The difficult conversation: a qualitative evaluation of the ‘Eat Well Move More’ family weight management service
Johnson et al. BMC Res Notes
The difficult conversation: a qualitative evaluation of the 'Eat Well Move More' family weight management service
Rebecca E. Johnson 0
Oyinlola Oyebode 0
Wendy Robertson 0
0 Collaboration for Leadership in Applied Health Research and Care West MidlandsCollaboration for Leadership in Applied Health Research and Care West Midlands, Division of Health Sciences, Warwick Medical School, University of Warwick , Coventry CV4 7AL, England , UK
Objective: The Eat Well Move More (EWMM) family and child weight management service is a 12-week intervention integrating healthy eating and physical activity education and activities for families and children aged 4-16. EWMM service providers identified low uptake 12 months prior to the evaluation. The aims of this study were to describe referral practices and pathways into the service to identify potential reasons for low referral and uptake rates. Results: We conducted interviews and focus groups with general practitioners (GPs) (n = 4), school nurses, and nursing assistants (n = 12). Data were analysed using thematic analysis. School nurses highlighted three main barriers to making a referral: parent engagement, child autonomy, and concerns over the National Child Measurement Programme letter. GPs highlighted that addressing obesity among children is a 'difficult conversation' with several complex issues related to and sustaining that difficulty. In conclusion, referral into weight management services in the community may persistently lag if a larger and more complex tangle of barriers lie at the point of school nurse and GP decision-making. The national prevalence of, and factors associated with this hesitation to discuss weight management issues with parents and children remains largely unknown.
Knowledge exchange; Public health practice; Health communication; Qualitative; Child obesity
Childhood obesity has short and long-term consequences
for physical and mental health [
]. It is recognised by
the World Health Organisation as one of the most serious
public health challenges of the 21st century . Despite
more than a decade of policy attention, a high prevalence
of childhood obesity persists in the UK [
]. For those
children who are overweight, behavioural lifestyle
interventions can result in clinically meaningful reductions
in overweight in children and adolescents, compared to
standard care or self-help [
In England, the National Institute for Health and Care
Excellence (NICE) recommends that tailored clinical
interventions should be considered for children with a
body mass index (BMI) at or above the 91st centile [
Public Health teams, situated within local government,
typically commission these services. Over 300 of these
services are likely to be running in England . NICE
guidance does not specify who should identify and refer
eligible children into provided services and these
practices may vary.
Many eligible children do not benefit from existing
services. This is partly due to attrition, where a child enters
but does not complete a programme, reported to be
between 27 and 90% [
]. However, many eligible
children may not be referred to appropriate services, or may
be referred but never initiate treatment. While there is a
growing literature on attrition, research into barriers to
referral to, and initiation of, childhood obesity treatment
remains scant [
This qualitative study explores the challenge
surrounding low referral and uptake rates into a community child
weight management programme despite comparatively
high retention, completion and service satisfaction of
participants. The study objectives were to (a) describe
current referral practices and pathways into the
programme, (b) identify potential reasons for low uptake,
and (c) make recommendations to improve service
The intervention “Eat Well Move More” (EWMM)
combines healthy eating and cooking education with
physical activity sessions. Three service offers exist: a school
programme (4–16 years), community programme
(7–11 years) and one-to-one sessions (12–16 years). The
intervention was developed in Solihull, England using
Public Health Outcome Framework guidance, and
principles of behaviour change [
]. Children may be
referred to EWMM by general practitioners (GPs), school
nurses, family support workers, paediatricians, or
selfreferral via the National Childhood Measurement
Programme (NCMP). NCMP measures height and weight
of school children in England. A letter is sent to families
indicating the child’s weight status based on BMI .
Information on EWMM and healthy lifestyles is provided
with the letter, and parents can self-refer into EWMM on
this basis. EWMM allows rolling admissions, so families
do not have to wait to join. It is free for referred children.
Qualitative, semi-structured interviews and focus groups
(FGs) were conducted with GPs and school nurses from
November 2015 to March 2016, by two female
researchers with previous interview experience and no previous
relationship with participants (RJ/WR). Topic guides
included questions about referral into EWMM and
invited responses on any other aspect of EWMM.
Interviews and FGs were audio recorded, and were an average
length of 10 min per interview and 30 min per FG.
Purposive sampling was used to request participation.
All GP practices within Solihull (N = 36) were contacted
first by telephone, second by email if listed and third by
fax. Targeted calls to practices where GPs were known
to refer into EWMM were completed as a second wave
of recruitment. Personalised emails from a Public Health
Consultant were completed as a third wave of
recruitment. Face-to-face or telephone interviews were offered
to GPs to suit their schedules.
School nurses were recruited via email and telephone
with all local area school nurse leads (N = 2); a request
was sent to attend school nurse monthly meetings. FGs
were conducted at school nurses’ monthly meetings to
maximise the range of views collected. Nurses attended
from schools in deprived and affluent areas of the
community to reflect socio-economic disparity in the
prevalence of child obesity [
Data were transcribed verbatim and anonymised. Each
dataset was analysed using a thematic analysis approach
]. RJ coded all data initially and these codes were
cross-checked and discussed with WR to ensure fit. Data
were organised in NVivo [
]. Data were analysed
deductively. Interviews and FG transcripts underwent initial
and then axial coding. Categories were identified and
themes emerged through an iterative process of refining
and expanding emerging concepts and issues related to
the research questions.
Interviews and FGs completed or attempted are
described in Table 1.
Two FGs were conducted with School Nurses and
Nursing assistants and four GPs completed interviews.
Findings are detailed below.
School nurses’ views
Most school nurses described an awareness of EWMM,
yet only three had made referrals into EWMM. Barriers
to pupils being successfully referred to the EWMM
programme emerged from school nurses’ experiences which
36 general practices
90 attempts to contact
(Lack of time given as main reason for
N = 12
Telephone interview (4)
Focus group (2)
are reflected in three themes (1) parent engagement; (2)
children’s autonomy; (3) NCMP letter (Box 1).
School nurses discussed how parents acted as barriers
and facilitators to EWMM referrals. Nurses described
scenarios where children sought out the school nurse
to address their weight, ending with parent contact for
permission to refer the child into EWMM. The referral
would not then be made because the parent declined the
referral. No further action would be taken on behalf of
the child. Direct quotes reflect some of the issues Nurses
expressed relating to this scenario (Box 1).
School nurses discussed the difficulty of how to engage
parents in supporting their children’s desire for making
healthy changes. Little consensus was reached on an
effective approach. There was a sense of helplessness conveyed
in both FGs. There was a clear consensus that there would
be little chance of acting on referrals and children making
and sustaining healthy changes without family support.
Most school nurses shared that children presenting issues
appeared highly motivated to make changes regarding
their weight, but expressed concerns as to how to
instigate and maintain changes within their family dynamic.
Children’s right to make decisions about their own
bodies was identified as an important inconsistency. Namely
Box 1: School nurses’ views and experiences
“But I’ve said to parents, just from asking for consent, to just speak to Eat Well Move More and see what they’re
about and just have a bit more information about it. But they don’t want it, it’s just you get completely shut
“[School Nurse relaying conversation with parent] “I think we’ll sort it out on our own because he’s doing a bit
more exercise, he’s cutting down on the crisps and stuff”…So that’s it, it stops”
“But you’re failing that child in a way aren’t you. And the referral to Eat Well is stopped because there’s no
parental consent, so you can’t… we see them in drop ins and things and healthy plate and healthy eating
and give them the leaflets, but…”
“SN2: I think the issue with that is though, it’s no good just having the children, you do need parents on board
as well, and then they’re going through the same process really”
“SN1: Well I think the children probably would have more impact on the parents than we would”
“But again it’s hard because that child is not… or young person is not in control of the cooking at home. And
I’m guessing that along with overweight children you’ve probably got overweight parents, so it’s not just
about impacting that one child it’s about trying to get the whole family on board”
“But I think they come very positive and want some help, but I think it’s then their ability to take that forward,
which I suppose is about the adolescence and, you know, whether their brain works really about they want
to do it but they can’t”
“Yeah, they’re thinking about body shape and how they feel about themselves”
“meals at home aren’t very healthy and what choice have they got about cooking…you go shopping with
mum…and say, oh I’d like that and can we try that, but that’s quite hard for… 11, 12 year old if mum is
very, you know, right we’ll buy this, this and this, and you have this Monday, this Tuesday…”
“Because there’s a bit of an issue there around giving competency to a 13 year old isn’t there?”
“…there’s an option [to challenge a parents refusal of HPV vaccine], … but with diet it would be slightly
different isn’t it because… if the child wants to address health needs then there should be an option available
“I think there is a stigma attached to it, the fact that some children are getting ‘fat letters’ and in actual fact in
that parents eyes their child hasn’t got a weight issue”
“…I’ve had parents come and see me at drop ins or ring me up saying, who do you think you are saying my
child is overweight? And it’s quite confrontational really”
“But I think in a lot of ways it’s not really useful to our service that we are being sort of tarred with the nurses
that call their children overweight, and it’s creating a bit of a barrier…”
“The only thing that I find sometimes a little bit frustrating is that you don’t have any feedback as to how
well the programme went; did the family or child lose weight or didn’t they attend; that’s the only criticism I
would have for the programme”
“… sometimes it would be nice just to have like a letter to say, completed a 6-week programme or a 10-week
programme and this is the outcome, really”
“it would be nice to know, are they attending,…but we wouldn’t know the outcome unless it sort of comes
back to us or we chase the family up to see whether they actually went, and what the outcome was at the
between a child’s right to challenge their parent’s refusal
of receiving the human papilloma virus (HPV) vaccine
(used as an example in one FG), versus their lack of right
to challenge a weight referral.
The National Childhood Measurement Programme
School nurses recognised the importance of the NCMP,
but expressed concern over negativity surrounding its
implementation. They discussed how the NCMP could
make conversations with parents difficult suggesting it
acts as a barrier to optimal communication between
parents, children and school nurses. Second, nurses reported
that NCMP data were not optimally utilised locally.
Nurses discussed the data currently ‘standing alone’ and
that contextualising NCMP data locally could be used as
a facilitator for engaging school nurses in ongoing
Closing the feedback loop
School nurses consistently expressed a need for feedback
from EWMM. Nurses described how feedback might
improve their knowledge of EWMM and what other
children and parents can expect, which could increase the
likelihood of parental engagement.
Knowledge of childhood obesity and EWMM Two GPs
interviewed had not referred into EWMM recently but all
Box 2 GP views and experiences
were aware of its predecessor programmes (Box 2). GPs
expressed the importance of services such as EWMM
feeding back whether a referral was taken up and if that
service was completed (echoing school nurses).
GPs suggested how they would like to receive
information about EWMM that would increase the chance of
referral into the service:
• A visual prompt in the GP office such as a chart or
characterisations of body shapes.
• More frequent face-to-face information sessions at
their practice to keep them up-to-date with what
services are available.
• Receipt of flyers and posters to put on practice notice
boards or electronic screens in practices.
• Regular follow up and feedback on patient
attendance, completion, drop out and outcomes.
Talking about child weight Two GPs did not see
addressing obesity as a problem and felt that parents were
generally receptive when child overweight was raised. The
other GPs interviewed described a hesitance to have this
‘difficult conversation’ with parents and children. GPs
offered approaches for addressing children’s weight which
included both parent-focused and child-focused ‘tactics’.
GPs felt this was a distinctly different conversation than
one had with adults and they needed to do it “carefully
and subtly” (Box 2).
GPs discussed strategies of addressing weight with
families (Box 2). Two GPs described a particular approach:
shifting the conversation from presenting symptoms
(such as asthma or joint pain) toward a focus on causes of
the symptoms might be, how weight might affect them,
and how losing weight might alleviate them.
Synthesis of findings This study has identified two
factors contributing to lower than expected referral rates
into a community child weight management intervention,
EWMM. First, a lack of knowledge exchange and feedback
between service providers and referrers. Second, a
resistance among health professionals to address child weight
with parents and children, which we refer to as ‘the
The taboo of overweight (considered here as an
avoidance of weight terminology and reluctance to engage
individuals in conversations about weight) was observed
in both school nurses and GPs. This is not a new or
surprising finding given a recent emphasis on personal
responsibility for weight management or the cultural
politics regarding children’s weight [
overweight remains an issue fraught with emotional,
psychological and physical risks, as well as benefits [
For two GPs in this study, the taboo of discussing a
child’s weight related to the hesitancy to have the difficult
conversation between parents, health professionals, and
children. Similarly, school nurses found that broaching
the subject of obesity with parents was challenging and
that they faced backlash from parents as a consequence.
This difficult conversation has been identified in other
populations as a barrier to referrals into weight
management services [
Our study reflects a small set of health professionals’
views on the continued challenge of raising the issue of
children’s weight, as well as how to manage that
conversation between parents, children and health
]. Interventions which promote conversations
between health professionals, children and families
have shown some success [
]; suggesting improved
confidence and skills among health professionals.
However the most effective and sustainable interventions
remain unclear [
]. A key insight from our conversation
with school nurses suggested that children’s voice and
autonomy merits greater consideration in approaches to
accessing weight management among children and
adolescents, particularly when their parents may hold
different views to addressing their weight. This finding has
been expressed elsewhere as important, illustrating a
next step in maximising uptake of effective weight
management interventions for children [
32, 34, 38
Our study identified a complicated network of
practicelevel communication and feedback challenges and
facilitators for a community-based child weight management
intervention. This study contributes to evidence that low
intervention uptake may be related to health
professionals’ hesitancy to have difficult conversations with
children and families.
Recommendations for practice and research
Future research could identify the extent to which health
professionals report ‘the difficult conversation’ as a
barrier to referral into child weight management services,
and develop related training and communication
strategies if warranted. Examining optimal training and
communication strategies between families and health
professionals that are more inclusive of children’s voice
and autonomy also seems warranted.
This study was conducted among a small purposive
sample of participants associated with a specific weight
management service. It may not be applicable to services
addressing child weight where intervention components
or referral pathways differ substantially. Very few GPs
responded to requests to discuss this topic, despite
multiple attempts to contact them. This means data saturation
may not have been reached and made it difficult to gauge
the extent to which identified barriers are commonly
perceived among the wider GP population in Solihull, and
BMI: body mass index; EWMM: Eat Well Move More; FG: focus group; GPs:
general practitioners; HPV: human papilloma virus; NCMP: National Child
Measurement Programme; NICE: National Institute for Health and Care
Excellence; OSOP: ‘One Sheet of Paper’ technique.
RJ, WR, SW and EK were responsible for developing the research questions and
study design. RJ and WR collected data. RJ coded, analysed and interpreted
the data, WR and OO checked the data for fit and contributed to
interpretation. RJ and OO wrote the manuscript. WR, SW, and EK contributed to the
manuscript. All authors agree to be accountable for all aspects of the work
in ensuring that questions related to the accuracy of integrity of any part of
the work are appropriately investigated and resolved. All authors read and
approved the final manuscript.
1 Collaboration for Leadership in Applied Health Research and Care West
MidlandsCollaboration for Leadership in Applied Health Research and Care West
Midlands, Division of Health Sciences, Warwick Medical School, University
of Warwick, Coventry CV4 7AL, England, UK. 2 Public Health and
Commissioning, Solihull Metropolitan Borough Council, Council House, Manor Square,
Solihull B91 3QB, England, UK.
We wish to thank the GPs and Nurses who kindly provided their experiences
The authors declare that they have no competing interests.
Availability of data and materials
All data generated or analysed during this study are available from the
corresponding author on reasonable request.
Consent for publication
Not applicable: No details, images or videos relating to an individual person
are included within this manuscript and hence consent for publication is not
Ethics approval and consent to participate
This study was approved by University of Warwick’s Biomedical Research
Ethics Committee, ID REGO-2016-1748. All participants were given a participant
information sheet which informed them about the purpose of the study, the
risks and benefits of the study, and the reports/publications to be produced
from it. Written consent to participate was obtained.
This work was supported by the National Institute of Health Research
Collaboration for Leadership in Applied Health Research and Care West Midlands,
and by Solihull Metropolitan Borough Council. The views expressed are those
of the author(s) and not necessarily those of the National Health Service,
National Institute for Health Research, Department of Health, or Solihull
Metropolitan Borough Council.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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