Health Visitor Communication Challenges on Child Obesity Concerns at 30 Months Assessment

Presented by: Ivana Oracova, NHS Greater Glasgow and Clyde

Health visitor communication with parents about child obesity concerns at the 30 month assessment Ivana Oracova, Trainee Health Psychologist NHS Greater Glasgow and Clyde

Background In 2010, over 20% of 4-5 year olds in Scotland were overweight or obese In Glasgow ~ 1 in 25 2.5 year olds will be identified as obese at the 30 month assessment Prevention and timely management of preschool obesity important for decreasing risk of obesity and chronic illness later in child s life Health visitors have a unique position to support parents with both prevention and management of child obesity: yet we know little about their experiences when communicating with parents about children s weight (Mikhailovich & Morrison, 2007)

Background Australia: Edvardsson et al (2009) o HVs (N=10) - preschool obesity difficult to raise, especially if parents also overweight: denial, defensiveness and excuses common reactions Laws et al (2009) o HV Survey (N=56) 22% never or rarely used growth charts - possibly reflecting a reluctance to raise the issue with parents/lack of confidence? Sweden: Regber et al (2013) o HVs (N=15) - BMI charts used inconsistently o obesity is sensitive, but parents prefer for their children to be slightly heavier UK: Redsell et al (2012) o HVs (N=30) - talked about their role in advising parents about diet but did not formally identify or intervene with larger infants

Aims to describe experiences of health visitors in Scotland when communicating and raising children's overweight with parents at the 30 month assessment to explore whether health visitors experience different communication challenges when raising the issue of children's overweight compared to raising speech and language concerns

Methods In depth semi-structured interviews (purposive sampling) with 19 health visitors (HVs) (18 females) Data collected between May and September 2016 8 HVs (42%) interviewed in person, 11 via telephone 10 HVs (47%) were from the North West, 9 from the North East Areas of Glasgow differences between areas in availability of preschool weight management interventions Average interview length: 44 minutes

Analysis: Stages 1. Data collection and initial data analysis All interviews audio recorded cyclical process: initial analysis of the data informed subsequent data collection - interview schedule slightly modified in light of emerging findings theoretical sampling: data collected until saturation was reached Data preparation All interviews were transcribed verbatim Familiarisation with data to obtain general sense of material All data are currently being imported to QSR N Vivo 11 software 3. Final data analysis Thematic content analysis using an interpretative, inductive approach Analysing and reviewing transcripts, identifying and coding for categories and themes from the data Data similar in meaning clustered together Gathering examples of each theme from the text 20-25% of interviews will be independently coded by second coder 2.

Results: Table1: Initial Coding Framework Interview transcript How do you think parents receive their child s obesity being raised? Parents own weight and weight related beliefs HV: Obesity is more difficult to raise because quite often you can have obese parents... I think its about being honest and upfront..it s about the language you use...everyone is a bit touchy about their weight I think... Parental reception of their child's obesity Why do you think this might be? HV: The overweight is...a personal thing ... I don t like telling people their child is overweight and I m sitting there overweight myself, but the speech and language I ve not got a problem with that Sometimes, I feel quite hypocritical because I'm...I've not done it myself you know but I say to them it's for their own good Professional duty to raise the concern Personal relationship with weight Obesity more difficult to raise than speech and language

Results: Table 2: Final Coding Framework Theme 1. Identification of obesity Subtheme 1. Obesity not common at 30 month assessment 2. Need for identifying obesity earlier 1. 2. Meeting parents where they're at Relationship with parent when raising the concern Personal relationship with weight Parental reception of their child's obesity Obesity more difficult to raise than speech and language Professional duty to raise the concern 2. Raising obesity concerns 3. 4. 5. 6. 3. Barriers to effective management of obesity

Theme 1: Identification of obesity HVs talked about the importance of identifying obesity as early as possible and providing parents with information about healthy diet and recommended physical activity levels Obesity was identified by measuring the child's height and weight and plotting this onto the centile charts, BMI charts were never or rarely used

1. Obesity not common at 30 month assessment ...you would think...there would be quite a few but actually...there's probably more on the other end of the scale...there are more children who are small and skinny and picky eaters rather than the ones who are overweight (HV13) ...majority of children who are overweight are picked up before 30 months because there are other concerns in the household impacting that child's world and it s usually the thing that's causing that child to be unhealthy... (HV6)

2. Need for identifying obesity earlier than at 30 months I wonder if there is a bit of a gap, I think a lot of the problems start when they go off baby foods, because they go from taking jars of baby food to eating a sausage roll with not very much in between. I don't know if obesity would be better addressed earlier, before parents get into habits and routines... (HV13)

Theme 2: Raising obesity concerns Raising obesity concerns to parents is a sensitive topic needs to be discussed appropriately Centile charts - a helpful visual tool a good 'way in' to raise the concern and an opportunity to ask about diet and activity levels Confidence to raise the subject rated to be 7 or higher However, having years of experience important to navigate these conversations successfully

1. Meeting parents at where they are Use softer/strengths based approach - look at each family in isolation Assess parents recognition of the issue Avoid medicalising ...most parents are quite offended when you broach the subject with them and you do need to do a bit of dancing around the gardens and soothe and calm the waters with them...(HV11) if you have the parents behind you, you can take the back seat and give family time to offload and let it sink in, it s about the containment you need to do in the beginning...how you would approach it doesn't depend on the subject but on the people you're talking to... (HV6)

2. Relationship with parents when raising obesity concerns ...the anxiety is the relationship, it's a very sensitive topic for parents...If you ask me how it makes me feel, it feels a bit unpleasant and its anxiety provoking, not majorly...but from a professional perspective this can impact your relationship with the family and they can avoid your appointments... (HV5) I think that s a relationship with the parent, I am confident to raise the concern, but your perception of how they are going to receive that you need to be careful... if you haven t got a relationship you have to be mindful of setting the scene ... (HV7) ...when you are new on the case load you haven t had time to build a relationship and a lot of people that I am meeting at 30 months, they haven t met me before... (HV3)

3. Personal relationship with weight I am not a size 10 myself so I am very conscious that you've got to also look healthy to give this advice (HV7) The overweight is a personal thing because I don t like telling people their child is overweight and I m sitting there overweight myself... I feel quite hypocritical because I've not done it myself but I say to them it's for their own good... (HV6) . ..we know ourselves that weight is a big issue for us as well and it does feel quite personal to have weight commented on... (HV13)

4. Views on parental reception of their child's obesity .. parents are in denial, they think it's just puppy fat and they'll grow out of it, they just don't see it as an issue (HV12) [it] may be taken as criticism of not looking after their child properly, so they can become quite defensive... oh he's big boned , he doesn't eat very much ... (HV13) most parents know if their child is overweight and need to hear it from someone else... (HV7)

4. Views on parental reception of their child's obesity When asked about any differences in parental reception of obesity versus speech and language concerns.... .... it is overweight that parents see much more as a failure, because they think they have control over what their child eats, [but not] whether their child speaks, it is something that they perceive they have done... (HV11) ...they want their children to be speaking... they are more inclined to tell you there is a problem with speech and language than obesity and I think it s all to do with peoples perceptions ... because there s always been a stigma put to people being overweight... (HV9)

5. Obesity more difficult to raise than speech problems Obesity is always a bit more difficult to raise because quite often you can have obese parents... It s about being honest and upfront... about the language you use...everyone is a bit touchy about their weight... (HV8) Obesity is very personal..I am less confident with it than speech because I feel like I am criticising the child's appearance... (HV13) I am much more confident raising speech and language [concerns] because parents really want their children to talk... (HV5)

6. Professional duty to raise obesity concerns This [raising of obesity] created a barrier in my relationship with the parent, but it's never not going to be raised, its a duty that I have as such... (HV5) ..you have to be discreet but there comes a time and place where you have to be honest about it... there's too much going on tip toes and we don't want to offend anybody [but] there's more harm to the child if we don't do something... (HV12) If mum and dad are sitting there and they are enormous, you re having to touch on them as well...[but] you still have to get the point over, you wouldn t want to not say anything... (HV4)

Theme 3: Barriers to effective management of obesity We are quite time restrictedso it s difficult but ...we get support ...so I think we can manage it to a certain degree but we get to a point where we need advice and support from another team... (HV3) It is frustrating that we have interventions, but don't have capacity to deal with people in timely fashion...and if we don't start straight away it takes away the cloud... (HV13) I don't think I am a specialist in that, I can identify at early stages ..but I think when they are quite obese they need further help...so I would feel confident up to a certain degree...but ...further than that a specialist could be much more in depth with it... (HV12)

Theme 3: Barriers to effective management of obesity I haven't used any obesity interventions but on paper it [MEND] seems a good intervention...what you have is ...people are looking for quick fixes....but with any intervention that asks parents to commit, parents are not keen to engage... (HV11) We get confused because services come and go...we have to check with each other because there have been so many changes and we all feel a bit overwhelmed about what you do and when.. (HV14)

Implications Prevalence of childhood overweight and obesity estimated to affect 60 million children by 2020 (de Onis et al, 2010) Supporting HVs and parents with skills for behaviour change important for prevention of child obesity Current challenges: Obesity not common for HVs? (e.g. Isma et al., 2013) HV guidance focus on other priorities need for guidelines to place stronger emphasis on preschool obesity Debunking the puppy fat myth support HVs to educate parents that Puppy fat can have lifelong health consequences Reducing stigma of obesity an ongoing challenge for us all

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