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Table 7 Summary of qualitative findings

From: Communication of children’s weight status: what is effective and what are the children’s and parents’ experiences and preferences? A mixed methods systematic review

Review findingConfidence in the evidenceExplanation of confidence in the evidenceContributing studies
Timing of information
Q1: Some parents felt that there was a lack of communication about the weighing and notification process. They wanted information about the weighing process before the testing occurred to know what to expect and again before the results were sent home in order to be prepared to receive the letter. They wanted the information to be up to date with recent measurements.ModerateMinor concerns: methodological limitations
Major concerns: relevance
[53, 54, 61, 70, 76]
Availability of information
Q2: Many parents believed that they should be asked to give consent for weight screening and the option to opt out. They felt that they had not received this information. Due to this, they felt that they had not had the option to give consent or opt out.LowMinor concerns: adequacy
Moderate concerns: methodological limitations
Major concerns: relevance
[60, 61, 76]
Q3: Many parents disliked that the information about and permission for testing was sent with other school documents which led to it being lost, not seen or not remembered. Parents wanted follow up information about nutrition and health sent separately from the results letter for the same reason.LowModerate concerns: relevance
Major concerns: adequacy
[53, 61, 67]
Q4: A few parents were frustrated that the school did not provide a platform for parents to give feedback on the weighing process and communication/notifications about it.Very lowMajor concerns: relevance and adequacy[53, 67]
Q5: Parents had varied opinions about whether all children should receive weight notification or only those children who fall outside of the healthy range. Parents who believed all children should receive notification were concerned about privacy and confidentiality. Those who believed only those who fall outside of the healthy weight should receive notification were concerned about the cost of sending notifications.LowMajor concerns: relevance and adequacy[63, 69, 70]
Amount of information
Q6: Many parents wanted more information about how to interpret the screening results they received in letters and growth charts. Many felt that they had limited knowledge and understanding of how to interpret the results and needed further explanation and assistance.ModerateMinor concerns: methodological limitations Moderate concerns: relevance[53, 54, 65, 70, 73,74,75,76,77]
Q7: Many children wanted more information about the weighing process before, during and after the process itself. For example, and introduction session and a follow up session. This lack of information can make them feel nervous, terrified or unsure.ModerateMinor concerns: coherence and adequacy
Moderate concerns: relevance
[55, 66, 71]
Source of information
Q8: Health care providers were a trusted source of information about a child’s weight and could influence parental motivation to address a child’s weight issues. Parents and adolescents felt weight assessments done by health workers were useful, took their advice seriously, and expected that it was their role to inform them about weight issues. They wanted the clinician to approach the weight conversation first in a sensitive, respectful, direct and positive manner using open questions. They wanted health care providers to be proactive in raising the topic, be forthright in their discussions, provide clear messages and in some cases link the child’s excess weight to health risks. They wanted the provider involved in developing a follow-up plan and to share the responsibility for the plan. Some preferred the HCP and did not want the school involved.ModerateMinor concerns: methodological limitations and relevance[53, 54, 56, 57, 59,60,61,62,63,64,65, 70, 71, 73, 74]
Q9: Parents wanted HCPs to intervene early and initiate conversations if they were concerned about a child’s weight and customize or tailor the weighing and communication process to each child.ModerateMinor concerns: adequacy
Moderate concerns: relevance
[54, 56, 57, 64, 73, 74]
Q10: Parents felt that there were long wait times to see their HCP and when they were seen that appointments were rushed.Very lowMinor concerns: coherence
Moderate concerns: methodological limitations
Major concerns: relevance and adequacy
[57, 74]
Q11: The way that HCPs reacted to the weight screening letter from the school or discussed the child’s weight led parents to believe or dismiss the screening results.LowMinor concerns: methodological limitations and adequacy
Major concerns: relevance
[53, 69, 70]
Q12: Many parents approved of receiving a letter delivered by confidential standard mail to communicate screening results. Many did not approve of sending the letter home with the child. Those who did not approve of the letter wanted a more personal form of communication such as a phone call, email or face-to-face meeting.ModerateMinor concerns: methodological limitations
Major concerns: relevance
[53, 54, 60, 61, 63, 65, 68, 76]
Q13: Secrecy, privacy and confidentiality were important to both children and parents during (conducted in a private and confidential manner) and after (who has access to the results and how they are delivered to parents) the weighing process. Participants were concerned with privacy in order to avoid teasing, bullying, embarrassment and stigma and in some case parents wanting to control access to the screening results so that children could not see them. However, some children wanted the social support of their friends while being weighed and measured.ModerateMinor concerns: methodological limitations
Major concerns: relevance
[53, 55, 60, 61, 63, 65, 68,69,70, 76]
Q14: Many parents wanted more individual follow up and specific, concrete, practical and age appropriate support and guidance for lifestyle changes for instance through additional information, guidance, supplemental materials or referrals to relevant programs. When this was not done, or felt to be lacking, it led to frustration and confusion and was often experienced as a barrier to addressing their child’s weight issue.LowMinor concerns: coherence
Moderate concerns: methodological limitations
Major concerns: relevance
[53, 54, 57, 60, 63, 67, 69, 70, 72]
Content of information
Q15: Parents had clear preferences for the format, content, presentation, literacy level and tone of the weight notification letters they received. Many felt that the letter lacked necessary information or wanted more information included to help them take to steps to improve their family’s health. Importantly, they wanted a simple, easy to understand, visual explanation of BMI and how to interpret the results.ModerateMinor concerns: methodological limitations
Major concerns: relevance
[53, 54, 60, 63, 67,68,69,70, 72, 76, 77]
Q16: Parents had clear preferences for terminology used in letters and health care providers when discussing/presenting the issue of children’s weight. This choice of terminology could communicate respect and promote engagement. These clear preferences for the terminology being used included specific words, to avoid judging, insulting or the feeling that parent’s worries were not being taken seriously. If parents felt defensive, judged or offended they sometimes refused to return to the provider.ModerateMinor concerns: methodological limitations
Major concerns: relevance
[54, 56, 61, 62, 64, 65, 72, 75]
Q17: Language barriers and not having translators limited communication between parents and the health services. When language barriers arose, parents were often given written materials instead of discussing the child’s situation with the provider. This limited communication was a barrier to growth monitoring.Very lowModerate concerns: methodological limitations
Major concerns: relevance and adequacy
[54]
Perceived susceptibility of being overweight
Q18: Some parents expected and accepted the results of the BMI letter and were not surprised. However, the majority of parents did not accept the results of the BMI letter. They did not consider their child overweight. They questioned the credibility of the process, the accuracy of BMI measurements, and that the letter varied from the information given by their health care provider. The feedback they were given did not match their perception of their child and the weight report was often discounted. Many viewed the letter as a judgement or criticism of their parenting.ModerateMinor concerns: methodological limitations
Moderate concerns: regarding relevance
[53, 58, 60, 61, 65, 67, 70, 73, 77]
Q19: Children who were overweight often were surprised by the results and entered a phase of denial or shock. They also question if the measurements were right as they felt the results must be a mistake. Weight results could cause changes in social structure among children as they start to identify with others who are the same as them. Many children reacted emotionally to learning their weight status. Those who were overweight often reacted with negative emotions or disbelief, which influenced their mental health and well-being and caused worry. Children who were normal weight often reacted with joy and happiness at the results.Very lowMinor concerns: adequacy
Major concerns: relevance
[66, 70]
Q20: Many parents participated in an ‘othering’ process when receiving feedback about their child’s weight. This process contributed to the dismissal of overweight feedback received by themselves or their non-othered peers using language to define themselves and separate them from the ‘other’ parents whom they perceived needed to be the target of obesity prevention and that these ‘others’ were often not listening. Another group, parents of normal weight children, believed that they were part of the group doing the right thing and viewed other people, especially those whose children were indicated to have weight problems as not doing things correctly.ModerateModerate concerns: relevance[58, 61, 67]
Perceived barriers to addressing weight issues in the school system
Q21: Parents commented that on one hand the school was doing the BMI measuring but on the other hand, in most cases, was not making changes to facilitate activity and healthier lifestyles for students within the school environment.Very lowMinor concerns: coherence
Moderate concerns: adequacy
Major concerns: relevance
[53, 61, 68, 70]
Cues to action
Q22: Many parents had an emotional response to being informed about their child’s weight, who was informing them about their child’s weight and their child’s weight. These varied from positive/neutral, negative, disbelief and more than one emotion. Often parents cycled through the emotions. This reaction was often tied to the child’s weight status with those receiving healthy weight notifications being most positive. A parent’s emotional reaction could influence their perception of the screening program and the school and their motivation to act.ModerateMinor concerns: methodological limitations
Moderate concerns: relevance
[53, 58, 60, 61, 65, 67, 69, 70, 77]
Q23: In some cases, parents said that receiving the letter about their child’s weight had been a cue to action. Other parents ignored, downplayed or dismissed the letters and took no action and for some their level of concern did not change. A few parents said the letter had no impact as they had already implemented changes in their household before receiving it and continued with these.ModerateMinor concerns: methodological limitations
Moderate concerns: relevance
[53, 61, 67, 69, 70, 77]
Self-efficacy
Q24: Many parents discussed their struggles with self-efficacy and their ability to make changes at home. Some felt concerned, hopeless and overwhelmed when it came to choosing which changes to make and how to implement them. They mentioned a lack of knowledge, access to services and finances.LowMinor concerns: methodological limitations
Moderate concerns: relevance and adequacy
[54, 69, 70, 73]
Q25: Many parents felt they lacked knowledge about how to communicate to their children about their weight or changing habits. They found this distressing and it caused fear and frustration. Some parents did not want children to see the letter or hear the results of their screening for fear of causing harm to self-esteem or body image. Other parents still chose to discuss the screening results with their children but feared doing harm. Many parents felt that involving a child in these discussions should be tailored to the child’s age. Parents wanted guidance and kid friendly suggestions for communicating to children about their weight.HighMinor concerns: methodological limitations and coherence[53, 57, 60, 64, 67, 70, 71, 73, 77]
Q26: Some children felt that they had limited information about what they can do about their weight situation. They rely on parents and guardians for information about what can be done.Very lowMinor concerns: methodological limitations
Major concerns: relevance and adequacy
[66]
  1. *Q Stands for Qualitative finding