Parental Factors Associated With Intentions to Initiate a Family-Based Pediatric Weight Management Program

Abstract

Background:

Childhood obesity can be addressed through family-based pediatric weight management; however, treatment enrollment in the United States is low. This study aimed to identify parental factors associated with intentions to initiate a family-based pediatric weight management program.

Methods:

Cross-sectional survey data were collected from an online panel of US parents with at least one 5- to 11-year-old child identified as likely to have overweight or obesity. Participants viewed a video about a hypothetical family-based pediatric weight management program, rated their 30-day initiation intentions for that program, and answered additional related questionnaires.

Results:

Participants (n = 158) identified as White/Caucasian (53%) or Black/African American (47%), were primarily female (61.4%) and married/cohabitating (81.6%) with children who were predominantly girls (53.2%) and, on average, 9-year-olds. Higher parents' perception of program effectiveness predicted initiation intentions (p < 0.001), while concern for their child's weight and parent depression and anxiety levels did not. Higher initiation intentions and perceived program effectiveness were reported by Black/African American participants (p < 0.01) and those with at least a bachelor's degree (p < 0.01) compared to White/Caucasian participants and those without a bachelor's degree, respectively. Initiation intentions were higher for those with greater financial security (p = 0.020) and fewer than three children in the home (p = 0.026). Participants endorsed initiation barriers of time constraints (25%), possible lack of enjoyment for the child (16.9%), and lack of family support (15%).

Conclusions:

Future program enrollment efforts may need to focus on strategies to increase perceived program effectiveness, although further research is needed that measures actual enrollment in real-world contexts.

Introduction

In the United States, childhood obesity has become a critical public health focus as rates of overweight and obesity among children and adolescents aged 2 to 19 years have tripled since the 1980s.¹ Furthermore, among this age group, obesity disproportionately affects racial and ethnic minorities at a prevalence rate of 24.2% among non-Hispanic Black children compared to 16.1% among non-Hispanic White children as of 2017–2018.²

Several pediatric health organizations and committees recommend a multidisciplinary, comprehensive approach for treating children (12 years old and younger) with obesity who are still subject to parental influence.^3–6 These evidence-based approaches emphasize behavioral strategies and health education to improve lifestyle habits rather than focus solely on weight loss.^5–8

Although family-based interventions targeting parents as change agents can help prevent and control childhood overweight and obesity,^9–12 low participant initiation may hinder the effectiveness of these programs.^8,13–15 In addition, some studies indicate lower initiation among racial/ethnic minorities and populations with low socioeconomic status, with historical underrepresentation among Black/African American families.^6,16–20

Several qualitative studies have been conducted to understand reasons for use or nonuse of family-based weight management interventions. In these studies, parents' reported reasons for enrolling in programs include a perceived need for external support, expected program benefits, and concerns about their child's physical and psychosocial well-being.^21–25 Reasons for not enrolling include no perceived need for structured weight management, lack of parent and child motivation, logistical and financial barriers, concern about possible stigma, and lack of family support.^22–24,26

A few quantitative studies have attempted to identify predictive factors for program engagement, primarily examining anthropometric and sociodemographic factors. These studies show that enrollment was higher among families that joined shortly after referral,²⁷ lived near the program location,^20,28 and had girls rather than boys with overweight or obesity.^8,29–31 Lower enrollment was found among single-parent households with low socioeconomic status, especially among Black/African American families, indicating a need for further study among this racial group.^{8,16,20,29,31}

While qualitative studies have begun to shed light on psychosocial factors and quantitative studies have examined sociodemographic factors, there are only limited data quantifying psychosocial predictors of treatment use. Existing research,^{21–24,32,33} and health behavior change theories, including the Andersen Model of Health Service Use^34–36 and the Health Belief Model,^37,38 suggest psychosocial factors that may affect pediatric weight management treatment use by parents, including their mental health (i.e., self-reported depression and anxiety levels), concern for their child's weight, and beliefs about treatment effectiveness. In addition to psychosocial factors, practical barriers such as financial and logistical barriers can impede treatment initiation.^8,20

The primary aim of this study was to identify modifiable predictors of intentions to initiate a hypothetical family-based pediatric weight management program among nontreatment-seeking parents. The secondary aims were to examine the relationship between key demographic characteristics and parents' program initiation intentions, perceived program effectiveness, and concern for their child's weight. An additional aim was to describe how often participants endorsed potential program initiation barriers.

Methods

Participants and Procedures

US adults aged 18 years or older were eligible if they indicated that they were parents or primary caregivers with at least one child in the home between ages 5 and 11 years identified as likely to have overweight or obesity. We considered the child likely to have overweight or obesity if the parent either (1) indicated that they perceived their child's current weight status was above normal weight or (2) reported that a health care provider told them within the last 3 years that their child has excess weight or needs to lose weight, and reported that the child's weight did not decrease since that wellness visit.

Parents with more than one child identified as likely to have overweight or obesity were asked to reply about the oldest child within the age range to reduce possible bias if they selected among their children, and to remain consistent with the average age of child participants from previous research.^3–6 Parents were ineligible if they enrolled themselves or their child in a pediatric weight management program within the last 12 months or if they indicated that their child had severe medical, behavioral, or developmental health issues.

Participants were recruited online through a panel service by Qualtrics, which sent targeted emails to individuals who indicated interest in being contacted for marketing research and other surveys. Qualtrics also provided compensation for the participants ∼$12/h. Quotas were set for 40% Black/African American, 40% White/Caucasian, 50% with less than a bachelor's degree, 50% with a bachelor's degree or higher, and 20% eligible for Supplemental Nutrition Assistance Program benefits and other assistance programs. Approval was obtained from the Institutional Review Board at the lead investigator's institution, and data were collected from May 2, 2022, to May 23, 2022.

Following online informed consent and screening procedures, participants completed an online cross-sectional survey that began with viewing an embedded 100-second video about a hypothetical family-based pediatric weight management program (Supplementary Fig. S1). The video was a 12-scene voice-over animated slide show with closed captions of the video script created by the lead investigator (Supplementary Video S1). This brief program description was modeled after family-based weight management programs grounded in evidence-based literature.^26,39 It included (1) learning new methods to support their child in making healthy food choices, (2) receiving assistance from a health coach in realistic goal-setting, and (3) receiving small-group support from other parents and children. Participants were not allowed to progress to the next survey segment until enough time had passed to watch the entire video. Immediately after watching the video, participants completed additional measures.

Measures

The complete questionnaire used is provided in the Supplementary Data S1. Demographic variables such as race, ethnicity, and gender were measured with self-report questions. Participants were asked how many children were in their household, and results were dichotomized into less than three or more than three to create similar-sized groups. Financial security was assessed using a question derived from previous literature asking them to describe their household's financial situation (e.g., “you are having difficulty paying the bills, no matter what you do”).⁴⁰ This approach has been used to account for variability in financial status across regions, cost of living, and family sizes.⁴¹ Responses were dichotomized as high (previously high) and low (previously moderate, low, and very low).

The primary outcome variable, program initiation intentions, was measured by calculating the mean of five semantic differential items developed in the style of Ajzen.⁴² Parents were instructed to indicate the response that best described their interest in joining the program if offered in the next 30 days. This timeframe was chosen to be consistent with past studies,⁴³ and to gauge parents' interest in participating if the opportunity were available soon. Items included response options such as 1 (be unlikely to join) to 7 (be likely to join) and 1 (definitely would not join) to 7 (definitely would join). Past use of this measurement approach has yielded high internal consistency.^43,44

Participants rated their perceptions of the described program's effectiveness using a five-item measure adapted from a perceived treatment efficacy measure originally for psychotherapy,⁴⁵ that has recently been used for an adult weight management program.⁴³ Concern for child's weight was measured using the first concern subscale from the Child Weight Risk Questionnaire.⁴⁶ Parents' self-reported depression levels were measured with the Center for Epidemiological Studies Revised Depression Scale (CES-D-R-10).⁴⁷ Parents' self-reported anxiety levels were measured with the Overall Anxiety Severity and Impairment Scale (OASIS).^48–51 Finally, participants rated six potential program initiation barriers identified in previous qualitative literature, such as difficulty finding time to participate, and enjoyability for the child.^23,26,52,53 In items created for this study, participants rated the extent each potential barrier would prevent them from joining the program described in the survey with responses ranging from 1 (strongly disagree) to 7 (strongly agree) (Supplementary Data S1).

Data Analysis

Data were analyzed using Statistical Package for the Sciences (SPSS) software version 28. We conducted a series of standard multiple regression analyses to separately test if the dependent variable (program initiation intentions) could be predicted by each independent variable (perceived program effectiveness, concern for child's weight, depression, and anxiety). Then, a single multiple regression analysis was conducted with all independent variables combined. In all regression models, we controlled for race, educational attainment, number of children in the household, and financial security. Independent samples t tests were used to compare initiation intentions, perceived program effectiveness, and concern for child's weight across race, educational attainment, number of children in the household, child sex, and financial security. Statistical significance was established at p < 0.05 for all tests.

Finally, we examined how often participants endorsed six potential program initiation barriers. Our sample size was calculated to achieve 85% power to detect a medium effect size (d = 0.5) when comparing initiation intentions across our key demographic groups (e.g., racial categories). This was estimated to require 73 participants per group, so we sought to recruit ∼150 total participants.

Results

Our final analytic sample included 158 participants. On average, the participants were in their late 30s (M = 38.2, SD = 7.2), primarily female (61.4%), married (81.6%), had households with less than three children (75.9%), and indicated low financial security (53.2%). About 47% were Black/African American, 50% had a bachelor's degree or higher, and 47% received or were eligible for food or financial assistance. Participants' children were ∼9 years old and mostly female (53.2%) (Table 1).

Table 1.

Participant Characteristics (n = 158)

Characteristics	n (%) or M (SD)^a
Parent age in years^a	38 (7.2)
Parent sex
Male	60 (38.0)
Female	99 (61.4)
Parent race
White/Caucasian	84 (53.2)
Black/African American	74 (46.8)
Marital status
Married/partnered	129 (81.6)
Single	13 (8.2)
Employment status
Employed full time	89 (56.3)
Other	69 (43.1)
Education
Less than a bachelor's degree	79 (50.0)
Bachelor's degree or higher	79 (50.0)
Financial security
High	74 (46.8)
Low	84 (53.2)
Received or eligible for food or financial aid	74 (46.8)
No. of children in the household
Less than three	120 (75.9)
Three or more	38 (24.1)
Child age in years^a	8.8 (1.7)
Child sex
Male	74 (46.8)
Female	84 (53.2)
Child race
White/Caucasian	84 (53.2)
Black/African American	74 (46.8)
Provider reported child's excess weight at wellness visit
Yes	116 (73.4)
No	42 (26.6)

M (SD), mean (standard deviation).

Descriptive statistics and correlations were calculated for all primary variables (Table 2). There was a statistically significant, strong positive correlation between program initiation intentions and perceived program effectiveness, r(158) = 0.73, p < 0.01.

Table 2.

Correlations and Descriptive Statistics for Primary Study Variables (n = 158)

Variable	Observed range	M (SD)	Cronbach's alpha	1	2	3	4
1. Program initiation intentions	1–7^a	5.70 (1.38)	0.963	—
2. Perceived program effectiveness	1.8–7^b	5.95 (0.92)	0.888	0.726^**	—
3. Parent concern for child's weight	0–4^c	3.04 (0.99)	0.929	0.038	0.059	—
4. Depression level	0–27^d	11.43 (6.95)	0.872	0.017	0.072	0.168^*	—
5. Anxiety level	0–20^e	9.92 (5.94)	0.946	0.119	0.163	0.190^**	0.729^**

p < 0.05, ^**p < 0.01 (one-tailed).

Possible range was from 1 to 7 with higher scores indicating greater initiation intentions.

Possible range was from 1 to 7 with higher scores indicating greater perceived program effectiveness.

Possible range was from 0 to 4 with higher scores indicating greater concern.

Possible range was from 1 to 30 with higher scores indicating greater self-reported symptom levels of depression.

Possible range was from 0 to 20 with higher scores indicating greater self-reported symptom levels of anxiety.

In multivariable regression analyses, perceived program effectiveness significantly predicted initiation intentions (β = 0.681, t = 12.29, p < 0.001), while parent concern for child's weight (β = 0.014, t = 0.189, p = 0.850), depression (β = −0.006, t = −0.082, p = 0.935), and anxiety (β = 0.045, t = 0.570, p = 0.570) were not significant predictors. When all four independent variables were included in a single regression model, perceived program effectiveness was the only statistically significant predictor (Table 3).

Table 3.

Multiple Regression Results for All Independent Variables Predicting Program Initiation Intentions (n = 158)

	B	SE	95% CI		β	t	p
	B	SE	LL	UL	β	t	p
(Constant)	−0.280	0.575	−1.416	0.856		−0.490	0.627
Perceived program effectiveness	1.030	0.085	0.863	1.198	0.684	12.16	<0.001
Concern for child's weight	−0.009	0.078	−0.162	0.145	−0.006	−0.11	0.913
Depression level	−0.011	0.017	−0.043	0.022	−0.053	−0.65	0.515
Anxiety level	0.002	0.020	−0.037	0.040	0.007	0.08	0.937
Race	0.312	0.169	−0.022	0.645	0.112	1.85	0.067
Education	−0.253	0.183	−0.615	0.108	−0.091	−1.39	0.168
No. of children in the household	−0.195	0.182	−0.555	0.166	−0.060	−1.07	0.287
Financial security	0.013	0.176	−0.335	0.360	0.005	0.072	0.943

B, unstandardized regression coefficient; β, standardized regression coefficient; CI, confidence interval; LL, lower limit; SE, standard error of estimate; UL, upper limit.

Mean scores were calculated for initiation intentions, perceived program effectiveness, and concern for child's weight across demographic characteristics (Table 4). For comparisons by race, Black/African American participants reported higher initiation intentions (M = 6.1, SD = 1.0) compared to White/Caucasian participants (M = 5.4, SD = 1.6; t = −3.95, p < 0.001). Black/African American participants also reported higher perceived program effectiveness (M = 6.2, SD = 0.7) than White/Caucasian participants (M = 5.8, SD = 1.0, t = −2.74, p = 0.003). For comparisons by educational attainment, participants who earned a bachelor's degree or higher (M = 6.1, SD = 1.1) reported higher initiation intentions compared to participants with less than a bachelor's (M = 5.3, SD = 1.5; t = 3.93, p < 0.001).

Table 4.

Comparison of Program Initiation Intentions, Perceived Program Effectiveness, and Concern for Child's Weight Across Key Demographic and Family Characteristics (n = 158)

Characteristics	Program initiation intentions			Perceived program effectiveness			Concern for child's weight
Characteristics	M (SD)	t	p	M (SD)	t	p	M (SD)	t	p
Race
White	5.4 (1.6)	−3.95	<0.001	5.8 (1.0)	−2.74	0.003	3.0 (1.0)	−0.41	0.679
Black	6.1 (1.0)			6.2 (0.7)			3.1 (1.0)
Education
Bachelor's degree or higher	6.1 (1.1)	3.93	<0.001	6.2 (0.7)	2.94	0.002	3.1 (0.8)	1.12	0.263
Less than a bachelor's degree	5.3 (1.5)			5.8 (1.0)			2.9 (1.1)
No. of children in the household
Less than three	5.8 (1.1)	1.96	0.026	6.0 (0.9)	0.94	0.160	3.0 (1.0)	−0.33	0.741
Three or more	5.3 (1.6)			5.8 (0.9)			3.1 (0.9)
Child sex
Male	5.8 (1.2)	−0.81	0.208	6.0 (0.9)	−0.45	0.652	3.1 (1.0)	−0.20	0.846
Female	5.6 (1.5)			5.9 (1.0)			3.0 (1.0)
Financial security
High	5.9 (1.3)	2.07	0.020	6.1 (0.9)	1.35	0.180	3.1 (0.9)	0.71	0.480
Low	5.5 (1.4)			5.9 (1.0)			3.0 (1.1)

Similarly, participants with at least a bachelor's degree (M = 6.2, SD = 0.7) had higher perceived program effectiveness than participants with less than a bachelor's (M = 5.8, SD = 1.0, t = 2.94, p = 0.002). For comparisons by the number of children in the household, higher initiation intentions were reported by participants with less than three children (M = 5.8, SD = 1.1) than for participants from households with three or more (M = 5.3, SD = 1.6; t = 1.96, p = 0.026). For comparisons by financial security status, initiation intention scores were higher for participants reporting high financial security (M = 5.9, SD = 1.3) than for participants reporting low security (M = 5.5, SD = 1.4; t = 2.07, p = 0.02) (Table 4).

The potential barriers to treatment use with greatest endorsement were difficulty finding time for the program (25%), concern that the program would not be enjoyable for the child (16.9%), and difficulty getting family support (15%) (Table 5).

Table 5.

Summarized Endorsement of Barriers to Pediatric Weight Management Program Initiation (n = 158)

Potential Barrier	Endorsement n (%)
Potential Barrier	Disagree	Neither agree nor disagree	Agree
1. Difficulty finding time	99 (61.9)	21 (13.1)	40 (25)
2. Not helpful to child	137 (85.6)	10 (6.3)	13 (8.1)
3. Too much effort	136 (85.0)	11 (6.9)	13 (8.1)
4. Not enjoyable for parent	125 (78.1)	17 (10.6)	18 (11.3)
5. Not enjoyable for child	113 (70.6)	20 (12.5)	27 (16.9)
6. Difficulty getting family support	124 (77.5)	12 (7.5)	24 (15.0)

To simplify reporting of these data, response options for each item were grouped into three cumulative categories of disagree, neither agree nor disagree, and agree.

Discussion

In the current study, we primarily examined the association of four modifiable parental factors (perceived program effectiveness, concern for child's weight, depression, and anxiety) with intentions to initiate a hypothetical family-based pediatric weight management program. Secondarily, we examined differences in initiation intentions and perceived program effectiveness across key demographic variables. Our primary finding was that parents who perceived the program as more likely to be effective had greater (hypothetical) initiation intentions, while intentions to initiate were not associated with parents' concern for their child's weight or self-reported depression or anxiety levels. We also detected differences in initiation intentions and perceived program effectiveness across demographic characteristics. These findings contribute to the literature by identifying an important target to address low initiation (perceived treatment effectiveness) and demonstrating the importance of examining demographic differences in treatment-related variables.

Overall, parents reported high interest in enrolling their child in a weight management program, especially if they perceived that the program would help their child better manage their weight. This finding is consistent with previous qualitative studies indicating some parents' belief in the effectiveness of such programs.^24,26,54 Contrary to our expectations, parents' initiation intentions were not related to concern for their child's weight. Concern may drive a parent's interest in wanting to help their child to lose weight but may not necessarily drive their interest in participating in a structured weight management program.^53,55–57 A parent's decision to use a program may have more to do with program-specific factors (such as their perceived program effectiveness or convenience of joining) than their level of concern for their child's weight.^24,26,57

Consequently, highlighting program benefits may be a more effective strategy for increasing parents' initiation intentions. We also observed that depression and anxiety levels were not significant predictors of initiation intentions, suggesting that parents experiencing symptoms of depression or anxiety may still show interest in joining a program to improve their child's health.

We found important differences in key variables by race. Contrary to the expected outcome, Black/African American respondents reported higher program initiation intentions than White/Caucasian respondents in this study, and higher perceptions of program effectiveness. Potentially, the higher perceived program effectiveness among Black/African American respondents may be driving the higher initiation intentions observed. Previous literature suggests lower ongoing program use among Black/African American families.^16,20,28 Thus, while Blacks/African Americans may indicate greater interest in joining a program, generally, other barriers may challenge them between intention and actual program engagement.

We also observed that parents with at least a bachelor's degree reported higher intentions to initiate the program and higher perceived program effectiveness than those without a bachelor's degree. This finding is consistent with previous literature examining the association between educational attainment and adult obesity treatment adherence,⁵⁸ and the role of educational attainment in health service use more generally.^59,60 Parents with higher education may be more aware of the long-term effects of childhood obesity, therefore, may be more interested in opportunities to help their child reduce their weight. Greater perceptions of program effectiveness among those with higher education may reflect possible past positive experiences with similar programs. These results suggest that efforts to increase engagement in family-based weight management programs should target perceptions of programs' effectiveness, particularly, among individuals with less education.

Additional research is warranted to better understand what factors may influence parent's perceptions of treatment effectiveness, and how to change those perceptions.

Participants with low financial security reported lower initiation intentions than those with high financial security, supporting previous research on the association between economic status and health service use.^59–61 In this study, several barriers endorsed may also relate to lower income. Lower financial security is often associated with time and transportation barriers, as parents with low incomes may have to work several jobs to meet their household expenses, compounded with unreliable access to transportation.^26,62 Thus, providing online options that reduce time and travel costs may also lessen the effects of financial status on initiation intentions.⁶³ Emphasis can also be placed on low- or no-cost options such as program vouchers and scholarships when recruiting families experiencing financial burden.⁶⁴

We also found that participants from households with fewer than three children had higher program initiation intentions than those with three or more. Families with three or more children may experience more challenges in coordinating multiple schedules among family members.^32,64,65 To mitigate these logistical challenges, flexible online program options should be offered.^63,66

Of the six participation barriers examined in this study, agreement was indicated most for difficulty in finding time for the program (25%), concern that the program would not be enjoyable for the child (16.9%), and difficulty in getting family support (15%). Online programs may alleviate some of the challenges of finding time for the program,⁶³ while efforts to highlight children's positive experiences in the program can address concerns about children's enjoyment of the program.^63,66,67

This study has several limitations. We focused on intentions to engage in hypothetical treatment. Future work measuring actual treatment initiation across a variety of contexts is warranted. While we attended to a variety of demographic characteristics, due to sample size limitations, we were unable to present data on race or ethnicity beyond Black/African American and White/Caucasian. Future studies should include other racial or ethnic groups to improve the generalizability of the findings. Future studies should also examine additional modifiable factors that might be proximal to decision-making, such as self-efficacy. We were unable to obtain weight measurements of children to confirm obesity. In addition, parent sex was not examined in this study, but future research should include it since previous research on family-based pediatric weight management has focused on mothers as the primary caregivers.^68,69 Consequently, little is known about the role of fathers in health-decision making for their child's weight management.⁷⁰

Conclusions

The study findings suggest that efforts to increase enrollment in family-based pediatric weight management programs should include a focus on educating potential participants about the benefits of program participation, especially in families with less financial security or education. Further studies are warranted to replicate these findings in a real-world context and to explore additional psychosocial and sociodemographic factors not included in this study.

Impact Statement

This study found that parents' perceptions about the effectiveness of a family-based weight management program influenced their interest in joining that program. In addition, Black/African American participants and those with at least a bachelor's degree reported greater perceptions of the program's effectiveness and greater interest in initiating.

Footnotes

Acknowledgments

The authors thank the survey participants for their time and contributions to this study.

Authors' Contributions

The authors' responsibilities were as follows: W.S.M. and M.A.M., conceptualized and designed the study, and W.S.M. incorporated improvements advised by A.R.M. and K.P.S. For data collection, W.S.M., M.A.M, and M.M.M.-M. coordinated and supervised the study. W.S.M. and M.A.M. analyzed the data. W.S.M. and M.A.M. drafted, reviewed, and revised the article. All authors critically reviewed the article for intellectual content, and approved the final article as submitted.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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