The intervention: Families for Health
Families for Health version 2 is a family-based programme aimed at the treatment of children (aged 6–11 years) who are overweight or obese. Delivery is group based, and the aim was to recruit groups of 8–12 families, with children and parents attending parallel groups. In families randomised to this arm, both parents were invited, together with all overweight and non-overweight siblings in the target age range. Where necessary, the start of a programme was delayed so that viable attendance numbers could be obtained. The programme was manualised, with detailed handbooks available to facilitators, parents and children. Groups were run on a Saturday morning or afternoon for 2.5 hours each week for 10 weeks. Follow-up sessions were planned for 1 and 3 months post intervention.
The main principles underpinning the Families for Health intervention were that the parents were identified as the agents of change responsible for implementing lifestyle change in the family.29
A solution-focused approach was employed, focusing on solutions rather than the problem. The programme emphasises parenting skills, relationship skills, and emotional and social development, and combines this with information about lifestyle, all of which are key to implementing and maintaining behaviour change.
Table 2shows an outline of the main content of the parallel parents’and children’s groups for the 10 weeks. The weekly topics in the Families for Health programme were broadly the same for both parents’and children’s groups, in order to promote greater understanding and discussion at home. The parents and children met mid-way each week for a healthy snack and an active game, with an aim of introducing ways in which children and parents could interact at home.
TABLE 1 Summary of changes to original FFH protocol approved by the NRES West Midlands: Coventry and
Warwickshire Research Ethics Committee and/or HTA programme
Change to protocol Approval Type and date approved
The CSRI was developed and given ethical approval prior to piloting
NRES Substantial amendment 1, 17 January 2012
The inclusion criterion was changed from children aged
7–11 years to 6–11 years (parents of 6-year-old children were
coming forward requesting to participate)
NRES/HTA programme
Amendment 2, 27 April 2012
The formatting of CSRI was changed after piloting, the poster for recruitment was revised and the letter used for recruitment via the NCMP was changed
NRES Amendment 3, 21 May 2012
Interviews were originally just going to be with families in the FFH arm, but the protocol was changed to include interviews with UC families as well in order to improve comparison with UC
NRES Substantial amendment 4, 6 August 2012
HTA programme
11 July 2012
Recruitment rates were slower than initially anticipated. The emphasis on the type of recruitment method used changed along with the study timelines as the study progressed. Approval was given for GP databases to be searched for potential overweight/obese children, who, once identified, were contacted via letter
NRES Substantial amendment 5, 8 May 2013
Addition of a seventh FFH programme in order to reach sufficient study participant numbers. This required a 9-month no-cost extension (to 31 August 2015) to the study to enable the 12-month follow-up of participants
HTA programme
Approved by HTA on 19 June 2014
CSRI, Client Services Receipt Inventory; FFH, Families for Health; GP, general practitioner; HTA, Health Technology Assessment; NCMP, National Child Measurement Programme; UC, usual care.
The parents programme of the Families for Health programme shared some of parenting skills topics from the Nurturing Programme from Family Links,27and included both behavioural (e.g. positive discipline,
family rules) and relationship (e.g. giving praise, raising self-esteem, emotional health) approaches to parent training. The support with parenting skills were integrated with family lifestyle topics around healthy eating and physical activity in the weekly sessions. The approaches include facilitated discussion, role-play, goal-setting, skill practice, a solution-focused approach and homework.
TABLE 2 Content of parents’and children’s parallel groups for Families for Health (version 2)
Week Parents’programme Children’s programme
1 Let’s get started
l What is health?
l Balancing act 1: energy in, energy out
l Let’s look after ourselves
Let’s get started
l Why be healthy?
l Balancing act 1: energy in, energy out
2 Balancing acts
l Discipline (including setting limits and praise)
l Balancing act 2: food our bodies need–
the Eatwell plate
Balancing acts
l Balancing act 2: what our bodies need to eat–
the Eatwell plate
l The gift of praise
3 Inner power–our ally for health
l Family guidelines and rewards
l Finding our power for health (focus on
physical activity)
Inner power–our health helper
l Our inner power
l Let’s get active
l Introducing the pedometer
4 The question of choice
l Our eating habits
l Children’s choices
Our choices
l Making strong choices
l Let’s go shopping
5 Health is a family affair
l How much we eat (portion sizes)
l Building self-esteem
Liking ourselves
l Glad to be me
l Let’s make a rainbow (of fruit and vegetables)
6 Feelings–a guide to our emotional health
l Thinking about feelings
l Active alternatives to staring at the screen
Getting to know our feelings
l Feeling up, feeling down
l Screen savers: what else can we do?
7 Solutions to stress
l Stress–and what we can do about it
l Coming to our senses
l Surviving at the supermarket
Time to chill out
l What winds us up?
l What calms us down?
l Activity taster
8 A world of labels
l Food labels: what do they mean?
l Labelling our children
Food detectives
l What’s on the label?
l Activity taster
9 Taking charge
l From problem to solution
l A healthy lifestyle or a life of diets?
l Meeting the challenge of special occasions
Living healthily
l Problems, puzzles and solutions
l Activity taster
10 A healthy family future
l Scaling the ladder to health
l We are stars!
l Family party: time to celebrate
The children’s programme included a focus on healthy eating using the Eatwell plate as the basis; circle time to discuss emotional aspects of their lives and enhancing self-esteem; and physical activity aimed to increase activity levels by participation in games, the use of pedometers and introduction to new physical activities. Families in the intervention arm were also eligible for usual-care interventions and any usual care they received was documented.
Training and selection of facilitators: Families for Health
Four facilitators, two for the children’s group and two for the parents’group, were required to run each Families for Health programme. Facilitators were identified from the local NHS or other services, and selected on the basis of personal attributes including empathy for families with overweight children and previous relevant experience, for example with running groups with parents and children. In site A, a formal application process was set up, whereas for sites B and C nominations were received through the leads for obesity. Professional backgrounds of facilitators included community nursing, teaching, youth work, leisure services and nutritionists.
Nineteen facilitators attended a 4-day training course in February 2012 provided by two trainers from Family Links. Trainers from Family Links were used to deliver the training because of the close association of the Families for Health programme with the Nurturing Programme from Family Links.27,28The training
covered the content, philosophy and logistics of running the programme. For some sessions facilitators were divided up into subgroups of whether they were facilitating the children’s or parents’group, and practised facilitating parts of the programme. Participants completed an evaluation form for each day of the training, including the level of confidence in delivering the Families for Health programme and rating the usefulness of the topics covered. Training increased facilitators’confidence in delivering the programme and most found the training a positive and useful experience. Further details of the evaluation of the training of the facilitators are inAppendix 1.
Usual-care control group
Families assigned to the control arm were offered any usual care that was available in their area. During the duration of the study, usual care for each locality varied.
Site A had the One Body One Life (Coventry City Council, Coventry, UK) 10-week programme, which is a group-based family intervention that has been subject to published evaluation.36This was available
throughout the study. The eligibility criteria for the One Body One Life programme was children aged 7–16 years, but was offered to the whole family if one or more member of the family was an‘unhealthy weight’. The programme took a solution-focused approach, with the 1.5-hour sessions comprising a 45-minute physical activity workshop and a 45-minute healthy eating workshop.
Site B had Change4Life (Department of Health, London, UK) advisors who offered one-to-one support for weight management for children aged 4–13 years who were overweight or obese. Recruitment to their service was via self-referral, referral from school health or other health professionals, and via the National Child Measurement Programme (NCMP). Visits were mainly undertaken at the child’s home. This service was available for the majority of the study, though in the final few months of recruitment funding for Change4Life advisors was withdrawn and a single telephone call was instead being offered.
In site C, usual care was one of the following: (1) a weight management programme for children and young people aged 7–15 years, comprising a two-step programme, MEND and Choose It (Wolverhampton City Council, Wolverhampton, UK), focusing on taster sessions for physical activity and healthy eating. Funding for this programme was withdrawn halfway through the study and so two alternatives were offered as ‘usual care’in site C, depending on the age of the child; (2) Weight Watchers®(Weight Watchers UK Ltd,
Maidenhead, UK) for young people aged≥10 years, who had to be accompanied by a parent; and (3) a referral to the school nurse for children aged 6–9 years, where children would be weighed and measured and offered advice. This type of usual care was not standard at the start of the study and, therefore, did not always occur as hoped.Table 3gives further details of the usual-care programmes.