Challenges of making healthy lifestyle changes for families in Aotearoa/New Zealand.

OBJECTIVE: The objective of the current study was to identify challenges of making and sustaining healthy lifestyle changes for families with children/adolescents affected by obesity, who were referred to a multicomponent healthy lifestyle assessment and intervention programme in Aotearoa/New Zealand (NZ). DESIGN: Secondary qualitative analysis of semi-structured interviews. SETTING: Taranaki region of Aotearoa/NZ. PARTICIPANTS: Thirty-eight interviews with parents/caregivers (n 42) of children/adolescents who had previously been referred to a family-focused multidisciplinary programme for childhood obesity intervention, who identified challenges of making healthy lifestyle changes. Participants had varying levels of engagement, including those who declined contact after their referral. RESULTS: Participant-identified challenges included financial cost, impact of the food environment, time pressures, stress, maintaining consistency across households, independence in adolescence, concern for mental health and frustration when not seeing changes in weight status. CONCLUSIONS: Participants recognised a range of factors that contributed towards their ability to make and sustain change, including factors at the wider socio-environmental level beyond their immediate control. Even with the support of a multidisciplinary healthy lifestyle programme, participants found it difficult to make sustained changes within an obesogenic environment. Healthy lifestyle intervention programmes and families' abilities to make and sustain changes require alignment of prevention efforts, focusing on policy changes to improve the food environment and eliminate structural inequities.

What affects programme engagement for Maori families? A qualitative study of a family-based, multidisciplinary healthy lifestyle programme for children and adolescents.

AIM: It is important that intervention programmes are accessible and acceptable for groups most affected by excess weight. This study aimed to understand the barriers to and facilitators of engagement for Maori in a community-based, assessment-and-intervention healthy lifestyle programme (Whanau Pakari). METHODS: Sixty-four in-depth, home-based interviews were conducted with past service users. Half of these were with families with Maori children and half with non-Maori families. The interviews were thematically analysed with peer debriefing for validity. RESULTS: Maori families experienced barriers due to racism throughout the health system and society, which then affected their ability to engage with the programme. Key barriers included the institutionalised racism evident through substantial structural barriers and socio-economic challenges, the experience of interpersonal racism and its cumulative impact with weight stigma, and internalised racism and beliefs of biological determinism. Responses to these barriers were distrust of health services, followed by renewed engagement or complete disengagement. Participants identified culturally appropriate care as that which was compassionate, respectful, and focused on relationship building. CONCLUSIONS: While Whanau Pakari is considered appropriate due to the approach of the delivery team, this is insufficient to retain some Maori families who face increased socio-economic and structural barriers. Past instances of weight stigma and racism have enduring effects when re-engaging with future health services, and inequities are likely to persist until these issues are addressed within the health system and wider society.

Prevalence of comorbidities in obese New Zealand children and adolescents at enrolment in a community-based obesity programme.

AIM: The aim of this study was to describe the characteristics at enrolment of children and adolescents referred to an obesity programme and to determine how the prevalence of comorbidities differed in Indigenous versus non-Indigenous children. METHODS: Participants were residents of a semi-rural region of New Zealand (NZ). Eligibility was defined by a body mass index (BMI) of ≥98th percentile or >91st centile with weight-related comorbidities. Fasting blood, medical and physical assessments were obtained. RESULTS: During the recruitment period from January 2012 to August 2014, 239 participants, aged 4.8-16.8 years, undertook assessment. Average BMI standard deviation score was 3.09 (standard deviation (SD) = 0.60, range 1.52-5.34 SD). The majority of participants were of either Maori (NZ's indigenous people (45%)) or NZ European (45%) ethnicity; 29% of participants were from the most deprived quintile of household deprivation. Maori participants were more likely than NZ Europeans to have a mother who smoked during pregnancy (52% vs. 28%, P = 0.001), a family history of type 2 diabetes (66% vs. 53%, P = 0.04), acanthosis nigricans on examination (58% vs. 20%, P < 0.0001), a low serum high-density lipoprotein cholesterol (27% vs. 14%, P = 0.03) or high serum triglyceride (38% vs. 24%, P = 0.03) concentration. CONCLUSION: The unique aspect of this study was the ability to recruit high levels of Maori participants and those from most deprived areas, indicating a high level of acceptability for these target groups. Comorbidities were prevalent in this cohort of overweight/obese school-aged children. While there were some differences in comorbidity prevalence between Maori and NZ Europeans, the overall clinical picture in our cohort, irrespective of ethnicity, was of concern.

Health system barriers to accessing care for children with weight issues in New Zealand: An interview-based study.

OBJECTIVE: To identify barriers created and maintained by the health system affecting engagement in a family-based multidisciplinary healthy lifestyle programme for children and adolescents in New Zealand. METHODS: We conducted 64 semi-structured interviews with participants of the programme (n = 71) with varying levels of engagement, including those who declined contact after their referral. Half the interviews were with families with Maori children, allowing for appropriate representation. Interviews were analysed using thematic analysis. RESULTS: Five health system factors affecting engagement were identified: the national policy environment, funding constraints, lack of coordination between services, difficulty navigating the health system, and the cost of primary health care. CONCLUSIONS: Engaging with a health system that creates and maintains substantial barriers to accessing services is difficult, affecting programme engagement, even where service-level barriers have been minimised. Lack of access remains a crucial barrier to improved health outcomes for children and their families experiencing childhood obesity in New Zealand. There is a need for comprehensive approaches that are accompanied by a clear implementation strategy and coordinated across sectors.

Determining barriers and facilitators to engagement for families in a family-based, multicomponent healthy lifestyles intervention for children and adolescents: a qualitative study.

OBJECTIVES: Recruitment and retention in child and adolescent healthy lifestyle intervention services for childhood obesity is challenging, and inequalities across social groups are persistent. This study aimed to understand the barriers and facilitators to engagement in a multicomponent assessment-and-intervention healthy lifestyle programme for children and their families, based in the home and community. DESIGN: Qualitative interview-based study of past users (n=76) of a family-based multicomponent healthy lifestyle programme in a mixed urban-rural region of New Zealand. Semistructured, home-based interviews were conducted and thematically analysed with peer debriefing for validity. PARTICIPANTS: Families were selected through stratified random sampling to include a range of levels of engagement, including those who declined their referral, with equal numbers of interviews with Indigenous and non-Indigenous families. RESULTS: Three interactive and compounding determinants were identified as influencing engagement in Whanau Pakari: acute and chronic life stressors, societal norms of weight and body size and historical experiences of healthcare. These determinants were present across societal, system and healthcare service levels. A negative referral experience to Whanau Pakari often resulted in participants declining further input or disengaging from the programme. A fourth domain, respectful and compassionate healthcare, was identified as a mitigator of these three themes, facilitating participant engagement despite previous negative experiences. CONCLUSIONS: While participant engagement in healthy lifestyle programmes is affected by determinants which appear to operate outside immediate service provision, the programme is an opportunity to acknowledge past instances of stigma and the wider challenges of healthy lifestyle change. The experience of the referral to Whanau Pakari is important for setting the scene for future engagement in the programme. Respectful, compassionate care is critical to enhanced retention in multidisciplinary healthy lifestyle programmes and ongoing engagement in healthcare services overall.