SciELO - Scientific Electronic Library Online

 
vol.88 número4Factores de riesgo y marcadores bioquímicos de la enfermedad metabólica ósea del recién nacido prematuroOsteomielitis crónica multifocal recurrente en paciente pediátrico, reporte de caso índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados

Revista

Articulo

Indicadores

Links relacionados

  • En proceso de indezaciónCitado por Google
  • No hay articulos similaresSimilares en SciELO
  • En proceso de indezaciónSimilares en Google

Compartir


Revista chilena de pediatría

versión impresa ISSN 0370-4106

Rev. chil. pediatr. vol.88 no.4 Santiago  2017

http://dx.doi.org/10.4067/S0370-41062017000400008 

ORIGINAL ARTICLE

 

Recommendations from parents of obese children in treatment to the health-care team: qualitative study

Recomendaciones de padres de niños obesos en tratamiento para el equipo de salud: estudio cualitativo

 

Andrea Garcíaa, Carolina Aspillagab, Claudia Cruzat-Mandichc, Barja S.d

aM.A in Child Mental Health, Centro de Estudios de la Conducta Alimentaria (CECA), Psychology Faculty, Universidad Adolfo Ibáñez
bPh.D in Psychology, Psychology Faculty, Universidad del Desarrollo
cM.A. Clinical Psychology, M.A. Psychotherapy, Ph.D. Psychotherapy Research, Professor-Researcher, Director of Centro de Estudios de la Conducta Alimentaria (CECA), Psychology Faculty. Universidad Adolfo Ibáñez
dMD, MSC in Pediatric Nutrition Josefina Martínez Hospital, Associate Professor of the Department of Pediatric Gastroenterology and Nutrition, Pediatrics Division. Faculty of Medicine. Pontificia Universidad Católica de Chile

Correspondencia a:


Introduction: The family plays an essential role in the adherence and effectiveness in the treatment of childhood obesity. Caregivers’ experience is fundamental for proper guidance. Aim: To describe the recommendations for the health-care team made by parents of children that are being treated for obesity. Patients and Method: Cross-sectional and descriptive study with a qualitative approach and purposeful sampling. In the first semester of 2015, interviews were conducted with nine parents of children from 4 to 10 years old that were being treated for obesity ad who had at least three medical appointments in the previous year. The data analysis was based on the Grounded Theory Approach through open coding. The study was ethically approved and informed parental consent was obtained. Results: The results were grouped in the following main categories: a) Health-care team-caregiver relationship, b) Health-care team-child relationship, c) Encouraging family participation, d) Encouraging therapeutic adherence in the child and e) Frequency of medical appointments. Conclusion: From the perspective of this group of parents of obese children, the health-care team should establish a close therapeutic bond with the children and their parents during the treatment process, in addition to encouraging family participation. The importance of developing therapeutic interventions that consider the perspective of the patient’s system is emphasized.

Keywords: Obesity,Parents,Pediatrics,Overweight,Obesity treatment


 

Introduction

Childhood obesity is one of the most serious public health problems of the 21st century. In Chile, the prevalence of obesity and overweight has surpassed the eutrophic widespread1. Obese children are under an increased risk of being obese in adulthood, as well as to develope some cardiometabolic complications2-4. Therefore, it is urgent to create strategies in order to prevent and to intervene in those affected5, since during childhood they assume most of the eating habits and practices that will last forever, during their lifetime6.

One of the main problems in treatment is the low therapeutic adherence7-12. According to national studies, about 50% of children who consult for obesity quit the treatment during the first six months, however those who do adhere have a clear improvement13,14. Consequently, strategies that improve adherence and thus, the performance of therapy are highly required.

Parents are extremely relevant in the beginning and during the evolution of childhood obesity, because they are the main example and the principal relationship in children’s life15. They are the ones who have the greatest influence on acquiring and maintaining healthy habits16,17. Therefore, it would be in the child’s home, rather than in some other establishment, where real work and effort would take place11. Thus, family-based treatment programs may be the most effective strategy, as they ease the necessary behavioral changes that improve the child’s health and weight16,18.

On the other hand, to achieve a succesful treatment of childhood obesity, and to keep all lifestyle changes, the integrated understanding between the health team and parents is the key, including as well the patient, regarding their general condition10,15,19. Lindelof, Vinther and Pedersen20, explained that to influence a person’s behavior in their daily life. it is necessary to understand the reasons that stimulate and guide such behaviors, which can be known by exploring the person’s experiences with their behavior. However, parents’ concerns about the health of their children often could differ from those of the health team21,22. Accordingly, it is necessary to explore their perceptions regarding the obesity of their children itself, in order to produce effective and lasting treatment strategies15,23. Moreover, to know the recommendations that parents could make to the team, would allow them to identify aspects that could ease or hinder this process. To investigate the reality that parents and patients percieved during the process of treatment of childhood obesity allows us to know the perspective of the consulting system and thus enable more effective interventions that improve adherence and therapeutic effectiveness. Despite this, there are few studies that address parents or primary caregivers’ perception, according to changes in their rutine or weight loss interventions for childhood obesity.

The objective of this study was to describe the recommendations to the health team of a group of parents caring for children who are being treated for obesity.

Patients y Methods

The study is based on a qualitative approach, the most appropriate to access this type of subjective processes, collecting the perspective of the subjects involved24. Intentional sampling was used through the strategy of “key informant” or the subject with prior knowledge of the object and field of study that favors the orientation, anticipation, contextualization and selection of the participants25.

As inclusion criteria, it was established that parents should be the main caregivers of the child28, between 20 and 45 years of age at the moment of their child’s birth. Children 4 to 10 years old, already diagnosed with obesity were included27, who had previously attended three or more consecutive medical evaluations. Those children in whom the goal of treatment was to maintain weight, or with the last control before 6 months, were excluded.

Fifteen parents of obese children were invited to participate in treatment with a nutritionist, taking place in two UC-CHRISTUS Outpatient Centers, with medical evaluation between July 2014 and July 2015. The sample consisted of 9 participants, who achieved the theoretical saturation of the main conceptual categories produced during the process of data analysis, that is, until the new data no longer provided new information26.

The collection of information was carried out through a semi-structured interview based on a thematic script, with a view to know their way of thinking and their feelings, including the aspects as their evolution, motivations, desires, beliefs and interpretation schemes25. In order not to bias the interview, the interviewer has no information about how was the child’s degree of obesity, nor their response to treatment. The interviews lasted approximately 60 minutes and were performed with each caregiver, after a medical examination of the child, in the same facilities. They were recorded by means of an audio recording and fully transcribed.

Data analysis was based on the strategy proposed by the Grounded Theory29, a methodology used to develop a theory based on data that is systematically captured and analyzed. The analysis was performed using open coding, a process in which the information collected to classify the material into concepts and categories is examined and classified30. In this study, the main scientific criteria is protected, such as transparency and contextuality; that is, the reader’s capacity to understand how the results were achieved, as well as the inclusion of the description of the produced data. Density, depth and applicability were also considered, which make reference to a detailed description of the information, generating the effect of triangulation on the results and their complexity. In addition, the triangulation of analysts is added to facilitate the discussion and consensus of all findings26.

Before starting the process, parents signed an Informed Consent, in which they accepted the use of voice recorder. The requirements of the Helsinki declaration of the World Medical Association on ethics in medical research in human beings and on the Chilean Law of Rights and Duties of patients were recognized and respected. The protocol was approved by the Committees of Ethics in Research of the Faculty of Medicine of the Pontificia Universidad Católica de Chile and the Universidad del Desarrollo.

Results

We present the recommendations that this group of parents would make to the health team. This information was organized in the following five categories (figure 1).

Figure 1. Summarized categories of recommendations from parents of obese children to the health-care team regarding their treatment.

Relationship between Caregiver-Health Team

Parents who were interviewed think that a closer and established health team-caregiver relationship is appreciated, in which the professional is smiling and always willing to solve doubts. This would require a kind treatment that creates confidence. Parents highlighted the importance of the health team to not to scold them.

“Is not like he [the health professional] condemns us because my child is gaining weight, he helps us and he welcomes us quite well. He does not tell to my child “hey, but what did you do?!”, so I guess that is the reason why it is also nice to come here. Even if he nag me or not, I do not come thinking “Geez!, my child has gained weight, I can’t imagine what he would say to me!”, because I had lived that before with other professionals. With others, it was like “listen to me, I’m telling you that you can not do so” and they treat you as if you were their children (Interview VIII, paragraph 20).

Some parents emphasize the importance of communication between the health team and the caregiver, being fundamental to explain and to guide in a polite way, with good manners and an understandable vocabulary.

“I believe that communication is everything ... When we ask something to a health professional, many doctors just write down, they do not answer much, they only write. I believe that if you go to the doctor, the doctor has to talk to you in terms that you understand, they can’t talk to me in medical terms because I will not get a thing” (Interview III, paragraph 58).

Apart from showing an honest concern about the child, parents value and appreciate that the health team also respect the caregivers’ habits, which may be different, but keeping in mind the main focus of sharing responsibilities. This involves also to include the other members of the family, explaining the risks and enhancing their commitment.

“I guess I have the ability to understand that all families are different. I am X* mother and I am the one who is a 100% in charge of her, but it is my mom who takes care of her. The doctor understood that very well, so I felt really supported that she could understand that it is not all because of my responsibility. Then, she has involved my mom to take part of this” (Interview V, paragraph 56).

*X is used in order to protect the child’s identity.

It is mentioned that it is important for professionals to have sufficient time to attend to the caregivers’ consultations, in order to address the problem of the disease and to explain the risks of obesity, so as to prevent them and to motivate perseverance.

“Caregiver: To me, she [the health professional]was very clear and so graphic when she said ... well, of course, we knew she [child] was chubby, but she explained us clearly how she would end in a few more years if she continues like this. And that was like a trigger, it moved me to continue. Interviewer: Would you say that those words motivated you to continue with the treatment? Caretaker: Yes, it marked me a lot, I think because of the impact that it caused in me” (Interview IX, paragraph 126).

It is important for the participating parents that the health team promote healthy eating in a flexible way, requesting that the consumption of certain foods could be reduced without prohibiting them. They also emphasize that recognizing the progress achieved favors a good relationship; This would add more confidence and more motivation to continue with the treatment.

Relationship between Health Team-Child

According to parents participating in the research, during treatment, it is important that the health team could establish a good relationship with their children, which might be demonstrated by expressing concern for the child’s well being. Likewise, a close relationship with the caregiver is necessary, which creates more confidence. According to this, they recommend that they could be more cheerful and always willing to clarify concerns and doubts when talking with children. These caregivers suggest a kind treatment for children, to not scold them, and to get their attention in a playful way, being an emotional helper, especially if they express their possible fears about failures.

“They have to be very tender and cozy with them, because they come with a bit with fear of the medical examinations. They do not come here happy, because they know they are going to measure their weigh and they could have gained some, or maybe they did not lose weight at all, so they are really scared, with fear. The nutritionist’s job or doctor’s duty is to welcome them, to treat them with love, telling them “You’ve gained some weight... well, it does not matter, let’s go, don’t give up!”. To support them and to continue along with them” (Interview VI, paragraph 58).

In order to establish a friendly treatment, they suggest that the health team ensure that the child is comfortable, talking about obesity with caution, avoiding the possibility of the child feeling hurt.

“No one likes to be fat, so I think they have to be super cautious on the subject. I have taken my daughter to other doctors, for many reason, sometimes because her tummy hurts or whatever reason, and of course, they tell me: “no, listen... this is because she is obese, she is fat” and my daughter listens to them, so she can’t take it positively” (Interview VIII, paragraph 34).

Most of the participants emphasize that it is important for the health team to establish a communication directed towards the child. This would strengthen the bond between they both, producing a feeling of satisfaction in the child, helping them to develop a greater awareness of this illness, assuming with responsibility their role and being motivated to adhere to treatment.

“I think that talking to the child is like super good, rather than talking to the parents. Because the doctor talked to X, and he was more aware after that. He already knew that he had an obesity problem before, but when she [the health professional] talked to him, she made X to think about what the doctor was saying, not what his parents told him. I think that was really good, that they have this bond with the child, because whenever you take your child to a doctor, the doctor always talks to the parents, he/she does not talk directly to the patient” (Interview III, paragraph 54).

On the other hand, certain caregivers recommend that health professionals who work with children may have sufficient skills in order to handle tantrums during controls.

To enhance the family participation

The caregivers who participated in the study recommend that the health team promote the participation of the family during the therapeutic process, as well as their support, motivating to change rutines to obtain healthy habits. To do this, it would be necessary for the team to explain to the family the importance of the participation of every member and also to include other caregivers in the medical examinations, this they could understand the problem and also the risks. They point out the need to promote family coexistence at the time of meals.

“She [the doctor] actually did a lot, she helped us as a family too, she referred us to the specialists, and guided us in diets, in how to change our way to feed, that we had to turn off the TV, that we have to eat with everyone gathered at the table, so these things helped us as a family” (Interview V, paragraph 124).

In addition, it is recommended that health professionals make separate interviews with different caregivers, in order to address the issue of obesity, as well as the therapeutic process.

To motivate the child to the therapeutic adherence

To encourage the therapeutic adherence in children, it would be important to motivate them to healthy habits and to encourage the patient to assume the treatment responsibility. It is emphasized in all participating caregivers the importance they give to how health workers congratulates the child for the progress made. Some say that, together with recognizing the effort and to highlight the favorable results, they should explain what remains to be achieved, giving enough motivation to persist.

“They have to congratulate them step by step, because children find it harder to assume, so if you congratulate them, children feel better and more willing, and they will not feel a rejection, saying “oh, I do not want to go to the doctor because the doctor is going to tell me that I am doing it wrong”; They have to always being ... How could I say it? Like giving them compliments, recognizing that “you did this well, but you lack a little bit in this other thing” (Interview II, paragraph 84).

Medical examinations’ frequency

Finally, it is indicated as a recommendation for the health team, that the examinations might be frequent, as this would help to complete and fullfil the therapeutic indications.

“I think that coming to the medical control more frequently is super important. In fact, I would prefer to come ... he said “we see each other in two months, or in a month”, so I said “no, in a month is ok”, because I prefer that, because that pushed us, it’s like a pressure that we have to behave well, that we can’t feel relaxed. I guess that is good, that we can not relax, because if we come in three months, we could say “bah, never mind, we relax two months and the last month we give it all”. No, that’s not the idea, the idea is that we have to be always worried. I think it is good that controls are more regular ... if is not, we tend to relax a little, saying “go ahead, eat that hot-dog, you have control in a month, so we could work on this the last week” (Interview IV, paragraph 106).

Discussion

This study shows that parents of children with obesity treatment who participated in this research give importance of how the health team tries to establish a close therapeutic bond between them and the children, and between them and their caregivers throughout the complete process. To enhance family participation and support, to encourage treatment adherence, to recognize the child’s achievements and to support them emotionally in situations of failure, by stimulating persistence are some of the most important factors mentioned. On the other hand, regarding healthy habits, the child is motivated to have a responsible attitude towards the treatment, adding that a greater frequency of the controls (medical examinations) would favor the child to fullfil with all the medical indications.

We should consider the perspective of the caregivers, since they are the ones who assume the priority of caring for the child with obesity. They interact with their social environment and they directly influence in multiple factors involved in this process. According to Lindelof, Vinther and Pedersen (20), the exploration of the experiences of the caregivers is necessary to understand the reasons that could stimulate and guide the behaviors related to the childhood obesity and its treatment.

This study provides some substantial keys about how it is possible to interfere, in favor of the welfare of the consulting system studied. Likewise, by taking concern of all the experiences of the caregivers, we would promote the therapeutic success of the child with obesity, allowing to carry out clinical interventions that fit the needs of those who consult, which could improve the effectiveness and therapeutic adherence, which are serious problems from the perspective of health professionals.

One of the limitations of this study could be the low sample size, despite we met the requirements of the theoretical saturation criterion that the qualitative methodology allows. In addition, the included patients comprehended a group with adherence to the treatment and possibly with a better response to it13; Therefore, the perceptions of their parents may not be the same compared to other types of families. In regard with this, it should be noted that the purpose of the study was to obtain an in-depth understanding of the experience of this interviewed group. Our strengths are the appropriate methodological application: the interviewer has no information about the obesity degree of the child and how is he/she responding to the treatment.

In conclusion, these results allow to understand the experiences of the caregivers studied and to know their recommendations for the health team. These data may be useful for professionals involved in the treatment of obese children in similar contexts, thus they could collaborate with the development of therapeutic interventions considering the perspective of the consulting system.

 

References

1. JUNAEB. Mapa Nutricional 2013. Disponible en: http://www.junaeb.cl/wp-content/uploads/2013/03/Informe-Mapa-Nutricional-2013.pdf (Accedido el 28 de abril de 2016).         [ Links ]

2. Organización Mundial de la Salud 2004. Estrategia mundial sobre régimen alimentario, actividad física y salud. Disponible en: http://www.who.int/publications/list/9241592222/es/. Accedido: 20 abril, 2016.         [ Links ]

3. Barja S, Arteaga A, Acosta AM, Hodgson MI. Resistencia insulínica y otras expresiones del Síndrome Metabólico en niños obesos chilenos. Rev Med Chile. 2003;131:259-68.         [ Links ]

4. Barja S, Arnaiz P, Villarroel L, et al. Dislipidemias en escolares chilenos: prevalencia y factores asociados. Nutr Hosp. 2015 May 1;31(5):2079-87.         [ Links ]

5. Dietz WH, Baur LA, Hall K, et al. Management of obesity: improvement of health-care training and systems for prevention and care. Lancet. 2015;385(9986):2521-33.         [ Links ]

6. González E, Aguilar MA, García C, et al. Influencia del entorno familiar en el desarrollo del sobrepeso y la obesidad en una población de escolares de Granada (España). Nutr Hosp. 2012;27:177-84.         [ Links ]

7. Faus AL, Leibowitz KL. Predictors of attrition form a behavior change-based pediatric lifestyle changes program for overweight/obese youth. Clin Pediatr. 2015;54:686-9.         [ Links ]

8. Skelton JA, Irby MB, Beech BM, Rhodes SD. Attrition and family participation in obesity treatment programs: clinician’s perceptions. Acad Pediatr. 2012;12:420-8.         [ Links ]

9. Jensen CD, Aylward BS, Steele RG. Predictors of attendance in a practical clinical trial of two pediatric weight management interventions. Obesity. 2012;20:2250-6.         [ Links ]

10. Stewart L, Chapple J, Hughes AR, Poustie V, Reilly JJ. The use of behavioural change techniques in the treatment of paediatric obesity: Qualitative evaluation of parental perspectives on treatment. J Hum Nutr Diet. 2008;21:464 73.         [ Links ]

11. Steele MM, Steele RG, Hunter HH. Family adherence as a predictor of child outcome in pediatric obesity intervention: Different outcomes for self-report and objective measures. Children’s Health Care. 2009;38:64-75.         [ Links ]

12. Kitscha CE, Brunet K, Farmer A, Mager DR. Reasons for non-return to a pediatric weight management program. Can J Diet Pract Res. 2009;70:89-94.         [ Links ]

13. Barja S, Núñez E, Velandia S, Urrejola P, Hodgson MI. Adherencia y efectividad a mediano plazo del tratamiento de la obesidad infantil. Rev Chil Pediatr. 2005;76:151-8.         [ Links ]

14. Moraga F, Rebollo MJ, Bohórquez P, Cáceres J, Castillo C. Tratamiento de la obesidad infantil: Factores pronósticos asociados a una respuesta favorable. Rev Chil Pediatr. 2003;74:374-80.         [ Links ]

15. Lorentzen V, Dyeremose V, Larsen BH. Severely overweight children and dietary changes-a family perspective. J Adv Nurs. 2012;68:878-87.         [ Links ]

16. Nowicka P, Flodmark CE. Family in pediatric obesity management: A literature review. Int J Pediatr Obes. 2008;3:44-50.         [ Links ]

17. Tyler DO, Horner SD. Family-centered collaborative negotiation: A model for facilitating behavior change in primary care. J Am Acad Nurse Pract. 2008;20:194-203.         [ Links ]

18. Boutelle KN, Cafri G, Crow SJ. Parent predictors of child weight change in family based behavioral obesity treatment. Obesity. 2012;20:1539-43.         [ Links ]

19. Lachal J, Orri M, Speranza M, Falissard B, Lefevre H, QUALIGRAMH, Moro MR, Revah-Levy A. Qualitative studies among obeses children and adolescents: A systematic review of the literature. Obes Rev. 2013;14:351-68.         [ Links ]

20. Lindelof A, Vinther C, Pedersen BD. Obesity stigma at home: A qualitative, longitudinal study of obese adolescents and their parents. Child Obes. 2011;7:462-74.         [ Links ]

21. Giannini C, Irby MB, Skelton JA. Caregiver expectations of family-based pediatric obesity treatment. Am J Health Behav. 2015;39:451-60.         [ Links ]

22. Garbutt JM, Leege E, Sterkel R, Gentry S, Wallendorf M, Strunk R. What are parents worried about? Health problems and health concerns for children. Clin Pediatr (Phila). 2012;51:840-7.         [ Links ]

23. Jones AR, Hyland RM, Parkinson KN, Adamson AJ, Gateshead Millennium Study Core Team. Developing a focus group approach for exploring parents’ perspectives on childhood overweight. 2009. British Nutrition Foundation Nutrition Bulletin. 34,214-219.

24. Krause M. Psicoterapia y Cambio. Una mirada desde la subjetividad. Santiago: Ediciones Universidad Católica de Chile; 2009.         [ Links ]

25. Gaínza A. La entrevista en profundidad individual. En: Canales M, editor. Metodologías de Investigación Social. Santiago de Chile: LOM Ediciones; 2006. p 219-61.         [ Links ]

26. Krause M. La investigación cualitativa: un campo de posibilidades y desafíos. Revista Temas de Educación. 1995;7:19-39.         [ Links ]

27. CDC- Clinical Growth Charts [serie en internet]. Atlanta: Centers for Disease Control and Prevention. Accedido el 5 de junio de 2016. Disponible en: www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm.         [ Links ]

28. Grau C, Fernández M. Familia y enfermedad crónica pediátrica. Anales Sis San Navarra. 2010;33:203-12.         [ Links ]

29. Glaser BG, Strauss AL. The Discovery of Grounded Theory. Chicago: Aldine Publishing Company; 1967.         [ Links ]

30. Strauss A, Corbin J. Bases de la investigación cualitativa. Técnicas y procedimientos para desarrollar la teoría fundamentada. 2a ed. Bogotá: CONTUS-Editorial Universidad de Antioquia; 2002.         [ Links ]

__________________

Received: 11-10-2016; Accepted: 6-2-2017

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed according to the Declaration of Helsinki and the World Medical Association regarding human experimentation developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regulations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This document is in the possession of the correspondence author.

Conflicts of Interest

Authors declare no conflict of interest regarding the present study.

Acknowledgements

We thank all the parents who were interviewed and their children for sharing their treatment experiences.

Correspondencia a:

Ana García Troncoso

angarciat@gmail.com

Creative Commons License Todo el contenido de esta revista, excepto dónde está identificado, está bajo una Licencia Creative Commons