This is the first study to investigate perceptions of pediatric obesity clinicians to better understand attrition, all of whom recognized it as a significant problem. Utilizing an in-depth qualitative approach, the findings revealed several key areas that clinicians believe influence attrition from pediatric obesity treatment. Clinicians recognized family characteristics (highly stressed, poor) and aspects of their treatment programs (scheduling, location) may contribute to attrition. There were themes of past experiences with treatment, family desire for immediate outcomes, and clinician-family relationships that influenced families’ motivation. Interestingly, many clinicians felt parents had greater confidence than their children. An unexpected finding was families rarely sought treatment on their own. This could be important since Motivational Interviewing34, 35
(used in all six participating programs) requires treatment to be patient-centered as a means to build motivation for change. If children and families are not actively seeking treatment, it may take time to prepare families or explore ambivalence regarding behavior change. However, clinicians interviewed did not comment on this or discuss possible implications.
The triangulation process, engaging the different levels of obesity treatment, yielded important similarities and differences. PC and TC clinicians had many similar perceptions, primarily the importance of relationships and communication in treatment, which they felt helped families manage barriers and modify goals. CB programs focused largely on engaging families through enjoyable curricula and incentives. Through the analysis process, it became apparent that CB clinicians may be sending contradictory messages about behavior change and reasonable expectations by sharing dramatic weight loss stories with families, frequently weighing children, and rewarding weight loss. This is interesting, given that all clinicians, including those in CB programs, stated outcomes should focus on health and habits rather than “a number on the scale.” CB and TC programs were similar in they focused heavily on preparing families for treatment, whereas PC programs had no pre-treatment orientation or preparation. With varying levels of obesity treatment, outlined in the 2007 expert recommendations, more research is needed in this area to confirm these findings and explore further.
There are several implications that can be drawn from this study. Across diverse treatment settings, attrition is recognized as a problem with multiple potential contributors: location; family barriers such as poverty and stress; scheduling and timing of programs; unrealistic expectations; and lack of family motivation. Though all programs recognized similar contributors, only TC programs aggressively addressed them, presumably because of their location within academic medical centers and better access to clinical resources. Unrealistic expectations and understanding treatment are potentially important areas to concentrate in order to improve attrition. Clinicians focused on these concepts and indicated efforts to address them, but were still seen as a problem. Despite clinicians’ best efforts, alternative approaches to building expectations may be needed to better address attrition resulting from errant expectations, as present activities may not be effective. Another potential area of future inquiry and investigation is the perception that parents have greater confidence than their children. In a family-based program, effort towards building motivation, confidence, and appropriate expectations may need to be directed towards the child as well as the parent. Previous research indicates children influence a family’s decision to drop out of treatment13, 36
, thus, inclusion of the child’s perspective could hold promise when determining how to address attrition.
Greater focus on these and other processes would be useful to improve obesity interventions, as they may help lower attrition rates and increase patient success in reaching goals. For instance, CB clinicians felt strongly that there are positive interactions when families receive treatment in group settings. PC and TC clinicians could enhance their treatments to provide families with more opportunities for social interaction, which has shown promise in prior research 37
. Conversely, PC and TC programs felt that building relationships with children and families improves retention. Thus, CB clinicians could potentially improve their approaches by facilitating relationship building with staff and participating families, another concept proven effective 38
. Finally, it is likely families who enroll in treatment solely based on physician referral may not desire weight management or be fully prepared to participate in treatment. For some families, encouragement by a physician or the opportunity to engage a needed resource could spur them to behavior change. For others, though, that may not be enough, nor be the right time. This could explain difficulties with motivation, unrealistic expectations, and under-valuing treatment (). Changing the process by which families are referred, enrolled, or prepared for treatment may potentially improve attrition and outcomes.
There are several limitations to this study. Foremost, this is a qualitative study, reporting perceptions of clinicians from a single state (North Carolina), and not participating children and families. This may not be representative of all approaches to treatment, programs in other locations, or of other patient populations. However, the study explicitly sought to collect a broad range of perspectives on attrition from various levels of treatment and clinicians. PC programs included in this study are unique: one is a large general pediatric practice that has developed a “program within a practice” with a dedicated physician and dietitian; the other program resembles a federally-qualified health center (does not receive government funding, but serves primarily a Medicaid population) and has resources not readily available to typical pediatric practices (dietitian). Therefore, this study did not engage primary care pediatricians attempting weight management in their office without other resources.
There are several avenues found in this study to explore further, both in research and clinically: the impact of preparing families for the treatment process; evaluating the effectiveness of incentives; and the value families place on treatment, in light of other life stressors. PC and TC clinicians felt strongly that developing open and trusting relationships with families may facilitate this process, as patients could be more likely to tell clinicians about barriers to treatment adherence. All clinicians perceived that families’ inaccurate expectations of treatment contributed to attrition, and reported attempts to build appropriate expectations. Treatment programs can “borrow” from each other as well: clinic-based programs could add more group programming to encourage social support, and CB programs could focus more on relationships with families in an effort to decrease attrition.
Attrition is recognized as a significant problem in pediatric obesity treatment. Clinicians that participated in this study represent the spectrum of obesity care providers, and all recognized drop out as a complicating factor in their treatment efforts. The findings of this qualitative study provide further avenues to investigate this problem: realistic expectations, importance of relationships with families, and addressing how families value treatment. This study can guide future qualitative and quantitative studies of obesity treatment programs, as a larger study of treatment programs can inform best practices. In particular, clinicians’ perceptions can assist in capturing the perceptions and experience of children and families participating in weight management programs, and has the potential to improve care and outcomes. Clinicians working in pediatric obesity can consider the experience and perceptions of the clinicians included in this study as they plan and modify their own family-based treatment programs, particularly when addressing the problem of attrition.