Lisa Arai

What works in practice: user and provider perspectives on the acceptability, affordability, implementation, and impact of a family-based intervention for child overweight and obesity delivered at scale

BackgroundAs part of a study considering the impact of a child weight management programme when rolled out at scale following an RCT, this qualitative study focused on acceptability and implementation for providers and for families taking part.MethodsParticipants were selected on the basis of a maximum variation sample providing a range of experiences and social contexts. Qualitative interviews were conducted with 29 professionals who commissioned or delivered the programme, and 64 individuals from 23 families in 3 English regions. Topic guides were used as a tool rather than a rule, enabling participants to construct a narrative about their experiences. Transcripts were analysed using framework analysis.ResultsPractical problems such as transport, work schedules and competing demands on family time were common barriers to participation. Delivery partners often put considerable efforts into recruiting, retaining and motivating families, which increased uptake but also increased cost. Parents and providers valued skilled delivery staff. Some providers made adaptations to meet local social and cultural needs. Both providers and parents expressed concerns about long term outcomes, and how this was compromised by an obesogenic environment. Concerns about funding together with barriers to uptake and engagement could translate into barriers to commissioning. Where these barriers were not experienced, commissioners were enthusiastic about continuing the programme.ConclusionsMost families felt that they had gained something from the programme, but few felt that it had ‘worked’ for them. The demands on families including time and emotional work were experienced as difficult. For commissioners, an RCT with positive results was an important driver, but family barriers, alongside concerns about recruitment and retention, a desire for local adaptability with qualified motivated staff, and funding changes discouraged some from planning to use the intervention in future.

The unseen child and safeguarding: ‘Did not attend’ guidelines in the NHS

Background Organisations in Englands National Health Service (NHS) are required to have ‘did not attend’ (DNA) guidelines to help deal with the ‘unseen child’. Aims To map DNA and associated guidelines in paediatric services, examine differences in safeguarding response and advice in the guidelines and explore the experience of guideline users. Methods A mapping approach was used to locate current DNA guidelines on English NHS organisations’ websites. Analysis of the guidelines was supplemented with qualitative data from those who produce, monitor or use them. Results Fewer than 8% of English NHS organisations had up-to-date guidelines in the public domain, though a further 41% stated that they had a DNA/similar policy in place or had an out-of-date guideline on their website. Advice to healthcare providers about the steps to take when a child DNAs fell into five categories: reflection and review; direct interaction with the family; indirect interaction with the family; liaison with internal colleagues; and external referral. Interviews with eight individuals led to the identification of four themes. The management of information flows was central to the effective management of DNA. Respondents also reported seeking support and advice from others. While all respondents spoke about the importance of supporting the family, the childs needs were central to dealing with non-attendance, and respondents demonstrated awareness of wider risk discourses. Conclusions We consider the implications of the work and suggest that evidence-informed guidelines developed nationally but tailored to specific services might be helpful for providers and users alike.

Time, Monetary and Other Costs of Participation in Family-Based Child Weight Management Interventions: Qualitative and Systematic Review Evidence

Background Childhood overweight and obesity have health and economic impacts on individuals and the wider society. Families participating in weight management programmes may foresee or experience monetary and other costs which deter them from signing up to or completing programmes. This is recognised in the health economics literature, though within this sparse body of work, costs to families are often narrowly defined and not fully accounted for. A societal perspective incorporating a broader array of costs may provide a more accurate picture. This paper brings together a review of the health economics literature on the costs to families attending child weight management programmes with qualitative data from families participating in a programme to manage child overweight and obesity. Methods A search identified economic evaluation studies of lifestyle interventions in childhood obesity. The qualitative work drew on interviews with families who attended a weight management intervention in three UK regions. Results We identified four cost-effectiveness analyses that include information on costs to families. These were categorised as direct (e.g. monetary) and indirect (e.g. time) costs. Our analysis of qualitative data demonstrated that, for families who attended the programme, costs were associated both with participation on the scheme and with maintaining a healthy lifestyle afterwards. Respondents reported three kinds of cost: time-related, social/emotional and monetary. Conclusion Societal approaches to measuring cost-effectiveness provide a framework for assessing the monetary and non-monetary costs borne by participants attending treatment programmes. From this perspective, all costs should be considered in any analysis of cost-effectiveness. Our data suggest that family costs are important, and may act as a barrier to the uptake, completion and maintenance of behaviours to reduce child obesity. These findings have implications for the development and implementation of child weight initiatives in particular, in relation to reducing inequalities in health.

What makes for a ‘good’ or ‘bad’ paediatric diabetes service from the viewpoint of children, young people, carers and clinicians? A synthesis of qualitative findings

Background There is mounting evidence that experience of care is a crucial part of the pathway for successful management of long-term conditions. Design and objectives To carry out (1) a systematic mapping of qualitative evidence to inform selection of studies for the second stage of the review; and (2) a narrative synthesis addressing the question, What makes for a ‘good’ or a ‘bad’ paediatric diabetes service from the viewpoint of children, young people, carers and clinicians? Results The initial mapping identified 38 papers. From these, the findings of 20 diabetes-focused papers on the views on care of ≥650 children, parents and clinicians were synthesised. Only five studies included children under 11 years. Children and young people across all age groups valued positive, non-judgemental and relationship-based care that engaged with their social, as well as physical, health. Parents valued provision responsive to the circumstances of family life and coordinated across services. Clinicians wanting to engage with families beyond a childs immediate physical health described finding this hard to achieve in practice. Limitations Socioeconomic status and ethnicity were poorly reported in the included studies. Conclusions In dealing with diabetes, and engaging with social health in a way valued by children, parents and clinicians, not only structural change, such as more time for consultation, but new skills for reworking relations in the consultation may be required.

Bureaucracy, trust and time: recruitment in a low-risk study of paediatric protocols for children who miss medical appointments

As Roe et al 1 point out, failing to ensure access to paediatric appointments has implications for a range of outcomes, including safeguarding. Here we report challenges we experienced in finding out from the frontline how protocols intended to address this problem are experienced on the ground. Following our did not attend (DNA)2 3 studies, we reviewed recruitment notes on our attempts to talk to people tasked with producing or implementing these protocols. After speedy institutional ethics review, we required research and development (R&D) approval from each trust where we had identified a relevant DNA protocol in order to ask potential interviewees if we could talk to them. R&D contacts were helpful but risk-averse. Challenges included …

Time, monetary and other costs of participation in family-based child weight management interventions

Background Childhood overweight and obesity have health and economic impacts on individuals and the wider society. Families participating in weight management programmes may foresee or experience monetary and other costs which deter them from signing up to or completing programmes. This is recognised in the health economics literature, though within this sparse body of work, costs to families are often narrowly defined and not fully accounted for. A societal perspective incorporating a broader array of costs may provide a more accurate picture. This paper brings together a review of the health economics literature on the costs to families attending child weight management programmes with qualitative data from families participating in a programme to manage child overweight and obesity. Methods A search identified economic evaluation studies of lifestyle interventions in childhood obesity. The qualitative work drew on interviews with families who attended a weight management intervention in three UK regions. Results We identified four cost-effectiveness analyses that include information on costs to families. These were categorised as direct (e.g. monetary) and indirect (e.g. time) costs. Our analysis of qualitative data demonstrated that, for families who attended the programme, costs were associated both with participation on the scheme and with maintaining a healthy lifestyle afterwards. Respondents reported three kinds of cost: time-related, social/emotional and monetary. Conclusion Societal approaches to measuring cost-effectiveness provide a framework for assessing the monetary and non-monetary costs borne by participants attending treatment programmes. From this perspective, all costs should be considered in any analysis of cost-effectiveness. Our data suggest that family costs are important, and may act as a barrier to the uptake, completion and maintenance of behaviours to reduce child obesity. These findings have implications for the development and implementation of child weight initiatives in particular, in relation to reducing inequalities in health.

Time, monetary and other costs of participation in family-based child weight management interventions: qualitative evaluation findings and evidence from the health economics literature

Background Childhood overweight and obesity have health and economic impacts on individuals and the wider society. Families participating in weight management programmes may foresee or experience monetary and other costs which deter them from signing up to or completing programmes. This is recognised in the health economics literature, though within this sparse body of work, costs to families are often narrowly defined and not fully accounted for. A societal perspective incorporating a broader array of costs may provide a more accurate picture. This paper brings together a review of the health economics literature on the costs to families attending child weight management programmes with qualitative data from families participating in a programme to manage child overweight and obesity. Methods A search identified economic evaluation studies of lifestyle interventions in childhood obesity. The qualitative work drew on interviews with families who attended a weight management intervention in three UK regions. Results We identified four cost-effectiveness analyses that include information on costs to families. These were categorised as direct (e.g. monetary) and indirect (e.g. time) costs. Our analysis of qualitative data demonstrated that, for families who attended the programme, costs were associated both with participation on the scheme and with maintaining a healthy lifestyle afterwards. Respondents reported three kinds of cost: time-related, social/emotional and monetary. Conclusion Societal approaches to measuring cost-effectiveness provide a framework for assessing the monetary and non-monetary costs borne by participants attending treatment programmes. From this perspective, all costs should be considered in any analysis of cost-effectiveness. Our data suggest that family costs are important, and may act as a barrier to the uptake, completion and maintenance of behaviours to reduce child obesity. These findings have implications for the development and implementation of child weight initiatives in particular, in relation to reducing inequalities in health.