PEC Innovation 1 (2022) 100074

Contents lists available at ScienceDirect

PEC Innovation
journal homepage: www.elsevier.com/locate/pecinn

Perspectives of healthcare professionals on facilitators, barriers and needs in

children with obesity and their parents in achieving a healthier lifestyle
⁎
Naomi de Pooter a,b, ,1, Emma van den Eynde c,1, Hein Raat d, Jacob C. Seidell b,
Erica L.T. van den Akker c, Jutka Halberstadt b
a
Department of Public and Occupational Health, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
b
Department of Health Sciences, Vrije Universiteit Amsterdam, the Netherlands
c
Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
d
Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To explore the perspectives of healthcare professionals (HCPs) within an integrated care approach on the
Pediatric obesity facilitators, barriers and needs in children with obesity and their parents in achieving a healthier lifestyle.
Integrated care Methods: Semi-structured interviews were conducted with eighteen HCPs working within a Dutch integrated care
Healthcare professionals approach. The interviews were analyzed by performing a thematic content analysis.
Behavior change
Results: Main facilitators identified by HCPs were support from parents and the social network. Main barriers were first
Qualitative research
and foremost family’s lack of motivation, which was singled out as a precondition for starting the behavior change pro-
cess. Other barriers were child’s socio-emotional problems, parental personal problems, lack of parenting skills, paren-
tal lack of knowledge and skills regarding a healthier lifestyle, parental lack of problem awareness and HCP’s negative
attitude. To overcome these barriers, main needs that HCPs suggested were a tailored approach in healthcare and a
supportive HCP.
Conclusion: The HCPs identified the breadth and complexity of underlying factors of childhood obesity, of which the
family’s motivation was pointed out as a critical factor to address.
Innovation: Understanding the patient’s perspective is important for HCPs to provide the tailored care needed to
address the complexity of childhood obesity.

1. Introduction groups in society, such as children in lower socio-economic positions, and

especially children with a migration background [9]. These socio-
Over the past decades, the number of children with obesity has in- economic health differences remain challenging in managing childhood
creased considerably worldwide [1]. In 2020, 2.6% of children aged obesity [10].
4 to 17 years had obesity in the Netherlands [2]. Childhood obesity The complexity of childhood obesity requires integrated care to achieve
can have serious short-term consequences, such as physical problems, and maintain behavioral change towards a healthier lifestyle [11-13]. An
psychosocial problems and a decreased quality of life, and long-term important prerequisite for successful integrated care is for it to be part of
consequences, such as an increased risk of premature mortality and an integrated approach connecting prevention, focused on creating a
adult morbidity, and reduced educational, economic, and social healthy environment for children in general, and obesity care and support,
chances [3-7]. focused on the individual child with obesity and its parents [14]. According
The development and sustainment of childhood obesity are influenced to the ‘National Model Integrated Care for childhood overweight and
by an interaction between different underlying individual factors, including obesity’ that was recently published in the Netherlands, effective obesity
biological and psychosocial factors, and environmental factors, including care goes beyond a healthy lifestyle, and includes attention for the underly-
the physical, social and economic environment [8]. These underlying ing individual and environmental factors influencing obesity [13,15].
factors indirectly cause obesity to be more common amongst disadvantaged These individual and environmental factors can vary largely between

⁎ Corresponding author at: Department of Public and Occupational Health, Amsterdam UMC Location University of Amsterdam, Amsterdam Public Health Institute, Meibergdreef 9, 1105 AZ
Amsterdam, The Netherlands.
E-mail addresses: [email protected] (N. de Pooter), [email protected] (E. van den Eynde), [email protected] (H. Raat), [email protected] (J.C. Seidell),
[email protected] (E.L.T. van den Akker), [email protected] (J. Halberstadt).
1
Joint first authorship.

http://dx.doi.org/10.1016/j.pecinn.2022.100074
Received 12 April 2022; Received in revised form 15 August 2022; Accepted 15 August 2022
2772-6282/© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).
N. de Pooter et al. PEC Innovation 1 (2022) 100074

families, leading to many different barriers and facilitators for behavioral 2.2. Data collection
change towards a healthier lifestyle [16-21].
Successful implementation of an integrated care approach partly Eighteen semi-structured interviews were conducted by one researcher
depends on healthcare professionals (HCPs) identifying the barriers (EvdE). EvdE has studied Psychology of Health Behavior with a special
that children with obesity and their parents face in obesity treatment focus on (childhood) obesity and has experience in childhood obesity inter-
[22]. Communication and treatment outcomes could be affected vention development and obesity care research. Each interview lasted ap-
when the perspective of the HCP on disease and treatment differs proximately 60 minutes and took place in a quiet location chosen by the
from that of the patient [23,24]. Previous research shows HCPs iden- HCP, often the workplace, with no other people present besides the inter-
tify many difficulties children with obesity and their parents face in viewer and the HCP. An interview guide was used during the interviews, in-
treatment within a multidisciplinary approach [22]. However, litera- cluding fourteen open-ended questions and some additional probing
ture suggests that there are also incongruent views and attitudes questions based on the socio-ecological model (see supplement A) [31].
around obesity management between HCPs and adult and adolescent The interviews were audio-recorded and transcribed verbatim, and the
patients, for example with regard to discussing the topic of weight interviewer kept field notes, describing her reflections on the interviews. A
[25,26,27]. In addition, successful integrated care goes beyond identi- member check was done by providing a summary of the interview tran-
fying the barriers within healthcare, and also requires HCPs to assess scripts to ensure accuracy according to the participating HCPs [32]. Many
and acknowledge a wide range of factors outside of healthcare that themes reoccurred in the interviews, but it was not possible to reach satura-
could help or hinder families in achieving a healthier lifestyle tion on all themes because of the exploratory nature of the study and the
[28,29]. By identifying these underlying factors together with the fam- broad questions that were asked on all levels of the socio-ecological
ily, HCPs can tailor the treatment to the family’s personal situation. model during the interviews [31].
This diagnostic pathway and perspective of HCPs working within an
integrated care approach on these factors remains unclear in the liter- 2.3. Data analysis
ature. Therefore, the current study examines the perspective of HCPs
within an integrated care approach on the facilitators, barriers and A thematic content analysis was performed by using the program
needs they observe in children with obesity and their parents in achiev- MAXQDA 2018. As the study is exploratory, the coding was done according
ing a healthier lifestyle. to Grounded Theory [33]. To ensure triangulation of researchers, the data
was coded and analyzed by two researchers (EvdE and NdP). The findings
2. Methods were discussed with a third researcher (JH).
To start the data analysis, the researchers read and summarized the in-
A qualitative study design with in-depth, face-to-face interviews was terview transcripts to familiarize with the data. Next, inductive coding was
adopted to answer two research questions: (1) what is the perspective of done independently by the two researchers, and two coded transcripts were
HCPs on the facilitators, barriers and needs that children with obesity and compared to reach consensus on a preliminary set of codes. Subsequently,
their parents experience in achieving a healthier lifestyle, and (2) what both researchers created a coding tree independent from each other and
facilitators and barriers do HCPs themselves experience in the support compared them to reach consensus on a preliminary coding tree. The
and care for children with obesity and their parents. This article describes remaining part of the transcripts were coded with this coding tree. This
the first research question, and Van den Eynde et al. (in preparation) was an iterative process and changes in the subcodes were documented in
describes the second research question. This distinction is made because a log [33]. Finally, seven important themes were determined to answer
these two questions comprise a different focus on childhood obesity care; the research question. The participating HCPs did not provide feedback
the perspective of HCPs on the experience of the child and parent with on the findings.
achieving a healthier lifestyle and the experience of HCP with providing
childhood obesity care. The same methods were used for both articles
2.4. Ethical considerations
and are described according to the COREQ (Consolidated Criteria for
Reporting Qualitative research) [30].
This study was not subject to the Dutch Medical Research Involving
Human Subjects Act (WMO). Therefore, the institutional review board of
2.1. Participants
the VU Medical Centre waived the requirement of medical ethical approval
(METC number 2018.234), and the general ethical standards of the depart-
To include various perspectives, different HCPs were recruited from
ment were followed. Before conducting the interviews, informed consent
institutions involved in the integrated care for children with obesity in
was signed by the HCP and consent for audio-recording was given once
the Netherlands, including pediatricians, Youth Health Care (YHC)
more verbally. To ensure the privacy of the participating HCPs, the inter-
nurses and YHC physicians. These HCPs are typically involved in differ-
view transcripts were anonymized.
ent steps of the integrated care process. The HCPs were recruited via
phone or email and the recruitment was based on convenience sam-
pling. Twenty HCPs were approached to participate in the study. Two 3. Results
of them were not included: one did not respond and one did not have
time for an interview. In total, 18 HCPs participated in this study, working in eight different
To ensure inclusion of experienced HCPs, three inclusion criteria were municipalities across the Netherlands. The characteristics of the partici-
identified prior to the recruitment: (1) pediatricians were included when pants have been described in Table 1.
they worked in an institution appointed as a center of expertise for child- The participating HCPs mentioned a large number of factors that in
hood obesity by the Dutch association for pediatrics, (2) YHC nurses and their perception help and hinder children with obesity and their parents
YHC pediatricians were included when they worked in a municipality in achieving a healthier lifestyle. In addition, they discussed what families
that contributed to the development and implementation of the Dutch need from HCPs and healthcare to overcome the barriers. A summary of
‘National Model Integrated Care for childhood overweight and obesity’, the facilitators, barriers and needs can be found in Table 2.
and (3) YHC nurses were included if they were appointed as coordinating
professional for the local integrated care and support for childhood obesity. 3.1. Individual child factors (theme 1)
Within the national model, a coordinating professional is appointed to iden-
tify and monitor children with obesity, manage their care and organize HCPs pointed out that socio-emotional problems of the child, such as
interdisciplinary collaboration [15,28]. stress, bullying and psychological problems can hinder children with

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Table 1 that are prioritized over a healthy lifestyle, such as psychosocial problems,
Descriptives of the participating HCPs. financial issues, divorces, or housing problems. All of the HCPs emphasized
Participant characteristics the importance of support from parents in the behavior change process.
Profession (n) “It [achieving a healthier lifestyle] is not always their first priority due to
Pediatrician 6
many other issues or distractions, such as poverty, informal care for elderly,
YHC nurse 11
YHC pediatrician 1
other worries, jobs, paying for housing….”
Gender (n) (YHC nurse 9)
Female 17
Male 1
Mean age (years; range) 43.8; 29–60a
Mean working experience with children with obesity (years; 8.7; 1–18b 3.3. Physical environment (theme 3)
range)
Age group of patients the participants generally work with (n)
Solely children of primary school age 8 HCPs also mentioned environmental challenges that could influence be-
Solely children of secondary school age 1 havioral change. Policies at schools were explicitly mentioned as a barrier
Both age groups 9 as programmes to create a healthy school environment are not always im-
a
Unknown for one participant plemented correctly. For example by still providing unhealthy, cheaper op-
b
Unknown for five participants tions in school canteens, or by allowing unhealthy treats in some classes but
not in others.

obesity in achieving a healthier lifestyle. It is thought to be important for 3.4. Socio economic environment (theme 4)
the HCP to address these problems.
HCPs mentioned a low feeling of support in families caused by weight-
3.2. Role of the parents (theme 2) related stigma in society. On the other hand, they mentioned the normaliza-
tion of overweight in society and misperceptions of a healthy weight, espe-
The HCPs indicated that many families want to change their lifestyle, cially in non-Dutch cultures. According to the HCPs, this could affect the
but are not able to do so because parents have other, personal problems family's problem awareness.

Table 2
Summary of facilitators, barriers and needs for every theme.
Themes Facilitators Barriers Needs

1 Individual child Feeling good about themselves; Socio-emotional problems; HCPs providing more insight into the importance of a healthier lifestyle;
factors knowledge and understanding behavioral problems HCPs addressing socio-emotional problems in healthcare
about a healthy lifestyle
2 Role of the parents Parents being supportive; Parents that do not take responsibility Financial support;
parents being involved; for the problem; HCPs supporting parents in improving parenting skills regarding a healthy
parents that set boundaries; parents that are controlling; lifestyle when children are still young;
parents functioning as a positive personal problems of parents; HCPs involving fathers in the health care
role-model lack of parenting skills;
lack of knowledge and skills regarding a
healthy lifestyle
3 Physical environment Healthy school environment; Obesogenic environment; HCPs supporting patients in coping with temptations, particularly
safe environment to play outside; incorrect implementation of policies at important with increasing freedom during puberty
the healthy choice being the easy schools and sports clubs;
choice; sports activities for children with obesity
appropriate and approachable are not continuous
sports facilities;
information about a healthy
lifestyle
4 Socioeconomic A social environment that supports Low socioeconomic position; HCPs referring to buddy project to increase the feeling of support;
environment a healthy lifestyle peer pressure to eat unhealthily; HCPs referring to role-models that inspire to achieve a healthier lifestyle
pressure of social media;
extended family with different ideas
about lifestyle;
weight-related stigma in society;
normalization of overweight
5 Cultural environment Traditional kitchen is not healthy; HCPs considering cultural norms and values in advice about a healthier
sporting is not common; lifestyle or parenting
misperceptions of a healthy weight;
large role of food;
not mastering the Dutch language
6 Family’s experience Taking small steps; Unrealistic expectations of healthcare; Supportive HCP;
with healthcare feeling in control of the treatment having to tell their story multiple times; tailored approach in healthcare;
negative attitude of HCPs; approachable healthcare;
seeing many different HCPs; consistent communication from different HCPs
vagueness of the healthcare system
7 Family’s motivation Experiencing the burden of Experiences of failure in the past; HCPs focusing on reducing the short-term physical and social
obesity; unrealistic expectations of the behavior consequences of obesity
experiencing the benefits of a change process;
healthier lifestyle; having no request for help;
confidence that change is possible parental lack of problem awareness

3
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3.5. Cultural environment (theme 5) did not show up at consultation hours, had a certain body posture (e.g.
slumped or with crossed arms) or were not taking any steps in changing
Cultural aspects of families were mainly mentioned as barriers and not their lifestyle when practical issues were solved. Particularly YHC
as facilitators. The participating HCPs mainly talked about the Turkish, nurses emphasized the importance of motivation in order to achieve be-
Moroccan and in one occasion the Polish culture. HCPs suggested it is havioral change.
important to consider cultural norms and values in their advice about a
“In the end they do want it, but they don’t know how because there is so much
healthier lifestyle, but also about parenting skills as the way in which
going on.”
children are raised might be different in every culture.
(YHC nurse 8)
“We definitely look from a Western perspective towards what a healthy
lifestyle is supposed to be […], but that view does not always match with
“Most children don’t want it […] If they are not motivated, then there is really
the way they [people with a non-Dutch cultural background] raise their
no point.”
children.”
(YHC nurse 8)
(Pediatrician 4)
Several factors were mentioned by the HCPs that could negatively influ-
ence the family’s motivation. For example, many families have not formu-
3.6. Family’s experience with healthcare (theme 6) lated a request for help themselves, but are diagnosed at a regular check
up with YHC professionals or are referred by other HCPs. According to
According to the HCPs, many children with obesity and their parents the HCPs, this could affect their problem awareness. The HCPs indicated
have had negative experiences with HCPs and feel resistance against that some parents do not acknowledge that their child has overweight or
YHC or the municipal health service. The HCPs mentioned several obesity, especially in younger children. Other parents do acknowledge it,
factors that could negatively influence the family’s experience with but do not find it problematic.
healthcare, such as unrealistic expectations of the treatment, having to
tell their story multiple times, and a negative attitude of HCPs. The “Often people come [to an appointment], but they don’t see the problem, and
HCPs emphasized the need for a supportive HCP who does not address they are not willing to do something about it.”
patients in a judgmental way. (Pediatrician 4)

“They are just hurt people and children, so I think the attitude of the
HCP is very important. I think it’s very important that people feel “It doesn’t have anything to do with not being motivated, but with not always
supported.” being able to see it [the overweight]”
(Pediatrician 1) (YHC nurse 8)

In addition, it is thought to be important to tailor the treatment to the HCPs indicated that the problem awareness can be influenced by the
family’s situation. In some cases, HCPs think it is necessary for patients to child experiencing the short-term physical and social consequences of obe-
gain more understanding about obesity and its consequences. In other sity, for example being teased, not being able to wear nice clothes or not
cases, it might be better to stay away from the focus on weight and the being able to join peers in sports. HCPs say families might be more
scale as this can make patients feel attacked and pressured. motivated when focusing on reducing these short-term consequences as
not everybody understands or prioritizes the long-term medical conse-
“I notice that the scale puts an enormous pressure on children. […] If you quences of obesity. In addition, it allows them to experience the benefits
take away that pressure and they manage to start exercising and they’re of the treatment.
having fun, that causes them to be in a more positive flow. They can enjoy
things more. Then automatically that helps to take steps towards a healthier “We might look at health and long-term [consequences], but I think children
diet or other steps.” look at it in a different way, they look at the present moment. So you know,
(YHC nurse 10) they might have the motivation because they want to wear those jeans or they
want to sport with their friends. They can have other reasons to start working
In addition, HCPs mentioned that in many cases it is important that chil- on it.”
dren and parents feel in control of their own treatment and decide which (YHC nurse 10)
goals they want to achieve and where they want to start. Some HCPs indi-
cated that sometimes it might be necessary that the HCP takes a step back
and waits for the family to be ready for it. Other HCPs indicated that this 4. Discussion and conclusion
does not always work and that some patients need the HCP to take the lead.
“I also experienced that sometimes letting go makes them come back 4.1. Discussion
again.”
(YHC nurse 13) 4.1.1. Facilitators and barriers
The participating HCPs mentioned a large number of facilitators and
barriers they observe in children with obesity and their parents in
“Some find that a bit difficult. They would rather have an instruction with: do achieving a healthier lifestyle. Main facilitators were support from par-
this and do that.” ents and the social network. Main barriers were child’s socio-emotional
(YHC nurse 16) problems, parental personal problems, lack of parenting skills, parental
lack of knowledge and skills regarding a healthy lifestyle, parental lack
of problem awareness, HCP’s negative attitude, and family’s lack of mo-
3.7. Family’s motivation (theme 7) tivation. Many of the facilitators and barriers in this study are consistent
with previous research into the perceptions of children with obesity and
On the one hand, HCPs mentioned that many families want to their parents on what helps and hinders them in achieving a healthier
change their lifestyle, but are not able to do so because of other prob- lifestyle [16-21]. The HCPs identify the breadth and complexity of dif-
lems. On the other hand, many HCPs mentioned that not every patient ferent personal and environmental challenges that families encounter
is ‘motivated’. HCPs described patients as not motivated when they in achieving a healthier lifestyle.

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4.1.2. Needs by assessing, connecting and finding common ground to what motivates the
In addition to acknowledging these facilitators and barriers, it is useful patient, instead of imposing their own perspectives or values on them
to consider what children with obesity and their parents need from HCPs [44,45]. On the one hand, the HCP in the current study seem autonomy-
and healthcare to overcome the barriers. This could offer practical tools supportive by connecting with what is considered motivating for the child
to support childhood obesity care. and its parents. This includes focusing on short-term physical and psychoso-
The environmental barriers (physical, socioeconomic and cultural) are cial benefits of the care process instead of the long-term medical conse-
beyond the direct influence of the HCP within the context of the integrated quences of childhood obesity. In previous research, children themselves
care approach. However, these barriers can be taken into account during also mentioned physical appearance and social considerations as motivat-
the care process. Participating HCPs suggested for example that patients ing [46]. On the other hand, the fact that HCPs describe patients as ‘unmo-
need the HCP to support them in coping with temptations in the obesogenic tivated’ might be caused by patients not being motivated for the HCP’s
physical environment or consider social and cultural norms and values in course of action. From the interviews it remains unclear what the HCP
advice about a healthy lifestyle. In addition, HCPs can enhance the family’s wants the patient to be motivated for, as the participating HCPs did not
feeling of support, for example by referring patients to buddy projects. In specify whether they think their patients had a lack of motivation to partic-
previous studies, children with obesity and their parents themselves have ipate in healthcare, change their lifestyle or lose weight in general. In addi-
also emphasized the importance of social interaction and support [18-20]. tion, HCPs did not mention the underlying emotional aspects of the lack of
The individual factors of the child, the role of the parents and the motivation (e.g. what the patient thinks or feels), and merely described
family’s experience with healthcare can be attempted to be influenced by patients as not motivated by means of their behavior (e.g. having a certain
the HCP. Participating HCPs suggested for example that patients need the body posture or not attending appointments). While it is important to pay
HCP to address the child’s socioemotional problems during the treatment attention to these visible symptoms of the lack of motivation, the Self-
and support parents in improving parenting skills regarding a healthier life- Determination Theory suggests understanding and validating the patient’s
style. Parents in previous studies have also pointed out their need for skill viewpoint is crucial in supporting their autonomy [45].
building around parenting [16,20]. In addition, HCPs suggested they can The perceived lack of motivation might be a critical point where the per-
contribute to creating a supportive healthcare environment for the child spective of the HCP differs from the perspective of the child with obesity
and its parents. For example by using thoughtful communication and and its parents, which could negatively affect communication and treat-
adopting a tailored approach, which could be structured with the patient- ment outcomes [47]. Families could seem unmotivated to HCPs, but may
centered model [34,35]. The importance of a supportive HCP with a posi- be hindered by other problems or priorities, or have other motivations for
tive attitude was also emphasized by children with obesity and their change.
parents [18,36]. The way in which HCPs address the topic of weight
appears to be particularly important for children with obesity, which was
4.1.4. Strengths and limitations
also mentioned by the HCPs in the current study [37]. However, HCPs
There are some limitations to this study. First, the HCPs were recruited
have been documented as common sources of stigma towards people
based on convenience sampling, which can be vulnerable to biases and in-
with obesity, which could undermine obesity treatment [36,37]. Few
fluences beyond the control of the researcher [32]. However, the use of
HCPs in the current study mentioned their own stigma, but some did men-
three inclusion criteria possibly decreased these limitations. Second, a qual-
tion the stigma of some other HCPs.
itative research design using interviews includes a risk of socially desirable
answers. Some topics could have been sensitive as they included personal
4.1.3. Motivation
factors of the participating HCPs, for example regarding the HCP’s attitude.
One striking result in this study is while acknowledging a large number
In addition, motivation could have been a sensitive topic as motivating
of individual and environmental barriers and facilitators, many HCPs
patients might be considered as the HCP’s responsibility. Third, female
singled out one prerequisite for starting the behavior change process: the
health care professionals were overrepresented in the study. However,
family’s motivation. When discussing the topic of motivation, HCPs men-
women also dominate the current health workforce worldwide [48].
tioned to a limited extent the possible causes for the lack of motivation.
Strengths of this study include that the participating HCPs are specialized
This is consistent with previous research findings suggesting that HCPs
in childhood obesity and have substantial work experience with children
find it hard to identify the drivers for lack of motivation in children with
with obesity. In addition, they worked in eight different municipalities
obesity and their parents [38].
spread across the Netherlands and consist of smaller and larger municipal-
In addition, the HCPs find it complicated to influence the family’s moti-
ities.
vation. Some HCPs indicated it is pointless to start the treatment process if
the child and/or its parents are not motivated, and the HCP should wait
until the family is ready for behavior change. This seems to reflect the 4.2. Innovation
Stages of Change Theory, which illustrates that the HCP can tailor motiva-
tional strategies to the patient’s stage of change [39,40]. However, previous Successful integrated care for childhood obesity requires HCPs to assess
research shows HCPs can take a more passive role in treating obesity as they and acknowledge a wide range of factors within and outside of healthcare
perceive a lack of patient motivation as an important barrier for successful that could help or hinder families in achieving a healthier lifestyle
treatment [22,41]. [28,29]. To the best of our knowledge, this study is the first to explore
However, according to the Self-Determination Theory, motivation can the perspective of HCPs working within an integrated care approach on
be enhanced by the HCP by meeting three basic psychological needs of these factors. Our findings show the importance of HCPs understanding
the patient: competence, relatedness and autonomy [42]. The need for the patient’s perspective to be able to tailor the treatment to the patient’s
competence can be supported by providing the patient with the required needs, in particularly with regard to the patient’s motivation. This is an im-
knowledge and skills for behavior change. The participating HCPs in the portant step in providing optimal support and can increase the chances of a
current study also mentioned the importance of children with obesity and successful treatment [47]. This study also shows the need for more research
their parents gaining more knowledge and understanding about obesity into the way in which HCPs can empower patients to set their own health
and a healthy lifestyle. However, previous research shows that HCPs them- priorities and agendas to enhance their autonomy and motivation accord-
selves sometimes lack knowledge and/or skills relating to weight manage- ing to the Self-Determination Theory. Empowerment in childhood obesity
ment [43]. HCPs can enhance the patient’s sense of relatedness by being is currently under researched [44,49]. In addition, more research is re-
genuinely involved and supportive. This was also mentioned by the partic- quired into the perspective of HCPs, children with obesity and their parents
ipating HCPs in the current study, although not in the context of influencing on the topic of motivation as it remains unclear in this study what they
the family’s motivation. The patient’s autonomy can be honored by the HCP envision the aspect of motivation to entail.

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Initiative: An initiative with support of the Dutch Heart Foundation and facilitators to initial and continued attendance at community-based lifestyle
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Obes Rev. 2017;18:183–94. https://doi.org/10.1111/obr.12478.
the Care for Obesity Project (VU University Amsterdam), which was funded [19] Perry RA, Daniels LA, Bell L, Magarey AM. Facilitators and barriers to the achievement
by the Dutch Ministry of Health, Welfare and Sport (grant numbers 328544, of healthy lifestyle goals: qualitative findings from Australian parents enrolled in the
329657, 977473, 332401). The funders did not have any role in the study PEACH child weight management program. J Nutr Educ Behav. 2017;49:43–52.
https://doi.org/10.1016/j.jneb.2016.08.018.
design, data collection and analysis, decision to publish or preparation of [20] Schalkwijk A, Bot S, De Vries L, Westerman M, Nijpels G, Elders P. Perspectives of obese
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Declaration of Competing Interest [21] Smith KL, Straker LM, McManus A, Fenner AA. Barriers and enablers for participation in
healthy lifestyle programs by adolescents who are overweight: a qualitative study of the
opinions of adolescents, their parents and community stakeholders. BMC Pediatr. 2014;
All authors declare that they have no known competing financial inter- 14:1–14. https://doi.org/10.1186/1471-2431-14-53.
ests or personal relationships that could have appeared to influence the [22] Schalkwijk A, Nijpels G, Bot S, Elders P. Health care providers’ perceived barriers to and
need for the implementation of a national integrated health care standard on childhood
work reported in this paper.
obesity in the Netherlands-a mixed methods approach. BMC Health Serv Res. 2016;16:
1–10. https://doi.org/10.1186/s12913-016-1324-7.
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