1. Introduction
Obesity is widely recognized as one of the most significant health problems affecting children in the 21st century [
1,
2,
3]. The prevalence of both overweight and obesity among children has increased dramatically over the last 30 years, with recent estimates showing that nearly 340 million children are affected worldwide [
1]. The consequences of childhood overweight and obesity are severe and concerning. Children with obesity are at an increased risk of experiencing co-morbidities including type 2 diabetes [
4], insulin resistance [
5], metabolic syndrome [
6], high blood pressure [
4,
7,
8], non-alcoholic fatty liver disease [
9], and asthma [
10]. Childhood obesity has also been associated with negative and serious psychosocial outcomes such as depression [
11] and reduced quality of life [
10,
12]. Furthermore, children with overweight and obesity tend to carry excess weight into later life [
13], which can lead to the development of additional health consequences during adulthood, including stroke [
14], osteoarthritis [
15], and some cancers [
15].
Consequently, there is an urgent need to design and implement effective and sustainable interventions that target the treatment of paediatric overweight and obesity [
16]. One type of intervention, widely accepted and utilized in the treatment of childhood obesity, is the family-based approach [
17,
18,
19,
20]. Family-based paediatric obesity interventions acknowledge the family environment as a unit, as well as the significant influence of parents both as gatekeepers and role models, on children’s health-related choices and behaviours [
17,
21,
22,
23,
24,
25]. Thus, these treatments typically focus on improving factors such as parental support, family dynamics, and aspects of the home environment to enhance health-related behaviours among children [
17,
19,
20,
25].
Central to the family-based approach, ‘parental involvement’ has been identified as a key component of successful paediatric weight management interventions [
18,
26,
27]. Kitzmann and colleagues (2010), for example, conducted a meta-analysis containing 125 experimental childhood overweight/obesity treatment studies to examine the effectiveness of interventions with high parental involvement (i.e., parents participated in all components of treatment) versus those with low parental involvement (i.e., only the child participated in the majority of the treatment components). The results showed that overall, childhood overweight/obesity treatment interventions consisting of high levels of parental involvement were significantly more effective with regard to improving child weight-related outcomes (i.e., weight, body mass index (BMI), standardized BMI (BMI-
z), and percentage overweight) than were interventions with low levels of parental involvement [
26].
Given the relative success of paediatric obesity treatment programs involving parents, researchers have also implemented and evaluated interventions that target parents as the “primary agents of change” [
27,
28,
29,
30,
31,
32]. Parent-focused interventions, also known as “parent agent-of-change” [
30,
31,
33] or “parent-only” [
28,
34,
35,
36,
37] interventions, are those that exclusively target parents in the treatment of childhood overweight/obesity [
33,
35]. While the primary outcomes generally remain child-focused, children are not directly involved in the intervention. Parent-only childhood obesity interventions have taken various forms based on focus (e.g., positive parenting skills [
30,
34], health knowledge/education and behaviour change [
38,
39], environmental modifications [
40], etc.) and setting (e.g., primary care [
41,
42], out-patient [
43,
44,
45], university [
39], and community [
46,
47]).
Generally speaking, childhood obesity treatment studies in which parents have been identified and included as the primary agents of change have resulted in reductions in children’s BMI-
z [
28,
45,
48] and BMI percentile [
41,
42]. In addition, the authors of various systematic reviews have found that parent-only interventions are either as effective as [
35,
36,
37] or potentially more effective than [
37] family-focused (i.e., parent- and child-focused) interventions in terms of reductions in children’s BMI-
z scores. Lastly, there is also evidence to suggest that parent-only childhood obesity interventions may be more cost-effective than traditional family-based interventions, as they are typically less expensive to implement and require fewer resources [
37,
49].
Approximately a decade ago, our research team developed and implemented a 4-week, family-based (i.e., parent-child) childhood obesity intervention, entitled the Children’s Health and Activity Modification Program (i.e., the original “C.H.A.M.P.” program [
50]). This 4-week group-based pilot program was delivered to 40 families over two consecutive years in the form of a summer day-camp for children (Monday–Friday, 9:00 a.m.–4:00 p.m.) plus weekend education/activity-based sessions for parents (Saturdays from 10:00 a.m.–2:00 p.m.). Overall, qualitative data indicated that C.H.A.M.P. was received positively by both children [
51] and parents [
52]. The quantitative results were also promising; significant improvements were found for children’s fat and muscle mass percentages from pre- to post-intervention, and significant reductions in BMI-
z were sustained 6 months post-intervention [
53]. Perhaps most noteworthy were the significant improvements in child- and parent-proxy reported quality of life, sustained up to 12-months post-intervention [
53], as well as improved physical activity self-efficacy from pre- to post-intervention [
54].
Interestingly, qualitative data gathered via focus groups conducted after the original C.H.A.M.P. program also revealed that parents and children expressed a desire for greater parental involvement [
51,
52]. For example, many children expressed that they required more support and participation from their parents in helping them to adopt and maintain healthy behaviour changes [
51]. In addition, C.H.A.M.P. parents noted that they would have liked additional education and program engagement opportunities (e.g., professional consultation, take-home materials, hands-on learning activities) and that they wanted program staff to hold them more accountable for lifestyle changes and participation in the program [
52]. However, despite expressing a need for more involvement in the program, parental adherence to the C.H.A.M.P. intervention was low in comparison to that of children (i.e., 69% vs. 91% over 4 weeks). Indeed, such findings are in line with the literature as participant adherence and attrition issues have been cited as important barriers to and limitations of other childhood obesity interventions, particularly those that target parents [
35,
37,
55].
On the basis of evidence from the original C.H.A.M.P. program (including parents’ perceptions of the program and recommendations for future interventions [
52]), as well as the growing literature and documented effectiveness of childhood obesity interventions targeting parents, our team recently developed and implemented a 13-week group-based intervention entitled “C.H.A.M.P. Families”. Whereas the original C.H.A.M.P. program was offered primarily to children (with a relatively small family-based/parental component), C.H.A.M.P. Families was offered to parents (with minimal direct child involvement) who had a child with overweight or obesity. The overall purpose of the C.H.A.M.P. Families program of research was to implement and assess the feasibility of the pilot intervention using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, a tool applied to facilitate the design and evaluation of health behaviour interventions [
56,
57,
58,
59]. Gathering information about participants’ perceptions of and experiences in such programs is a critical component of assessing intervention acceptability and feasibility [
60]. Thus, the primary objective of the current study was to explore the perspectives of parents who participated in the C.H.A.M.P. Families intervention with regard to their experiences in the program, as well as the program’s influence on various aspects of child and parental wellbeing (i.e., health behaviours, parental confidence for supporting health behaviour change, and family communication). A secondary purpose was to explore parents’ perceptions of the program’s strengths and weaknesses, and to identify practical issues that could help to inform the design of future childhood obesity treatment programs. While previous studies have highlighted parents’ perspectives of their experiences related to primary care [
61,
62] and family-based childhood obesity interventions [
63,
64,
65], to our knowledge, this is the first study to explore the perceptions of parents in the context of a community-based, parent-only lifestyle intervention targeting childhood obesity.
4. Discussion
The purpose of this study was to explore parents’ perspectives related to their role(s) as the ‘primary agent-of-change’ in a parent-focused childhood overweight/obesity program, as well as the perceived impact of the program on child and parental health and wellbeing. Program strengths and weaknesses, as well as practical issues and recommendations that could contribute to the design of future family-based treatment programs for paediatric obesity were also elicited. Several studies have highlighted parents’ perspectives of their experiences related to primary care [
61,
62] and family-based interventions [
63,
64,
65], but to our knowledge, this is the first study to explore the perceptions of parents in the context of a community-based, parent-only lifestyle intervention targeting childhood obesity.
The parents who participated in focus groups described several perceived benefits for children (i.e., improved dietary behaviours, increased physical activity, and enhanced empowerment and autonomy), families (i.e., enhanced family dynamics and healthy food choices), and themselves (i.e., greater parental confidence to support and promote health behaviours in children), all of which were attributed to their involvement in the program. One additional and unanticipated benefit of the program that was highlighted by many parents related to the free, active programming that was offered to children at the YMCA during the parent-only sessions. Though this programming was not part of the formal intervention and was originally intended to reduce barriers to participation, it was noted by participants to have very positive outcomes for both children and parents. Interestingly, while parents noted improvements in their confidence to serve as agents of change for their families and to have conversations with children about health- and weight-related issues, they also emphasized that these areas could be addressed more explicitly in future paediatric obesity treatment programs. For example, several parents articulated challenges associated with relaying program content to children, suggesting that while they felt they had sufficient knowledge about the health topics discussed during the sessions, they lacked the necessary tools and strategies to effectively implement changes in the home environment. Some parents also noted that their children would likely be more receptive to the information if it came from an “expert” rather than from a parent or guardian. With regard to communication, many parents expressed a desire to protect their children’s feelings and self-esteem, which they believed could be damaged if they did not broach certain health- and weight-related topics sensitively.
Indeed, poor family communication has been found to be associated with an increased risk of child overweight/obesity [
81], and certain types of parent-child weight-related talk has also been identified as potentially detrimental to a child’s health and wellbeing [
82]. For instance, in a 2016 meta-analysis consisting of 4 intervention studies and 38 associative (cross-sectional and prospective) studies, Gillison and colleagues found that communication consisting of weight criticism (i.e., teasing) and encouraging weight loss increases the likelihood of poor physical self-perceptions, dysfunctional eating, and dieting behaviours in children [
82]. Conversely, Gillison et al. reported that encouraging healthy exercise and diet without discussing weight directly was associated with less unhealthy weight control and dieting behaviours among children [
82]. Unfortunately, evidence-based resources and strategies to help parents navigate conversations with children about food and weight management are lacking in the literature [
81,
82]. Furthermore, it important that as researchers, we acknowledge the possibility that we may inadvertently draw parents’, and subsequently children’s, attention to weight given that weight-related measures such as BMI-
z are often the primary outcome in childhood obesity studies [
35]. Thus, shifting the focus towards healthy lifestyles and facilitating positive and supportive family communication are important considerations for future paediatric overweight/obesity interventions [
82]. Additional barriers to health behaviour change identified by C.H.A.M.P. Families participants, including time constraints, parenting issues, and lack of social support, were consistent with those that have been previously cited by parents in the childhood obesity treatment literature [
62,
63,
64].
As noted previously, C.H.A.M.P. Families was informed by feedback from parents who took part in the original C.H.A.M.P. program [
50], many of whom advocated for greater parental involvement and accountability in future paediatric obesity interventions [
52]. Despite evidence indicating that parent-only interventions for childhood overweight/obesity may be as effective, or even more effective, than parent-child interventions [
37], many of the parents in the current study noted that their children would have benefited from increased participation in the program. Taken together, it is reasonable to suggest that parents seem to desire a childhood obesity treatment program that is relevant for, and balances the involvement and accountability of, both parents and children.
While nearly all of the feedback about C.H.A.M.P. Families was positive, one parent did note that the delivery of content provided by one of the invited guest speakers was not relatable or relevant to their family. Although this comment was not deemed to be sufficient to warrant its own theme per se, such feedback will certainly be used by our team in the development of future programs.
One of the most impactful components of C.H.A.M.P. Families identified by participants was the sense of community and belonging that developed among the parents in the program. Connecting with other parents in a group-based setting was perceived by parents, especially those who had experienced stigma associated with having a child with overweight/obesity, as very powerful; many noted that they valued feeling as though they were “not alone”. This finding stresses the importance of cultivating a positive and inclusive group-based environment to support health behaviour change [
83]. Groups can be powerful facilitators of change for and adherence to a variety of health behaviours [
83,
84,
85,
86], and in the context of childhood obesity, group-based programs have been shown to be more effective in reducing child BMI-
z scores than treatments administered individually [
87,
88]. As stated previously, C.H.A.M.P. Families was intentionally designed using several evidence-based group dynamics strategies [
74] that have been used successfully in previous family-based childhood obesity interventions [
50] in an attempt to enhance adherence, group cohesion, and other health-related outcomes.
In addition to the importance of the group environment, participants emphasized that their experience in the program was enhanced by the rapport developed between themselves (including their children) and the Project Coordinator whom they described as likeable, engaging, and non-judgmental. Weight bias among primary care providers [
89,
90], as well as exercise and nutrition professionals [
91], has been well-documented in the literature and has been shown to compromise patient outcomes and quality of care [
92]. Furthermore, perceptions of judgment from health professionals can have a negative effect on weight loss [
93]. While this intervention was administered by researchers in a community setting, it remained important for program staff to foster supportive relationships with participants to ensure that they felt accepted and did not experience stigma or judgment.
The present study is not without its limitations. First, given that the focus groups were moderated by members of the research team, it is possible that the positive feedback received from participants was influenced by social desirability [
94], despite the use of honesty demands [
75]. Second, the focus groups were conducted immediately following the intervention which might have increased positive perceptions related to the program and also limits the researchers’ ability to capture participants’ long-term perspectives of the program. Third, while the majority of C.H.A.M.P. Families participants (75%) attended a focus group session, there were four participants who did not participate in the focus groups (one who withdrew from study and three who had scheduling conflicts) and thus, whose perspectives and experiences were not captured. Three of the four participants who did not partake in the focus groups reported lower than average household income and/or education levels, and the same number of participants (although not necessarily the same individuals) attended ≤ 50% of the C.H.A.M.P. Families sessions. Given our small sample, it is unclear whether these factors impacted program participation or effectiveness, or whether the current findings might have differed had these individuals shared their experiences in a focus group. Fourth, it should be noted that despite efforts to recruit a diverse sample of participants, the individuals who participated in these focus groups, and in C.H.A.M.P. Families overall, were fairly homogenous in terms of their ethnicity and socioeconomic factors (i.e., household income and education). This is in line with a previously noted limitation in the childhood obesity intervention literature in which individuals of ethnic minorities and low socioeconomic status tend to be under-represented [
55]. Further research examining strategies to improve recruitment, engagement, and adherence of these individuals is warranted. Lastly, as a result of the limited sample size, it was difficult to assert with confidence that true data saturation was reached.