overweight children. Child Obes, 2015; 11:17–176.

16.

Cote

, Byczkowski

, Kotagal

, et al. Service quality and attrition: An examination of a pediatric obesity program. Int J Qual Health Care, 2004; 16:165–173.

17.

Owen

, Sharp

, Shield

, Turner

. Childrens' and parents' views and experiences of attending a childhood obesity clinic: A qualitative study. Prim Health Care Res Dev, 2009; 10:236–244.

18.

Teevale

, Taufa

, Percival

. Acceptability and non-compliance in a family-led weight-management programme for obese Pacific children. Public Health Nutr, 2015; 18:2625–2633.

19.

Twiddy

, Wilson

, Bryant

, Rudolf

. Lessons learned from a family-focused weight management intervention for obese and overweight children. Public Health Nutr, 2012; 15:1–8.

20.

Visram

, Hall

, Geddes

. Getting the balance right: Qualitative evaluation of a holistic weight management intervention to address childhood obesity. J Public Health (Oxf), 2013; 35:246–254.

21.

Consumer Focus Collaboration. The Evidence Supporting Consumer Participation in Health. Consumer Focus Collaboration: Canberra, 2001.

22.

National Health and Medical Research Council. Guide to Effective Participation of Consumers and Communities in Developing and Disseminating Health Information: Practical Advice for Individuals and Organisations Involved in Developing, Evaluating and Disseminating Health Information. National Health and Medical Research Council: Canberra, 2006.

23.

Skelton

, Irby

, Geiger

. A systematic review of satisfaction and pediatric obesity treatment: New avenues for addressing attrition. J Healthc Qual, 2014; 36:5–22.

24.

Popay

, Roberts

, Sowden

, et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Lancester, United Kingdom: Lancaster University, 2006.

25.

Cooper

, Ryan

, Ells

, et al. Weight loss interventions for adults with overweight/obesity and chronic musculoskeletal pain: A mixed methods systematic review. Obes Rev, 2018; 19:989–1007.

26.

Klassen

, Douglass

, Brennan

, et al. Social media use for nutrition outcomes in young adults: A mixed-methods systematic review. Int J Behav Nutr Phys Act, 2018; 15.

27.

O'Cathain

, Murphy

, Nicholl

. Three techniques for integrating data in mixed methods studies. BMJ, 2010; 341:1147–1150.

28.

Pace

, Pluye

, Bartlett

, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud, 2012; 49:47–53.

29.

Bejarano

, Milkes

, Hossain

, et al. Longitudinal associations of visit satisfaction and treatment alliance with outcomes in pediatric obesity clinic visits. Child Health Care, 2017; 46:282–300.

30.

Braet

, Jeannin

, Mels

, et al. Ending prematurely a weight loss programme: The impact of child and family characteristics. Clin Psychol Psychother, 2010; 17:406–417.

31.

Kitscha

, Brunet

, Farmer

, Mager

. Reasons for non-return to a pediatric weight management program. Can J Diet Pract Res, 2009; 70:89–94.

32.

Nogueira

TFD

, Zambon

. Reasons for non-adherence to obesity treatment in children and adolescents. Rev Paul Pediatr, 2013; 31:338–343.

33.

Sallinen Gaffka

, Frank

, Hampl

, et al. Parents and pediatric weight management attrition: Experiences and recommendations. Child Obes, 2013; 9:49–417.

34.

Skelton

, Martin

, Irby

. Satisfaction and attrition in paediatric weight management: Satisfaction in weight management. Clin Obes, 2016; 6:143–153.

35.

Tremblay

, Perez

, Rasquinha

, et al. Recommendations from parents to improve health services for managing pediatric obesity in Canada. Acad Pediatr, 2016; 16:587–593.

36.

Stewart

, Chapple

, Hughes

, et al. Parents' journey through treatment for their child's obesity: A qualitative study. Arch Dis Child, 2008; 93:35–39.

37.

Grimes-Robison

. Benefits and Barriers to Pediatric Weight Management Programs. Ann Arbar, AL: University of Alabama, ProQuest Dissertations Publishing, 2012.

38.

Mulgrew

, Shaikh

, Nettiksimmons

. Comparison of parent satisfaction with care for childhood obesity delivered face-to-face and by telemedicine. Telemed J E Health, 2011; 17:383–387.

39.

Zenlea

, Thompson

, Fierheller

, et al. Walking in the shoes of caregivers of children with obesity: Supporting caregivers in paediatric weight management. Clin Obes, 2017; 7:300–306.

40.

García

, Aspillaga

, Cruzat-Mandich

, Barja

. Recommendations from parents of obese children in treatment to the health-care team: Qualitative study. Rev Chil Pediatr, 2017; 88:495–501.

41.

Fjone

. Child and Family Responses to Weight Management Programs: A Qualitative Investigation. Ann Arbar: School of Public Health, Loma Linda University, ProQuest Dissertations Publishing, 2011.

42.

Woolford

, Sallinen

, Schaffer

, Clark

. Eat, play, love: Adolescent and parent perceptions of the components of a multidisciplinary weight management program. Clin Pediatr, 2012; 51:678–684.

43.

Skelton

, Irby

, Beech

, Rhodes

. Attrition and family participation in obesity treatment programs: Clinicians' perceptions. Acad Pediatr, 2012; 12:420–428.

44.

Reinehr

. Lifestyle intervention in childhood obesity: Changes and challenges. Nat Rev Endocrinol, 2013; 9:607–614.

45.

Prochaska

, Velicer

. The transtheoretical model of health behavior change. Am J Health Promot, 1997; 12:38–48.

46.

Mason

. Health Behavior Change: A Guide for Practitioners. 3rd ed. United Kingdom: Elsevier Health Sciences, 2018.

47.

Barlow

, Dietz

. Management of child and adolescent obesity: Summary and recommendations based on reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics, 2002; 110:236–238.

48.

August

, Caprio

, Fennoy

, et al. Prevention and treatment of pediatric obesity: An Endocrine Society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab, 2008; 93:4576–4599.

49.

McGovern

, Johnson

, Paulo

, et al. Clinical review: Treatment of pediatric obesity: A systematic review and meta-analysis of randomized trials. J Clin Endocrinol Metab, 2008; 93:4600.

50.

Casazza

, Fontaine

, Astrup

, et al. Myths, presumptions, and facts about obesity. N Engl J Med, 2013; 368:446–454.

51.

Bell

, Kravitz

, Thom

, et al. Unmet expectations for care and the patient-physician relationship. J Gen Intern Med, 2002; 17:817–824.

52.

Foster

, Wadden

, Phelan

, et al. Obese patients' perceptions of treatment outcomes and the factors that influence them. Arch Intern Med, 2001; 161:2133–2139.

53.

Foster

, Wadden

, Vogt

, Brewer

. What is a reasonable weight loss? Patients' expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol, 1997; 65:79–85.

54.

Dalle Grave

, Calugi

, Compare

, et al. Weight loss expectations and attrition in treatment-seeking obese women. Obes Facts, 2015; 8:311–318.

55.

Grave

, Calugi

, Molinari

, et al. Weight loss expectations in obese patients and treatment attrition: An observational multicenter study. Obesity, 2005; 13:1961–1969.

56.

Dalle Grave

, Melchionda

, Calugi

, et al. Continuous care in the treatment of obesity: An observational multicentre study. J Intern Med, 2005; 258:265–273.

57.

Ames

, Thomas

, Patel

, et al. Should providers encourage realistic weight expectations and satisfaction with lost weight in commercial weight loss programs? A preliminary study. Springerplus, 2014; 3:1–5.

58.

Geller

, Srikameswaran

. Treatment non-negotiables: Why we need them and how to make them work. Eur Eat Disord Rev, 2006; 14:212–217.

59.

Van Cleave

, Egleston

, Brosch

, et al. Policy research challenges in comparing care models for dual-eligible beneficiaries. Policy Polit Nurs Pract, 2017; 18:72–83.

60.

Russell

, Gregory

. Evaluation of qualitative research studies. Evidence Based Nurs, 2003; 6:36–40.

61.

Press

. Patient Satisfaction: Defining, Measuring, and Improving the Experience of Care. Chicago, IL: Health Administration Press, 2002.

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