Health professionals' views and experiences of discussing weight with children and their families: A systematic review of qualitative research

Background: Healthcare professionals are ideally placed to discuss weight management with children and families to treat and prevent childhood obesity. The aim of this review was to collect and synthesize primary research evidence relating to health pro-fessional's views and experiences of discussing weight with children and their families. Methods: Systematic searches were conducted using the following databases: MEDLINE (OVID), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE (OVID), PsycINFO (OVID) and Healthcare Management Information Consortium (HMIC). Twenty-six full text qualitative studies published in English Language journals since inception to October 2019 were included. Papers were quality assessed and synthesized using an inductive thematic analysis approach. Results: Data analysis generated five themes: sensitivity of the issue, family – professional relationships, whole systems approach, professional competency and sociocultural context. Conclusion: Supporting behaviour change through discussion of healthy weight with children and families is an important part of the health professional's role. Tailored information for professionals, including resources and training, facilitates them to confidently talk to children and families about weight prioritized within interventions. The success of such interventions requires commitment from a range of professionals to ensure healthy weight is tackled through a whole system approach.

children with overweight experience bullying or harassment. With nearly a third of children aged 2-15 years affected by overweight or obesity, the problem is rapidly increasing (Health and Social Care Information Centre, 2015).
Supporting individuals to change unhealthy behaviours through the use of brief, opportunistic interventions is advocated as one way of preventing behaviour-related illnesses (Abraham et al., 2009).
Healthcare professionals (HCPs) are well placed to talk to children and their families about weight, to address the issue before it progresses. In the United Kingdom, a 'Making every Contact Count' policy mandates that all professionals in the public sector have a responsibility to routinely tackle behavioural causes of ill health, including poor diet and lack of physical activity. This is also recommended within the UK's National Institute for Health and Care Excellence (NICE) guidance on behaviour change (NICE, 2014). Indeed, changing behaviour has great potential to improve child and family health and thus can arguably be considered the responsibility of every paediatric HCP. Nevertheless, evidence has suggested that it does not routinely happen (Elwell et al., 2014). It is important therefore to understand the challenges HCPs face in discussing weight with children and families during contacts with them.
Reviews conducted in the area of child weight management, have to date, focussed on the perspectives and views of parents/caregivers (Bentley et al., 2017;Gillison et al., 2016;Lampe et al., 2020). Research has shown that parents who seek help from professionals relating to their child's weight have received mixed responses (Edmunds, 2005). A systematic review investigating HCPs' views on child weight (Bradbury et al., 2018) identified barriers to raising discussions with parents including professional-parent interactions and organizational issues.
However, this review focussed on professionals initiating discussion with parents only. It did not include professionals who raise the issue of weight directly with the child/young person whose weight is being discussed. In this review, we synthesize the qualitative evidence related to health professional's views and experiences of discussing weight with children and their families. Synthesizing qualitative research is recognized as a valuable method for identifying barriers to health promotion policies and practices and informing effective and engaging health interventions (Thomas & Harden, 2008). Rather than aggregating data as in traditional 'narrative' approaches, qualitative reviews aim to further understanding by going 'beyond the content of the original studies' (Thomas & Harden, 2008, p. 3).

| AIM
The aim of this paper is to systematically collect and synthesize primary qualitative research evidence relating to health professional's views and experiences of discussing weight with children and their families.

| Search strategy
A search strategy was developed using terms based on the population (e.g., HCPs), issues (e.g., discuss*), setting (e.g., healthcare) and context (e.g., weight management). The search strategy included a combination of free text and index terms. Synonyms were combined using the word OR and concepts were combined using the word AND (Boolean logic) (Figure 1). citations. Studies that clearly did not meet the inclusion criteria (see Table 1) were excluded, and all other possible relevant citations were retrieved as full text copies for assessment for inclusion in the review.

Key Messages
• Obesity is a complex issue and a major threat to children's health and wellbeing.
• Reviews conducted in the area of child weight management, have to date, focussed on the perspectives and views of parents.
• This study found that supporting behaviour change through discussion of healthy weight with children and families is an important part of the health professional's role.
• The success of such interventions requires commitment from a range of professionals to ensure healthy weight is tackled through a whole system approach.
Two reviewers (SA and GH) independently assessed the eligibility of retrieved full text papers. Disagreements were resolved by discussion with a third member of the research team (RW). A PRISMA study flow chart was used to summarize papers included and excluded at each stage. Each study excluded at the full paper screening stage was described in the excluded studies table along with the reason for exclusion.

| DATA EXTRACTION
Studies were read and re-read before data were extracted and recorded on a pre-prepared form. As well as basic study information, data were extracted from the findings and discussion sections of included papers on key themes, ideas and concepts as expressed in original terms by the participants (first-order constructs) and also by the authors (secondorder constructs). Information about study setting, methodology and participants was extracted to provide a context for data synthesis. Two reviewers (SA and RW) independently obtained and recorded the data.
Where the authors were unsure or disagreed, discussions were held with a third member of the research team (GH).

| CRITICAL APPRAISAL OF INCLUDED STUDIES
Two reviewers (SA and RW) independently assessed the quality of the included studies using the Critical Appraisal Skills Programme (2014).
Studies of all quality were included, but the quality of studies was taken into consideration during data synthesis, so that those studies rated as having a higher quality were given more weight within the analysis. Discrepancies were resolved through discussion with the wider research team.

| DATA SYNTHESIS
Data synthesis was carried out using an inductive thematic approach (Thomas & Harden, 2008). Thematic synthesis has three stages: coding of text 'line-by-line', development of 'descriptive themes' and generation of 'analytical themes'. While the development of descriptive themes remains 'close' to the primary studies, the analytical themes represent a stage of interpretation whereby the reviewers 'go beyond' the primary studies and generate new interpretive constructs, explanations or hypotheses. This approach enables a systematic and transparent approach to data analysis and facilitates generation of rich data-driven themes (Thomas & Harden, 2008).
Initial coding was carried out by one reviewer (SA) with a subset of studies coded by two reviewers independently (GH and RW). Codes were then discussed, and a coding frame iteratively developed and agreed upon. Differences between codes were resolved through discussion. Findings of the review were reported in line with best practice guidance (Tong et al., 2012). To ensure trustworthiness throughout the process, the authors presented a narrative account of the synthesis and illustrated each theme using quotes taken directly from the included studies. A clear and transparent audit trail detailing a reflexive approach and discussions with the wider team was conducted.

| FINDINGS
The initial search generated 1434 records. Twenty six studies met the criteria for inclusion in the review ( Figure 2).

| STUDY CHARACTERISTICS
The included studies present qualitative data exploring the views and experiences of HCPs discussing weight management with children and their families. The characteristics of each study are presented in

| CRITICAL APPRAISAL
A summary of the critical appraisal results is presented in

| A sensitive issue
Raising the issue of weight was highlighted to be a sensitive matter by health professionals in all studies. Many reported that discussing the child's weight in front of a parent and child risked alienating and offending families. Fear of eliciting a negative response from families was thus evident amongst professionals. Nurses, in particular, demonstrated careful consideration of the language they used in approaching the topic: actively avoiding words such as 'obesity' and 'obese' and instead referring to, for example, clothing sizes as small, medium and large.
There is a fairly fine line between how much you can say to people and putting them offand then you have lost them completely.
In addition, the issue of body mass index (BMI) not being an exact measure was highlighted, particularly in cases where children presented with more developed muscles: 'we don't measure whether this is muscles or fat … both boys and girls can often be quite solid … and we don't take that into account' (Helseth et al., 2017). The appropriateness of using BMI as an indicator of overweight was thus discussed, with some GPs choosing to use growth charts rather than BMI: If they are on the 50th percentile for their height but the 100th percentile for their weight, most parents realise there is a problem so I tend to do that rather than give a number. (GP) (King et al., 2007) The use of growth charts was viewed as an essential resource for professionals especially practice nurses when raising the issue. Due to the visible nature of the chart, professionals felt families benefited from seeing the progression the child was making with their weight.
HCPs reported that initiating conversations about weight was difficult for children who were perhaps not yet able to understand the severity or extent of the issue. GPs, for example, reported that raising the subject of weight in front a child could lead to psychological distress, which nurses further suggested could lead to adverse consequences such as disordered eating or damaged self-esteem, especially for adolescents: It's the body image thing that especially young women have to face, and probably guys too. You do not want to make someone so hyper-concerned that their weight that is pushes them into other types of unhealthy eating habits. (Nurse practitioner) (Findholt et al., 2013) It was further reported that when parents presented as defensive or angry in response to the topic of weight being addressed, professionals avoided raising the topic again for at least another year. Moreover, the scale of a child's weight impacted on how they raised the issue. For example, it was considered easier to discuss weight with children with overweight than those with obesity. This was T A B L E 3 Critical appraisal of included studies

| Family-professional relationships
Professionals reported that raising the issue of a child's weight was influenced by the relationship between the professional and the family. Nurses, for example, reported that they had confidence in raising the issue of child weight management, but only when they had known the family for a long time 'if it is someone you haven't seen very often and then it's more tricky' (Edvardsson et al., 2009). Such familiarity offered the opportunity to intervene early when signs of overweight were present, again, suggesting that they felt more comfortable with working to prevent the issue rather than responding to it. Nurses felt gaining respect from families was vital when raising weight for discussion 'I throw the ball backit's your life how would you like it to be?' (Bonde et al., 2014). Furthermore, health professionals reported that their relationship with the family depended on perceptions of, and respect for the professionals' role. Some health professionals did not raise the subject if they felt it would harm their relationship with the family.
The relationship between professionals and families was affected when parents failed to engage in the discussion and when they did not view their child's weight as problematic: 'parents do not always accept that their child has a weight issue' (Turner et al., 2016). Additionally, professionals reported conflicts between the parent and child, especially when a parent did not perceive the child's weight as an issue, but the child did. It was observed then, that power dynamics between parents and children presented a challenge to HCPs in raising the conversation. Where parents acted as the decision-maker for their child regarding dietary habits and physical activity, HCPs recognized that younger children were less able to make their own decision to support them with a healthy weight.
GPs further suggested that working with adolescents was different from working with children. Interestingly, adolescents tended to raise the discussion with the GPs first, rendering a need for developmentally appropriate conversations with young patients, who can become increasingly body conscious as they transition towards adulthood. In addition, GPs reported that females were more confident in raising the issue of weight during conversations about the contraceptive pill. It was acknowledged that HCPs needed to demonstrate sensitivity to this aspect of age differences of paediatric patients, which as a result, supported their relationship with the patient.
It's easier with adolescents, they are a bit more aware of things and a bit more conscious of things around them and perhaps they understand better. (GP) (King et al., 2007) 11.3 | Whole system approach Health professionals suggested that tackling child weight should be viewed as a collaborative approach between organizations and professionals rather than the responsibility of one sole profession.
School nurses clearly felt that there was a lack of organizational support, especially when attempting to implement interventions: 'If the [school] principals aren't on board you can forget it, they're going to shut it down' (Steele et al., 2011). They also highlighted that other professionals, such as teachers and sport coaches, could be more supportive of nurses' efforts in raising the discussion. School nurses in particular reported that the burden of responsibility for discussing weight management was a huge issue and that there was not enough support from the multi-disciplinary team. GPs were also aware that a child's weight was not just a medical issue and stemmed from several wider determinants of health, requiring input from a range of professionals.
When children were referred to other services following a discussion about weight, nurses described experiences of dismissive behaviour from professional colleagues, providing examples of when their referrals were not taken seriously. Further to this, health professionals mentioned that they can often feel unsure of where to refer children to due to lack of available support or specialized services. As one GP suggested, 'there is no treatment as such' (Walker et al., 2007).
In all studies, health professionals acknowledged that behaviour change is difficult and that supporting families to manage weight without input from other organizations such as childcare centres, preschools, schools and school canteens was challenging. HCPs were clear on their view that tackling childhood obesity required implementation of interventions early in the child's life with family-based support for healthy eating and physical activity. School nurses in particular, reported that they 'work closely with the public health officials' to raise awareness of overweight and obesity and to support behavioural changes.
It's about behaviour change. They need to change their behaviour and that's very hard to do, it's more than just

| Professional competence
Despite acknowledging their role in preventing and addressing child overweight, professionals were less clear on their competence and confidence to raise the issue. While GPs, for example, reported that they have an important role to play in tackling the issue, they expressed that part of their role was to be direct and honest with patients, to 'be more proactive in helping diagnose but then also helping to steer treatment as well' (King et al., 2007).
In some studies, raising the discussion about weight was perceived to be the responsibility of GPs and practice nurses, with one GP stating 'certainly our role is to raise it with parents' (Walker et al., 2007). Further to this, some HCPs felt tackling the issue of child weight management was a responsibility of parents, families and public health officials: It's a social problem and cultural problem and it's a family problem as well. It's got to be a big public health drive, a campaign to inform people really. (GP) (Walker et al., 2007) Mixed levels of confidence to address weight issues were reported, with the professional's own self-efficacy playing a role when raising the matter. Professionals disclosed that they worried about making matters worse and felt that they did not have the communicative skills to tackle the issue. Frustrations were further expressed amongst professionals who felt unsure about what to do once they had raised the topic. As a result, the competency of all professionals was questioned, as was the sufficiency of training: 'we're not trained formally, you're not confident in what you are delivering you know' (Turner et al., 2016).
Another barrier to raising the discussion of weight management with children and their families, described in all studies, was a lack of time and capacity. Due to limited appointments, professionals reported that one of the reasons they did not raise the issue was not seeing the child regularly. GPs specifically reported that they did not raise the issue as they knew it 'takes a long time' (Walker et al., 2007).
Professionals also reported lack of clear protocols and resources,  (Steele et al., 2011) What resources are available in the community for treating paediatric obesity? You're looking at it. We're really the front line and the last line (Physician assistant) (Findholt et al., 2013).
Frustrations were reported by professionals when they felt 'unable to find relevant information to hand to families' (Jones et al., 2014) making it difficult to continue the conversation as families wanted additional support to which professionals were not able to provide or signpost to.

| Sociocultural context
HCPs demonstrated awareness that discussions needed to be tailored to the family's sociocultural context. Cultural factors, for example, were seen as an obstacle especially when language barriers between the professional and family were present. Nurses reported that they struggled to raise the discussion with individuals from a different cultural group, particularly if they felt judged by the family for not understanding their cultural backgrounds. HCPs reported that some cultures viewed overweight and obesity as a sign of a healthy child and wealth of the family, and therefore, they did not see this as an issue. One practice nurse reported that parents deliberately wanted their child to be overweight due to influence of older relatives 'there are parents who want their 1-3 year olds to be chubby … and that's when the parents are satisfied' (Regber et al., 2013). Discussing weight in this context was thus approached with caution, as HCPs worried about being perceived to critique the family's culture. Furthermore, professionals proposed that the norms around obesity were changing more generally, suggesting that an overweight child is now commonly viewed as having a normal weight thus making it more dif- This was particularly prevalent in countries where healthcare was available at a cost and due to parent's inability to pay. Parenting styles were also reported to be a challenge as it was difficult to raise the issue of eating habits with families where portion sizes were inappropriate or food was used as a reward.
It's very hard to tell a mother to stop feeding their child so much … it's a deeply psychological thing … yes … it's sort of love and food. (Nurse) (King et al., 2007) In a study of children with asthma, HCPs reported that children use food as a way to cope with having asthma 'they get all sad and then some people turn to food' (Clarke et al., 2018). The impact of healthy eating was reported in all studies with a focus on food being perceived as a reward in some cultures.

| DISCUSSION
This review thematically synthesized 26 papers reporting health professionals' views and experiences of discussing weight with children and their families. There was consistency in findings across the studies leading to five themes: a sensitive issue, family-professional relationships, whole systems approach, professional competence and sociocultural context. Although previous reviews have synthesized evidence in this area (Bradbury et al., 2018;Lampe et al., 2020;McPherson, Hamilton et al., 2017), this review is the first to include discussions with both children and their families, recognizing that the challenges of talking to these groups (children, young people and parents) may be different.
Supporting other reviews, barriers to discussing weight with families, from the perspective of HCPs, related to sensitivity of the topic (Bradbury et al., 2018;Kovacs et al., 2018). However, the findings of this review further add that HCPs fear alienating families when they raise the issue of weight. While professionals reported feeling uncomfortable about such discussions here and elsewhere (Jacyrya et al., 2018), evidence suggests that making use of parental concern for the child's health can be an effective way of supporting attempts to address the issue of overweight (Bradbury et al., 2018). Having said this, it is recommended that these discussions occur without causing distress. In the United Kingdom, The National Child Measurement Programme (NCMP) was developed to monitor national trends in child heights, weights and BMI, leading to parents of children with overweight being informed and offered support to help reduce their child's excess weight (Sallis et al., 2019). But while the NCMP provides excellent monitoring data, providing this feedback by letter has, as yet, had little impact on obesity rates. Significant research has examined feedback from parents regarding the programme, with many parents indicating that it makes them feel judged, distressed and unsupported by professionals (Falconer et al., 2014;Grimmett et al., 2008;Mooney et al., 2010;Syrad et al., 2015).
Moreover, rates of obesity tend to be higher in children with additional needs or disabilities (Rimmer et al., 2011). The present review included research on professionals working with children with asthma and overweight (Clarke et al., 2018)  unclear (McPherson, Hamilton et al., 2017). It is imperative that professionals feel confident and supported with raising the issue of weight, with such skills embedded within basic training. Similar to the current review, HCPs have previously identified time constraints and lack of resources as factors that determined whether healthy lifestyle conversations took place and they questioned their professional competency in raising the discussion (Barlow, 2007;Elwell et al., 2013).
Studies have demonstrated that the professional's own health behaviours were also believed to influence raising the discussion of healthy behaviour change (Elwell et al., 2013;Laws et al., 2008), a finding that is supported by this review whereby HCPs struggled to raise the dis- Moreover, the Foresight Report (Butland et al., 2007) and World Health Organization (Branca et al., 2007) have previously suggested that a whole system approach to tackling obesity and promoting a healthy weight is critical. HCPs in this review highlighted the importance of a 'whole systems approach' in tackling obesity with it being the responsibility of all professionals working with families, in raising the discussion. Programmes that have been designed to tackle childhood obesity, using an integrated, multi-stakeholder, whole system approach, for example, EPODE (together let us prevent childhood obesity) and the Amsterdam Healthy Weight Programme, have shown promising results (Busch et al., 2018;Gregory, 2019;Specchia et al., 2018).
The importance of using behaviour change theories and strategies when developing interventions to prevent or tackle obesity is widely accepted (Martin et al., 2013;Nixon et al., 2012;Summerbell et al., 2005). What this review adds, however, is that communication strategies are also of paramount importance when discussing healthrelated issues, in particular those as sensitive as weight (Berry, 2007;Edgar & Volkman, 2012). While literature suggests that accurate, clear and honest communication is vital when discussing obesity (Harris et al., 2014), professionals remain unsure of how best to communicate with families about weight, holding concerns about how individuals will respond upon discussing weight issues (Berry, 2007).
Given the huge relevance of behaviour change in tackling obesity (Gillison, 2019), interventions to support health professionals should incorporate a theoretical framework using behavioural change evidence at the root of implementation (Abraham & Michie, 2008

| IMPLICATIONS
The results of this study suggest a number of challenges experiences by HCPs in discussing weight with children and families. Making use of existing policies and frameworks, Table 4 summarizes practical suggestions for supporting health professionals in this aspect of their work.

T A B L E 4 Supporting health professionals to initiate discussions about weight with children and families
Taking a whole systems approach A multi-disciplinary, boundary spanning approach to supporting healthcare professionals should be adopted. This could include the following: Shared care and structured treatment plans (Rhoades et al., 2011). Working collaboratively with a range of multi-disciplinary professionals including GPs, school nurses, dieticians and psychologists to support families (Bush et al., 2018;Gregory, 2019;Specchia et al., 2018). Implementing policies and practices to support and promote healthy weight, food and physical activity that span organizations and sectors (e.g., health, education and planning).
Making use of behaviour change theory and techniques UK NICE guidelines stipulate that behaviour change approaches should be used in the management and tackling of childhood obesity. Examples of behaviour change techniques include the following: Increasing self-efficacy through mastery of skills, vicarious experience, verbal persuasion and emotional states (Bandura, 1997). Goal setting (goals for increasing physical activity levels and changes within diet using the SMART approach [small, measurable, achievable, recorded and timed]). Self-monitoring (working with the child and family with set goals to enhance motivation and monitor progress) Developing referral pathways Referral pathways should be developed and implemented, enabling professionals to actively support families in changing their behaviour once child weight is identified as problematic. Helpful strategies might include the following: Developing a directory for local resources that can be accessed quickly by professionals at the point that the conversation about weight is raised. Making use of interventions such as social prescribing (referring patients to activities or programmes available within the community to improve their health and wellbeing; Bickerdike et al., 2017;Messiah et al., 2016). Working with local sectors to raise the awareness of such interventions, contributing to normalization of community-based exercise.
Upskilling the workforce Professionals require training and support to feel confident in their own competence to address the issue of paediatric weight management. Training professionals in the fundamentals of cognitive and behavioural strategies would be beneficial. Evidence-based approaches might include the following: UK Framework for talking about weight with children (Public Health England, 2017) Motivational interviewing has been found to be effective in supporting weight loss in children Hettema et al., 2005;Wong & Cheng, 2013).

Providing a consistent message
Healthcare professionals need to provide a consistent message to families regarding child weight across services and sectors. Communication on child obesity needs to be accurate, appropriate, clear, honest, accessible and delivered in a sensitive manner (Moorhead et al., 2013). Existing frameworks that could help HCPs provide a consistent message include the following: Knowledge translation casebook designed to support positive weight-related conversations between HCPs, children and their families (Provvidenza et al., 2019). Recent UK documents designed to support HCPs as part of the national Child Measurement Programme (Chadwick et al., 2019). Using digital technology to enhance healthcare through a web of connection between the community and healthcare providers (Siegal et al., 2018).

| CONCLUSION
This qualitative review synthesizes the experiences of health professionals in raising weight for discussion with children and their families.
Findings suggest that discussing weight remains a sensitive issue, for which professionals would benefit from further training in communication strategies, enabling them to develop confidence in their competence to raise the issue of child weight management.