Social Work in Health Care, 50:787–800, 2011

Copyright © Taylor & Francis Group, LLC

ISSN: 0098-1389 print/1541-034X online
DOI: 10.1080/00981389.2011.597316

Parent Perceptions to Promote a Healthier

Lifestyle for Their Obese Child

MICHAEL CAMPBELL, PhD, LCSW

Nemours Children’s Hospital, Orlando, Florida, USA

JANE M. BENTON, MD and LLOYD N. WERK, MD, MPH

Division of Consultative Pediatrics, Nemours Children’s Clinic–Orlando,
Orlando, Florida, USA

Parents of children referred to a pediatric multidisciplinary

weight-management clinic were queried regarding the importance
of and their readiness to promote healthy lifestyle behaviors with
their children and also regarding their confidence in their abil-
ity to adopt those changes. Among the 193 children’s parents who
completed a questionnaire (93.7% response), greater than 75%
of respondents recognized the importance of healthy eating and
physical activity, and many indicated feeling both confident and
ready to make changes. Surprisingly, even among those not confi-
dent, parents also indicated they were ready to change their child’s
eating (p < .001). This study explores the discrepancy between
parents indicating a high level of importance and readiness to pro-
mote healthy lifestyle behaviors but having less confidence that they
would actually be able to enact change.

KEYWORDS children, obesity, health behavior promotion, moti-

vational interviewing

Received September 7, 2010; accepted May 24, 2011.

This study was funded by Nemours. We gratefully acknowledge Sharon Corp for
coordination and questionnaire collection, Teresa Cabezas for data abstraction, and Stacey
Armatti-Wiltrout and Mandy Layman for expert review. Finally, we extend our thanks to the
families who offered their time in the execution of this study.
Address correspondence to Michael Campbell, PhD, LCSW, Nemours Children’s Hospital,
9145 Narcoossee Road, Suite A200, Orlando, FL 32827. E-mail: micampbe@nemours.org

787
788 M. Campbell et al.

Many of today’s youths and their families are faced with the challenge
of childhood obesity and its related comorbidities. According to national
surveillance by the Centers for Disease Control and Prevention, 12.4% of
children aged 2 to 5 years, 17.0% of children aged 6 to 11 years, and 17.6 %
of adolescents aged 12 to 19 years can be characterized as obese (body
mass index (BMI) greater than or equal to 95th percentile) (Ogden, Carroll,
& Flegal, 2008). Children in Central Florida have a similar prevalence of
obesity (Health Council of East Central Florida, n.d.). Obese children are
at an increased risk for medical conditions such as heart disease; hyper-
tension; dyslipidemia; diabetes and related metabolic disorders; gallbladder
disease; adult obesity; and some cancers (Whitlock, Williams, Gold, Smith,
& Shipman, 2005; Kirk, Scott, & Daniels, 2005). They are also at risk for
psychological conditions such as depression (Sjöberg, Nilsson, & Leppert,
2005).
Weight management, as with the adoption of other healthy lifestyle
behaviors such as smoking cessation (Prochaska & DiClemente, 1983) and
discontinuation of drug abuse (Miller, Yahne, & Tonigan, 2003), has pre-
sented a considerable challenge to traditional medical intervention strategies
(Resnicow et al., 2001). Recent guidelines proposed by an expert commit-
tee (Barlow & Expert Committee, 2007) of representatives from 15 health
care organizations recommend structured weight management to effect
lifestyle change by using patient-centered communication with techniques
such as motivational interviewing (MI) (Krebs et al., 2007). This patient-
centered communication technique is designed to help families negotiate
their feelings of ambivalence related to making healthy changes (Resnicow,
Davis, & Rollnick, 2006; Rollnick, Mason, & Butler, 1999; Miller & Rollnick,
2002).
An initial key step in effecting lifestyle change is a clinician’s assess-
ment of a family’s sense of how important it is to make a change, how
ready they are for change, and how confident they are that they can effect
this change (Rollnick et al., 1999). Importance can be operationalized as the
degree to which there is discrepancy between change and the status quo,
and it encompasses a willingness to make a change. Readiness is a dimen-
sion in which priority is used to rank timeliness for change. Confidence,
by contrast, underscores the sense of ability to enact that change (Miller &
Rollnick, 2002). When combined, the assessment of perceived importance,
readiness, and confidence (IRC) to effect change in a specific behavior
can help the clinician identify a family’s initial starting point along the
continuum of the transtheoretical model’s (Prochaska & DiClemente, 1994;
Wilson & Schlam, 2004) five stages of change (precontemplation, contem-
plation, preparation, action, and maintenance) (Prochaska & DiClemente,
1983; Wilson & Schlam, 2004). This model begins with the perspective that
the current behavior (e.g., smoking, drug use, excessive eating, and lack of
physical activity) is not an issue, and it culminates in the sustained adoption
 Parent Perception to Promote a Healthy Lifestyle 789

of healthy behaviors; knowing the starting point, as well as progress, helps

with informed selection of strategies to facilitate behavior change.
Motivational interviewing is a communication style that allows clini-
cians to diffuse resistance and reduce ambivalence, which in turn promotes
advancement along the transtheoretical stages of change (DiLillo, Siegfried,
& Smith, 2003). At various points along the treatment process, IRC to adopt
behavior changes must be assessed, and periodically reassessed, to match
MI techniques to the patient’s current level of importance and readiness
(Rollnick et al., 1999) and to facilitate confidence to enact changes. These
factors offer the best indicators of actual behavior change. Efforts to promote
IRC are more likely to lead to success in helping families adopt healthier
lifestyles (Rollnick et al., 1999).
Structured weight management using MI is recommended for obese
children seen in a multidisciplinary weight-management clinic (Resnicow
et al., 2006). Parents and other primary caregivers are in a unique posi-
tion to effect change in their child’s adoption of healthy lifestyle behaviors
(Golan, 2006; Golan & Crow, 2004; Lindsay, Sussner, Kim, & Gortmaker,
2006). Parents provide behavioral modeling, set limits on family behavior,
supply food choices in the household, and facilitate access to healthy activity
options. As a result, parents’ perceptions of IRC to change have a direct effect
on the adoption of healthy lifestyle behaviors for their children. We propose
that there is an association among the IRC dimensions (importance, readi-
ness, and confidence). In this study, we examined the relationship between
parents’ self-reported perception of IRC to adopt healthy behavior changes
in their child’s eating habits and physical activity level.

RESEARCH DESIGN AND METHODS

The Nemours Florida Institutional Review Board reviewed and approved

this study. This cross-sectional, retrospective study was based on a conve-
nience sample of parents or guardians (“parents”) of children aged 3 to
17 years who were referred to the Nemours Children’s Clinic–Orlando
Multidisciplinary Weight Management Clinic between August 2006 and
December 2007. Obese children, as determined by BMI classification (Krebs
et al., 2007) (BMI ≥ 95th percentile), and overweight children (BMI between
85th and 95th percentile) with identified comorbidities who are located
within a 100-mile radius of Orlando, Florida, are routinely referred for
evaluation and treatment. The clinic advocates a team approach (Nowicka,
2005; Bronstein, 2003; Institute of Medicine Committee on Quality of Health
Care in America, 2001) to the medical, nutritional, and psychosocial evalua-
tion and ongoing management of children with obesity and obesity-related
comorbid conditions.
790 M. Campbell et al.

Before their initial office encounter, parents of prospective patients were

asked to complete a baseline history form and a questionnaire (Appendix)
to explore their perception of IRC to effect change in a variety of lifestyle
domains. During the initial patient encounter, clinicians used the completed
questionnaire to inform goal setting and negotiation of strategies to effect
lifestyle change through the use of MI. All questionnaires collected from new
patients during the study period were abstracted into an electronic database.
We adopted questions in a standard MI format (Miller & Rollnick, 2002)
to measure parental perception in the domains of general behavior, eating
habits, and physical activity habits. The questionnaire responses were then
analyzed using standard frequencies, means and standard deviations, and
2-sided Pearson chi-square analyses. Variables were dichotomized compar-
ing the “top box” or highest responses [5] with the combined scores of all
others [4 to 1]. The top box score was used because it reflects the high-
est level [5] of confidence and readiness for change, whereas lower scores
[4 through 1] reflect some level of ambivalence. Market researchers have
found that the likelihood to engage in an action is closely influenced by
a top box score (Menzes & Serbin, 1991; Reichheld, 2003). Associations
between IRC for change were assessed using chi-square analysis.
To address the issue of missing data, questionnaires with more than 10%
of items missing were excluded from the final analysis. Given the nominal
nature of the dataset, remaining questionnaires with missing items had the
omitted values imputed by mode replacement (Gliner & Morgan, 2000).
There were no questionnaires included with more than 5% of items with
missing values in the questionnaires. Analyses were conducted using SPSS
14.0 software (SPSS Inc., Chicago, IL).
Using a key words in context (KWIC) approach (Ryan & Bernard, 2000),
parents responded to qualitative questions regarding perceived barriers to
adopting healthy behavior and regarding elements they believed would
help them feel more able to establish healthy behavior changes. The KWIC
approach serves to identify the main concepts (the keywords presented in
italics), which are listed in the middle of a passage or phrase, and is pre-
sented with a certain amount of context on either side. These qualitative
comments were analyzed for themes, thus adding a richer interpretation
of the role of IRC in the parents’ perceptions regarding the adoption of a
healthier lifestyle among families of severely obese children.

RESULTS

Among the 206 questionnaires collected for this study, 13 met the exclusion
criteria due to incomplete data. The excluded families were found to have
similar baseline characteristics to those enrolled in the study sample. A sin-
gle questionnaire was completed by each child’s parent, with 83.9% maternal
 Parent Perception to Promote a Healthy Lifestyle 791

TABLE 1 Baseline Characteristics

Female [# (%)] 105 (54)

Age [mean (SD)] (in years) 11.3 (3.1)
Initial BMI percentile [mean (SD)] 99.1 (1.03)
Insurance at 1st visit [# (%)] Commercial 101 (52)
Medicaid 93 (48)
Self-pay 4 (2)
Other 2 (1)

Race/ethnicity [# (%)] American Indian 1

Pacific Islander 1
Non-Hispanic 105 (54)
Black 34 (18)
White 71 (37)
Hispanic 67 (37)
Black 6 (3)
White 61 (32)
Other 25 (13)

respondents, 9.3% paternal respondents, and 6.7% with the respondent char-
acterized as “Other.” Of the 193 children with a completed questionnaire,
51% were female with a mean age of 11.3 years (SD = 3.1) and mean BMI
of 99.1 percentile (SD = 1.03). None of the children had a BMI less than the
95th percentile for gender and age (Table 1). Parents completed an initial
comprehensive health assessment, and all of the children were identified as
having at least one comorbidity. Of these children, 78.4% had findings of
insulin resistance (acanthosis nigricans, hyperinsulinemia, or both), 58.4%
had cardiovascular conditions (elevated blood pressure, hyperlipidemia, or
both), 57.8% had underlying respiratory conditions (asthma, exercise intoler-
ance, or both), and 42.7% had some sleep disturbance (snoring, obstructive
sleep apnea, or both). Less than 25% of these children had other comor-
bid conditions (e.g., gastrointestinal conditions such as reflux esophagitis
or fatty liver disease, musculoskeletal conditions such as slipped capital
femoral epiphysis, or other possible obesity-related disorders). The majority
(88%) of children had multiple comorbidities: 15.0% of the children had two
comorbidities, 16.8% had three comorbidities, and 56.2% had four or more
comorbidities identified.
On a scale of 1 to 5 (5 indicating the highest rating), most parents
rated a high level of concern and importance to their child’s weight (mean
4.7 [SD = 0.7]), to their child changing his or her eating habits (mean 4.7
[SD = 0.7]), and to their child changing his or her physical activity habits
(mean 4.7 [SD = 0.8]) (Table 2). The high percentage of top box scores
regarding the importance of making changes in eating (78%) and physical
activity behaviors (76.6%) clearly establishes that respondents overwhelm-
ingly felt both domains were important areas for change. Further, their
792 M. Campbell et al.

TABLE 2 Importance, Readiness, and Confidence to Change: Mean, Standard Deviation, and
Proportion Scored High (5)

193 (n) surveys Scale 1 (low) to 5 Mean % with

(high) (SD) “5”

Child’s present weight or Level of concern 4.7 (0.7) 77.1

body size Weight issues cause problems 3.9 (1.3) 44.4
Eating habits Importance 4.7 (0.7) 78.0
Willingness to change 4.6 (0.8) 71.7
Confidence to change overall 4.1 (1.1) 50.7
Confidence to remove sugary 4.3 (1.0) 56.6
drinks from diet
Confidence in eating 3.9 (1.2) 41.0
5 fruits/vegetables
Readiness to change child’s eating 4.8 (0.7) 80.5
habits
Readiness to change own eating 4.6 (0.9) 72.7
habits
Readiness to change family’s 4.6 (0.8) 73.2
eating habits
Physical activity habits Importance 4.7 (0.8) 76.6
Willingness to change 4.6 (0.9) 71.7
Confidence to change overall 4.3 (1.0) 53.7
Confidence to reduce screen time 4.0 (1.2) 48.3
Confidence to engage in vigorous 3.9 (1.2) 43.4
activity
Readiness to change child’s 4.6 (0.8) 69.8
physical activity
Readiness to change own 4.5 (0.8) 67.3
physical activity
Readiness to change family’s 4.5 (0.8) 62.9
physical activity

reported readiness to effect changes in eating (80.5%) and physical activ-

ity behaviors (69.8%) was relatively high; however, overall confidence of
making changes in eating (50.7%) and physical activity behaviors (53.7%)
lagged behind (Table 2).
Concerning confidence and readiness to change eating habits, 98 of
the respondents were ready among 104 who were confident (94.2%) to
change eating habits, and 67 were ready among 89 who were not confi-
dent (75.3%) to change eating habits (χ 2 [1, n = 193] = 12.399, p < .001)
(Table 3). Confident parents were 1.25 times as likely (or 25% more likely)
to identify themselves as ready to make healthy eating changes. Concerning
confidence and readiness to change physical activity, 96 of the respondents
were ready among 110 who were confident (87.3%) to change the current
level of physical activity, and 47 were ready among 83 who were not confi-
dent (56.6%) that they could change the current level of physical activity (χ 2
[1, n = 193] = 21.577, p < .001) (Table 3). Confident parents were 1.54 times
 Parent Perception to Promote a Healthy Lifestyle 793

TABLE 3 Associations Between Readiness for Change and Confidence in Change

Chi-square
# (%) value∗ p-value

Ready to change eating habits Confident 98 (94.2%) 12.399 <.001

Not confident 67 (75.3%)
Ready to change physical activity Confident 96 (87.3%) 21.577 <.001
habits
Not confident 47 (56.6%)
∗
Based on continuity correction computation (2-sided).

as likely (or 54% more likely) to identify themselves as ready to make healthy
eating changes.
Parents shared their perspective on barriers to adopting healthy behav-
iors and on elements they believed would facilitate establishing healthy
behavior changes. Parents reported that lack of motivation and worry for
social stigma (both for the child and their family) present significant obsta-
cles to making changes (e.g., “She doesn’t want to be seen doing exercise or
other things, so, I need help to convince her.”). Parents also indicated that a
hectic schedule for their child (e.g., “He struggles with balancing his school-
work, homework, and getting active . . .”) as well as their own work–life
balance (e.g., “. . . my work schedule . . .”) present struggles to implement
change. Another theme that arose from their responses was the combined
pressures of hectic schedules and financial constraints. Parents report con-
cerns that they are not able to balance these seemingly competing needs
(e.g., “. . . working and not being home to monitor what he eats,” and, “not
having enough money to provide the right foods in the house”) as barriers
to adopting healthy behavior change.
Despite these apparent barriers, families were able to identify factors
they felt might help them to adopt changes. Parents felt some positive
change would lead to more positive changes (e.g., “If he loses weight he
might get motivated to eat healthier.”). Parents also reported that MI tech-
niques, such as partnering with the child and his or her family and rolling
with any resistance brought to treatment, could facilitate change in behav-
ior (e.g., [they needed] “. . . advice/counseling without pressuring her too
much,” [and felt it was important to] “. . . avoid forcing her” [to change]).
Parents report that behavior modification strategies, such as targeted goal
setting, could be a tool for change (e.g., “. . . would like a written detailed
plan that [they] would have to follow . . . ”). Finally, families sought assis-
tance in improving self-esteem (e.g., “. . . that she has to love herself first”),
and parents indicated that unconditional support from health care providers,
from family members, from social support members, and from the patients
themselves would help to promote healthy lifestyle change (e.g., “we need
support from the WHOLE family”).
794 M. Campbell et al.

DISCUSSION

The traditional medical model of expert-directed “top-down” communication

exists in stark contrast to the collaborative exchange of information that
flows from the use of MI (Rollnick et al., 1999). In the traditional medical
model, the health-care provider informs patients and their families about
the potential risks and concerns surrounding the disease to educate and
persuade them that this important issue needs treatment. Our data indicate
that the parents referred to our clinic come to an initial visit already armed
with the belief that weight control is important and have a high level of
readiness to act to treat it. Unfortunately, they appear to lack the confidence
to put a treatment plan into action.
By identifying those families who lack confidence in their ability to
make specific behavior changes relating to eating and physical activity
habits, we were provided an opportunity to build self-esteem, promote
self-accountability, and to negotiate with families to identify and engage
in specific, measurable, and attainable goals with consistent, positive
praise regardless of how small the achievement. Such efforts to empower
confidence may result in the adoption of healthier lifestyle behaviors.
Unlike in previous studies (Rhee, De Lago, Arscott-Mills, Mehta, &
Davis, 2005), the child’s age was not found to be a factor in reported levels
of readiness to adopt healthier lifestyle behaviors in our data. The major-
ity of parents who sought help for their obese child found the domains of
healthy eating and physical activity highly important; however, we discov-
ered an apparent “disconnect” for some parents. Even among parents of
children with morbid obesity, we found high levels of readiness to become
healthier that were not matched by the same degree of confidence in their
ability to make specific behavior changes relating to eating and physical
activity habits. This discrepancy suggests a strong desire to enact a health-
ier lifestyle but a lack of confidence to succeed in making such changes.
High levels of readiness with low levels of confidence to undertake health-
ier lifestyle behaviors may highlight the fundamental struggle in the battle
against pediatric obesity.
A recent study (Taveras, Mitchell, & Gortmaker, 2009) utilizing tele-
phone interviews with parents and guardians of children aged 2 to 12 years
with BMI > 85th percentile (either overweight or obese) determined that
parents often lack the confidence to enact healthy lifestyle behaviors includ-
ing reducing screen time, limiting sugary-drink consumption, and avoiding
fast-food consumption. Similar to our study, evidence was found to support
the relevance of clinician assessment of IRC in helping bridge this confi-
dence gap. Confidence among parents of obese children was found to be
lower than parents of overweight children. In contrast, our study explored
the constructs of importance and readiness for change in addition to confi-
dence, which revealed the discrepancy between confidence and readiness.
Further, we suspect the lower level of confidence found in our subjects may
 Parent Perception to Promote a Healthy Lifestyle 795

reflect the greater overall morbidity in their children. The interplay among
importance, readiness for change, and confidence to enact change may vary
with morbidity and requires further investigation.
On the basis of our study, a consistent theme in parents’ responses
revolved around the need to find ways to motivate their child to see the
importance of adopting healthy lifestyles as well as ways to engage the
entire family in the promotion of lifestyle change. As the literature indicates,
through the use of MI, clinicians can attempt to engage and bolster a family’s
sense of confidence in their ability to make changes by negotiating with the
family to identify their individualized steps for attaining a healthier lifestyle.
By acknowledging the apparent gap between the parents’ reported IRC to
change, clinicians can target identified barriers and negotiate with families
to increase their adoption of a healthier lifestyle.
Families reported considerable struggles with balancing time and
money related to weight management. The collection of information regard-
ing perceived barriers to adopting lifestyle change allows a more efficient
exchange of information at the onset of treatment. By evaluating IRC to
change before initiation of treatment of obese children, clinical efforts can
be both targeted and individualized for a patient and family, leading to a
more efficient use of time and other resources.
This study contributes to the limited body of evidence of the use of MI
in a pediatric weight-management clinic. It also provides insight into the rela-
tionship between parents’ self-reported perception of importance, readiness,
and confidence to adopt healthy behavior changes in their child’s eating
habits and physical activity level. Parents who bring their child to a weight-
management clinic often present with limited confidence that they can enact
healthier lifestyle change despite their apparent sense of the importance of
the need for change and belief of their readiness to engage change. The
assumption that presenting to a weight-management clinic indicates resolu-
tion of ambivalence and confidence of effecting change may commonly be
false. When asked, parents can identify significant challenges to change as
well as possible strengths to allow change. Based on our findings, we believe
it essential that clinicians screen families perceived IRC to help craft family-
centric treatment to build confidence and overcome their unique barriers to
achievement.
The use of a convenience sample (all new patients presenting in a
time period) instead of randomized sampling may limit applicability to a
broader population (Babbie, 2006). Further, since the weight management
clinic has an inclusion criterion of BMI > 95%, referred patients tended to be
severely obese and the encounter triggered by significant health concerns.
However, these factors would likely have caused a smaller effect size in the
discrepancy between reported readiness and confidence.
The reliability of use of a questionnaire to assess perceived IRC in
changing eating and physical activity and to further inform MI before an
initial office visit has not been validated. It is possible that parents recorded
796 M. Campbell et al.

socially desirable responses. Likewise, there is a lack of evidence assessing

the fidelity of responses to these written questions compared with those
elicited during MI. Further, without longitudinal evaluation of actual behav-
iors and obesity-related outcomes, the clinical significance of these initial
parental perceptions of IRC to effect long-term change is unclear.
Continued effort and research are needed to assess patient and family
perception of IRC to change behavior and the perceived obstacles to making
these changes. Identifying the discrepancy among the components of IRC
to change provides an opportunity for care providers to set realistic expec-
tations regarding successful behavior change, to identify potential barriers,
to diffuse resistance and ambivalence, and to match MI techniques to the
families’ current level of IRC to enact healthy behavior change to promote
confidence that will lead to other healthy changes. A majority of parents
reported a sense of importance to and readiness to effect change, yet dis-
played some ambivalence to their confidence. Further research is needed
to identify the actual execution of behavior change by reported importance
and readiness, but modified by confidence.

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APPENDIX
Parent Perception to Promote a Healthy Lifestyle 799
800 M. Campbell et al.