Motivational Interviewing in Before School Checks

The document begins by highlighting the significant global issue of childhood obesity. It cites figures from the World Health Organization (WHO), indicating that 170 million children worldwide are considered above a healthy weight, with over 41 million children under five years of age classified as highly above a healthy weight in 2016. The report emphasizes that this problem disproportionately affects lower socioeconomic populations within middle-to-upper-income countries. The focus then shifts to New Zealand, where the 2016/17 Health Survey reveals that 12% of children aged two to fourteen are classified as extremely high weight. Children aged two to four years have the highest rates of morbid obesity. New Zealand ranks fifth among OECD countries for high body mass index (BMI) statistics among children aged five to seventeen. This section effectively sets the stage by illustrating the significant and widespread nature of childhood obesity, both globally and specifically within the context of New Zealand, making a clear case for the necessity of interventions.

In response to these alarming statistics, the New Zealand government implemented a childhood weight reduction plan. This plan includes targeted interventions, increased support for at-risk children, and education on healthy food choices and exercise. A key initiative within this plan is the Raising Healthy Kids target, launched with the goal of identifying 95% of high-weight children (BMI ≥ 98th percentile) by the end of 2017. This identification was to occur through the Before School Check (B4SC) program, with subsequent referrals to health professionals for clinical evaluation. These referrals included family-based nutrition, physical activity, and lifestyle interventions. Effective communication with whānau (families) is highlighted as a crucial element in ensuring participation in these healthy lifestyle programs. While not formally funded, motivational interviewing (MI) was recommended as an effective, evidence-based method for patient-centered communication to facilitate these referrals. This section clearly outlines the government's response to the childhood obesity crisis and underscores the critical role of communication in successful intervention strategies.

Despite the implementation of the Raising Healthy Kids initiative, the document points out challenges with the Before School Check (B4SC) program's effectiveness. While registered nurses involved in B4SC have received some training in motivational interviewing (MI), their proficiency in using this technique remains unknown. There's uncertainty about whether nurses effectively apply MI or any behavior change talk skills during their interactions with families. This uncertainty forms the basis for the study, which directly addresses the need to investigate nurses' experiences of weight-related conversations with whānau and their understanding and application of MI within the B4SC context. The section establishes a clear research gap, indicating that while the initiative aims to improve communication, the actual practice and effectiveness of the chosen communication methods are questionable. This lack of clarity highlights a crucial area requiring further investigation.

This study aimed to investigate New Zealand nurses' experiences with weight-related conversations within the Before School Check (B4SC) program. The central focus was on understanding the nurses' comprehension and application of motivational interviewing (MI) techniques in these conversations. The research utilized a mixed-methods approach, employing both quantitative and qualitative data collection. A questionnaire was used to gather information on nurses' professional background, training in lifestyle counseling, attitudes, and the barriers they faced. However, due to lower-than-anticipated survey response rates, the study incorporated individual and group interviews to facilitate richer data acquisition. This combination of methods allowed for a comprehensive understanding of nurses’ experiences and the challenges of using MI in a real-world setting. The study's methodological approach aimed to provide a balanced perspective that accounts for both quantitative metrics and qualitative narratives.

The study employed a questionnaire to gather data on various aspects relevant to nurse-led motivational interviewing (MI) for childhood weight management. Data collected included personal details, professional expertise, training received, attitudes towards lifestyle counseling, and perceived barriers to effective communication. To ensure ease of participation and high response rates, the questionnaire included diverse question formats. These formats ranged from simple yes/no questions and multiple-choice options to open-ended questions allowing for more nuanced responses. The Likert scale was also incorporated to gauge attitudes and perceptions regarding weight-related conversations and interventions. Following the questionnaire, interviews (both individual and group) were conducted to provide a deeper understanding of nurses' experiences. This combination of approaches allowed the researchers to gather a broad range of data covering both quantitative measures of knowledge and attitudes and detailed qualitative accounts of nurses' actual practices.

The study included registered nurses involved in the Before School Check (B4SC) program. The participants' demographic characteristics such as age, health condition, ethnicity, gender, and socioeconomic level were not predetermined exclusion criteria. The intervention of interest was nurse-led motivational interviewing (MI) for weight reduction in children. This could be either a standalone intervention or part of a broader intervention, such as weight-loss programs, Cognitive Behavioral Therapy (CBT), Social Cognitive Therapy (SCT), or nutritional counseling. MI was compared to standard care, which could include recommendations for weight loss, body measurements, health information, diet counseling, various exercise classes, prescribed and self-directed care, or no intervention. The inclusion of various intervention types allowed for a comparison of MI's effectiveness against different approaches.

The study's data collection commenced with a questionnaire designed to gather information on various aspects of nurses' experiences with weight-related conversations and their use of motivational interviewing (MI). The questionnaire included sections on personal details, professional expertise, and training in lifestyle counseling. It also aimed to identify barriers nurses faced in these conversations. The design prioritized clear, concise questions to avoid overwhelming participants. A range of question types were used—yes/no, multiple choice, open-ended, and rank-ordered using the Likert scale—to capture diverse data points related to attitudes, knowledge, and practices. The Likert scale was employed extensively to gauge the nurses' attitudes, ideas, or knowledge on the phenomena of childhood weight management and effective communication strategies. The overall aim was to create a survey that was easy to complete, providing a comprehensive and yet accessible method to gather essential information.

The study's methodology included both questionnaires and interviews, with interviews intended as a follow-up to the initial survey to gain deeper insights. While initially, focus groups were planned, the low response rate to the survey led to a shift to individual interviews, conducted either in person or via telephone. The interviews were semi-structured, allowing for flexibility in exploring themes that emerged during the conversations. Ethical considerations were central to the process, adhering to Human Ethics Committee (HEC) guidelines. Informed consent was obtained from all participants, confidentiality and anonymity were ensured, and potential risks were assessed. Approval was sought and obtained from the Human Ethics Committee (HEC) and Pegasus Health PHO before data collection commenced. Specific considerations were given to anonymity, data storage and access, and consultation with Ngāi Tahu, a significant Māori iwi, as necessary.

The research employed thematic analysis to process the qualitative data gathered from the interviews. This involved a systematic process of coding and identifying themes across the entire dataset. The coding aimed to capture the underlying meaning of the data, with data chunks ranging from single lines to multiple lines of text. Repeated reading and constant review were employed to ensure thoroughness and inclusiveness. Thematic analysis allowed for the identification of recurring patterns and themes within the qualitative data from nurses' accounts, providing valuable insights into their experiences, challenges, and approaches. This qualitative analysis complements the quantitative data from the questionnaires, providing a richer and more comprehensive understanding of the nurses' perspectives.

The study revealed significant barriers hindering effective communication regarding childhood weight. A major obstacle was parental non-acceptance of the weight issue, often stemming from misinterpretations of their child's weight. Parents might normalize their child's size due to factors like high birth weight or familial traits, or express shock upon being informed their child is above a healthy weight. This parental perception is consistent with a New Zealand health survey finding that 90% of parents of high-weight children (aged two to four) were less likely to perceive their child as having a weight problem. Nurses reported difficulty navigating these beliefs, often hesitant to directly challenge parents' perceptions, fearing offense. This reluctance to confront the issue created a barrier to effective intervention. Additionally, the nurses' own limited and generalized training in motivational interviewing (MI) created uncertainty and reduced confidence in their ability to engage parents in constructive conversations around weight management.

Beyond parental perceptions, several other barriers emerged from the study findings. Time constraints faced by nurses emerged as a significant challenge, often limiting the duration and depth of conversations. The one-day motivational interviewing (MI) training received by the nurses was deemed insufficient. Many nurses reported reverting to habitual communication methods when they perceived MI as too challenging or unnecessary, indicating a need for more comprehensive training and ongoing support. The inadequate training resulted in a lack of confidence and competence in applying MI techniques effectively. Moreover, the study highlighted a pattern of referrals primarily to General Practitioners (GPs) rather than directly to lifestyle programs. This was largely due to the perception that referrals to GPs were less demanding for both the whānau (families) and the nurses. This preference, however, indicates a potential gap in the effectiveness of the pathway for achieving the intended weight management outcomes.

Despite the challenges, the study also identified facilitators that contribute to successful weight-related conversations. Parents who were already motivated to address their child's weight were more receptive to information and referrals. Nurses reported finding these conversations easier to navigate, resulting in more effective information provision, goal setting, and successful referrals. The use of tools like 'BeSmarter' also emerged as a facilitator. This tool helped nurses and parents to collaboratively identify areas for improvement and set achievable goals. The study suggests that these more collaborative approaches, focusing on shared decision-making and goal setting, could be more effective than a solely directive approach. This highlights the importance of aligning intervention strategies with the parents' readiness and willingness to change, emphasizing the importance of client-centered approaches.

The study's findings highlight significant challenges in addressing childhood obesity within the New Zealand context, particularly concerning the effectiveness of nurse-led interventions within the Before School Check (B4SC) program. Parental non-acceptance of the weight problem emerged as a major barrier. This often stemmed from misperceptions about their child's weight, including normalizing the child's size due to familial traits or high birth weight. Nurses expressed reluctance to directly confront these misperceptions due to a fear of offending parents. Another key barrier was the nurses' inadequate training in motivational interviewing (MI), resulting in limited confidence and inconsistent application of MI techniques. The brief MI training (a one-day workshop) proved insufficient for nurses to effectively handle the complexities of these weight-related conversations. Despite these difficulties, the study noted that parents already motivated to address their child's weight were more receptive to information and referrals. The use of tools like 'BeSmarter', which aids in goal setting, was also shown to facilitate more positive interactions.

Based on the study's findings, several key recommendations are proposed to improve interventions for childhood obesity in New Zealand. Firstly, the researchers advocate for more comprehensive and targeted motivational interviewing (MI) training for nurses. This training should exceed the current one-day program, perhaps following a model of at least 20 hours in the first year and 4-8 hours annually thereafter. The training should emphasize eliciting 'change talk' rather than solely focusing on behavior change. Crucially, post-training feedback and coaching are recommended as essential components for skill retention and increased confidence in applying MI techniques. The study also suggests that incorporating children into weight-related conversations could be beneficial, although this requires additional training to equip nurses with the necessary skills. The researchers emphasize the need for policymakers to be fully aware of the challenges nurses face in communicating with whānau about children's weight, to inform and improve the effectiveness of the B4SC program and subsequent referral pathways.

The study acknowledges several limitations. The reliance on nurses' self-reported experiences, without recording actual B4SC sessions, introduces potential bias and limits the accuracy of assessing MI implementation. The low response rate to the initial survey necessitated a shift to interviews, potentially affecting the representativeness of the sample. The use of a single researcher conducting the interviews also poses a limitation. The lack of follow-up after the interviews means some questions that arose during data analysis could not be confirmed. These limitations highlight the need for future research to employ more robust methods, such as recording B4SC sessions, and to include larger, more representative samples of nurses. Further research could also explore the whānau's perspectives to provide a more comprehensive understanding of the dynamics involved in addressing childhood weight issues. Such research would significantly enhance the understanding of the barriers and facilitators in achieving positive outcomes.