Phase 1 Survey
One hundred and eighteen postal survey questionnaires were returned within the study period representing GPs, practice nurses, health visitors, nursery, community and children's nurses. Eighty-four participants responded to the initial postal survey (n = 243), a response rate of 34%, and a further 34 were recruited via the on-line survey. We do not have a denominator for the number of individuals who may have received an invitation to complete the on-line version of the survey via email.
As there were only a few responses from children's and community nurses, their responses were combined with practice nurses to form a single 'registered nurse' group. Two respondents were excluded as they could not be allocated to a professional group, giving a useable sample of 116. Most participants were experienced HCPs having been in practice for at least 10 years (Table
1).
Table 1
Prompt guide for semi-structured interviews
Questions about healthcare professionals' current practice, training needs
|
Can you describe your role in relation to discussing diet with parents of children under 1 year old? |
How do you think parents of children under 1 years old feel about your dietary advice? |
Are there any aspects of your advice that parents are reluctant to implement or find difficult to implement? |
Are there any parent characteristics that make it more likely that they will follow your advice about diet in children under 1? |
Have you undertaken any training in relation to providing advice about diet to children under 1 year old? |
Questions about identification of 'infants at risk' and healthcare professionals strategies
|
What do you think are the most important risk factors for childhood overweight/obesity? |
Do you have infants or young children on your caseload that you think might become overweight/obese children? |
How do you manage situations where an infant's growth increases disproportionately on the percentile charts? |
For example, if an infant's growth went up from the 50th to the 90th percentile or crosses three percentiles with no corresponding rapid growth in head circumference or length? |
What else might you need to know? |
Have you found anything that makes it difficult to discuss with parents that their infant or young child is 'at risk' of becoming overweight? |
What would help you to overcome this? |
How do you find dealing with parents whose infants are overweight/obese? |
Questions about weight management and intervention
|
Can you describe any intervention you have initiated with parents whose infants or young children have grown too quickly? |
How might healthcare professionals work with parents of infants 'at risk' to prevent childhood overweight/obesity? |
What type of intervention might be needed? |
What information should an intervention contain to make it useful for healthcare professionals to use with parents? |
In your view how could the information be presented clearly and consistently by different members of the PHCT? |
Is there anything else you would like to mention that you think would be useful? |
Thank you |
All participants had been consulted by parents for advice about infant feeding. Nursery nurses (Fisher exact probability = 0.009) and health visitors (χ
2
(1) 26.35, p < 0.001) were significantly more likely to have been consulted at least weekly compared to other professions. GPs (χ
2
(1) = 9.5, p = 0.002) and registered nurses were less likely to have been consulted (χ
2
(1) = 7.3, p = 0.006). Self-rated confidence in providing infant feeding advice differed significantly between professional groups (Kruskall Wallis χ
2
(3) = 19.16, p < 0.001). Health visitors were significantly more confident about the advice they provided than GPs (post-hoc Mann Whitney test Z = 3.44, p = 0.001) and nurses (Z = 3.92, p < 0.001). Knowledge about health risks associated with obesity, as measured by the ORK-10, also differed significantly between groups (χ
2
(3) = 26.7, p < 0.001). Health visitors were more knowledgeable about the health risks of obesity than nursery nurses (Z = -2.6, p = 0.009) but less knowledgeable than GPs (Z = 4.26, p < 0.001) who had a median score of 9/10. GPs were also more knowledgeable than registered nurses (Z = -2.59 p = 0.01) and nursery nurses (Z = -4.27, p < 0.001). Registered nurses were more knowledgeable than nursery nurses (Z = -2.85, p = 0.004) (Table
2). Overall, participants who were most frequently consulted around infant feeding were less knowledgeable about the risks associated with obesity (r = 0.34, n = 114, p < 0.001). There was no relationship between HCPs self-rated confidence and their knowledge about obesity risk (Table
3).
Table 2
Demographic characteristics of sample
Gender | |
Male | 19 (17.4%) |
Female | 97 (83.6%) |
Age
| |
20-29
|
7 (6.0%)
|
30-39
|
21 (18.1%)
|
40-49
|
46 (39.7%)
|
50-59
|
36 (31.0%)
|
60+
|
6 (5.2%)
|
Profession | |
Nursery nurse | 8 (6.9%) |
Health Visitor | 27 (23.3%) |
Nurse (practice nurse or community nurse) | 29 (25.0%) |
General Practitioner | 52 (44.8%) |
Years of Experience
| |
Less than one year
|
1 (0.9%)
|
1-5
|
23 (19.8%)
|
5-10
|
23 (19.8%)
|
10+
|
69 (59.8%)
|
Table 3
Comparison between professional groups for dependent variables
Consulted about infant feeding at least once a week | 8 (100%) | 27 (100%) | 9 (31.1%) a
| 20 (39.2%)a
|
Confidence about giving feeding advice | | | | |
Very confident | 2 (25%) | 4 (14.8%) | 2 (7.1%) a
| 4 (7.8%) a
|
Confident | 5 (62%) | 23 (85.2%) | 11 (39.3%) | 27 (52.9%) |
Slightly confident | 1 (12.5%) | 0 (0%) | 13 (46.4%) | 19 (37.3%) |
Not confident | 0 (0%) | 0 (0%) | 2 (7.1%) | 1 (2.0%) |
Knowledge about risks of obesity Median (IQR) | 5.5 (4.25-6.75) | 7 (5-8) | 8 (6-9) | 9 (8-9) |
Phase 2 interviews
Telephone interviews were conducted with 12 GPs (n = 6 male, n = 6 female; n = 7 white British, n = 2, British Asian, n = 1 Middle Eastern, n = 2 British Indian) and 6 practice nurses (all female, white British).
1. Attribution of childhood obesity to family environment
Participants viewed childhood obesity as having a genetic/biological origins but causation was also attributed to economic, educational and emotional poverty within families.
I think an obese parent is certainly a factor, I think poor socio-economic groups tend to have less knowledge on diet, as well as less money "to", they think that a healthy diet is more expensive. I do feel that a lot of young parents now haven't learnt how to cook, from basics. PN213.
I think yeah I think poor social circumstances as well and diet because I think from what I've seen I think the children poor, but when I mean poor in social circumstances I'm not talking about money, I'm talking about a family unit. GP211.
Participants did not identify infants who were obese but considered that some were over fed, particularly those on formula milk who were weaned early.
Over feeding... early weaning would count as overfeeding. Over feeding I would think was the most important factor. GP240.
There was a strong belief that parent's feeding strategies were adversely influenced by their peers and family, particularly grandparents.
They seem to have a lot of input from older generations, who say, oh that baby's hungry, it should be weaned, and you know, going back to when they used to put a Farley's Rusk in the bottle I think! So I talk to them about inappropriately weaning the baby because I think what a lot of mum's who find it quite hard work having a young baby, they can get quite a lot of messages from extended family that weaning the baby will settle it, help it sleep through the night and make it more content. GP241.
2. Infant feeding advice as the health visitor's role
There was a strong belief that the role of general practice is to manage non-routine problems or illness and those who expressed that view denied any knowledge about appropriate infant feeding.
My recent experiences have been constipation and reflux. Weaning, I can't remember anything about the weaning thing. GP211.
Participants believed that infant feeding advice was the responsibility of the health visiting team, who have traditionally led the way in advising parents about infant feeding [
36].
Have very little err involvement in under one year olds. I tend to recommend that the parents take the queries to the health visitor erm because I think it is really important that we don't end up with conflicting advice cos that's the worst thing you can do when you've got a new baby. GP203.
I don't really as a Practice Nurse deal with under ones as a dietary thing, it would be the Health Visitor. PN217.
However, there was a minority view that GPs should actively promote healthy infant feeding although this was not supported nor expressed by any of the practice nurse participants.
One of the most important positive things you can put across to parents with the under ones is that now is the best time to tackle it because if you can tackle it then you know the under ones still eat what they're given, they don't eat what they take, they eat what they're given, you can start to reverse the trend. GP240.
Obesity prevention and management during early years was seen as the role of the health visitor or other specialist practitioner not the role of the GP or practice nurse.
Who should deliver it, well the health visitor would either deliver it herself or she would know where parents could go to get the information. GP240.
3. Professional reliance on anecdotal or experiential knowledge about infant feeding
Participants suggested that obesity services were targeted at adults and identified a lack of training for childhood obesity prevention and management.
And there isn't any training available, it's not like being sat there, folding our arms, and saying oh dear we don't know what we're doing, there isn't anything that I know of that we can go on, otherwise we'd all have been on it by now I think. We've all been on endless rounds of adult training, and adult intervention for obesity till we're purple. PN219.
Participants described how the information they used to support the advice they provided to parents about infant feeding was gained anecdotally or experientially.
I guess just general reading, like the GP magazine, some parenting books which I have read a few of, discussion with my wife and other colleagues, other colleagues with young children. But no formal training at all. GP241.
And quite often it's, it's not just being as a GP it's more like a maternal thing in my experience as a mum really that's been able to guide them. GP211.
Participants felt that little guidance and training was available to them. Some, but not all, participants were happy to provide infant feeding advice in response to parent's requests.
Like I mentioned I never had any training, but I'm giving advice, and I'm sure there's lots of other people in the same position. GP251.
If I was more clued up on what information to give I would feel happy to do that so it would boil down to education I think. PN217.
4. Difficulties with recognition of, or lack of concern for, infants "at risk" of becoming obese
There was a lack of explicit recognition that infants could be identified as overweight or obese.
I personally, currently don't have any patients that I thought were, are particularly high at risk, at the present time. GP250.
However, participants acknowledged that some infants demonstrated excess weight gain but lacked common terminology to describe this. Participants expressed the view that intervening with overweight or obese infants during non-routine or illness consultations was problematic for a number of reasons. GPs suggested it was often difficult to intervene with the parents of these infants because they had no visible growth record available to them. The parent-held records which contain information about infant feeding and growth were not usually available during a non-routine or illness consultation. Therefore their responsibility for following up/reinforcing infant feeding advice provided by others was negated.
Most of them don't bring them [parent held record or red books] unfortunately, but yes, definitely I've seen a few babies that look a bit larger than they should be. GP251.
They don't come in with their red books, so quite often I don't know what centile they're on so you know you just see a baby and it looks sitting on mum's lap, at one a lot of them are walking and he just looks chubby. GP211.
There was reluctance to target at risk infants for preventative activities.
To be honest I haven't looked specifically at targeting that age group. GP242.
Participants described how they might mentally note the weight of an infant but would not intervene until they were older and already overweight or obese.
So I think there are some families that you can identify where the children already you can see are slightly carrying more weight than they should do. But I don't think necessarily that you see that as an under one. I don't feel I can see that as an under one child, these are usually around sort of four year olds onwards that you start to really see. GP239.
5. Prioritising relationship with parent over best practice in infant feeding
Participants were aware of the guidance supporting best practice in infant feeding but some of them made exceptions with parents whom they perceived to be struggling to cope. They described how some parents found it difficult to manage their infant's needs and to reduce the demands made on them they adapted the care they provided. This might involve soothing infants with additional food and/or weaning early to ensure the parent has a good night's sleep.
In this practice we have a lot of single mums, young mums, unsupported mums, not particularly good accommodation, and they've got the baby 24/7 with either no support from boyfriend or a boyfriend who's a waste of space, one of the things that wears them down incessantly is sleep disturbance because they don't get the help, they're concerned if the baby's crying all night, the neighbours complain, or the neighbours think they're not looking after the baby, etc., etc., they've got a very high aim to get the baby to sleep well, so they will feed the baby in the hope of it sleeping, and I think they also see giving the baby solids early as a way of getting the baby to sleep. GP240.
GPs were sympathetic to these parents and supported some of their decisions especially in relation to deviating from the Department of Health's current weaning guidance [
36]; a position reflected in a related study of parents' views.
They are only guidelines and you will get babies that have been born at nine pounds that no way can they cope 'til they're six months without some solid food erm it's just you have to be sensible about things and you know erm there are lots of issues people will have had children years ago where you know we weaned much earlier and they'll be in-laws interfering and you need to be aware of every individual's personal situation, can't have a hard and fast rule but err you know certainly I always recommend they try and wait until the baby's six months but I don't ban people from weaning sooner if they have a desire to. GP203.
There was also a perception that identifying infants as overweight or obese would be stigmatising and might jeopardise the professional relationship with the parent.
I would, although as I've said I haven't that particular situation, I would just find that embarrassing and difficult to bring up, and I think it would be the fact that they would feel I was criticising them and their parenting, or their overweightness, if that was the risk factor. GP218.
6. Lack of shared understanding for dealing with early years obesity
Participants did not identify a common way of dealing with families where the diet was perceived to be unhealthy and infants and children were "at risk" or already overweight or obese. A range of different approaches were suggested which were not based on evidence or guidance.
Well postnatal, postnatal. So I think that would be a start, but then also through you've got mother and toddler groups, there's lots of groups that go on, parenting groups, and you know even at nurseries and things like that there's ways to get it in, education in. So I think education is really key. GP243.
Something that helps them, so in other words it's supportive rather than sort of tell them off that they're doing something wrong, it is understand, just understand why it's happened and say you know what this is not entirely your fault and I would go through let me see how we can work together on this and see what we can do. GP252.
There was a suggestion from practice nurses that any further expansion of their role around obesity prevention activities would require additional training.
If it was sort of deemed that we should be doing it erm a bit more sort of training on how to have a structured approach. PN227.
However, whilst participants tried to focus on appropriate early years interventions many of their responses were more suitable for childhood obesity management than primary prevention.
I think a programme of support, that's actually structured, and I know that that's what you're getting involved with, and I actually think that is what's most useful, and not just mostly focusing on activity really, rather than just on what they're eating because I think in an age where our kids generally sit and play computer games, the parents don't feel the kids are safe to be able to go out. GP239.