Implementation of national guidelines for the prevention and treatment of overweight and obesity in children and adolescents: a phenomenographic analysis of public health nurses’ perceptions

Abstract

ObjectiveTo explore and describe how public health nurses (PHNs) perceive the implementation of national guidelines for the prevention and treatment of overweight and obesity among children and adolescents in well-baby clinics and school health services.Design, sample, and measurementsAn explorative descriptive design was carried out through individual interviews with 18 PHNs and analysed according to the phenomenographic tradition.ResultsFour implementation strategies were described and assigned a metaphor: the structured PHN, pragmatic PHN, critical PHN, and the resigned PHN. Competence, patient receptiveness, internal consensus, interdisciplinary collaboration, resources, and organizational embedding were the determinants identified that most frequently affect implementation, and these determinants were distributed at different levels of the organization. The extent of facilitation seemed to determine which implementation strategy would be used.ConclusionsHow PHNs implemented the guidelines for overweight and obesity were affected by determinants at different organizational levels. Contextual facilitation of implementation seemed better in larger organizations, but factors such as leadership, drive, and experience compensated in smaller municipalities. The implementation of guidelines was hindered when the barriers exceeded the benefits.

Barriers and facilitators to implementing practices for prevention of childhood obesity in primary care: A mixed methods systematic review

“…PCPs' competence and perceived confidence, 23,32,33,44,49,70 role‐specific specialist education and training (e.g., pediatricians and pediatric nurses), 28,29,35,36,44,45,50,56,59,64 participation in obesity training 32,33,70 and breastfeeding training, 56,57 familiarity with guidelines 32,33 and greater experience of working with children and mothers 30,34,53,59,60 were all identified as facilitators of practice. PCPs who believed that their role in prevention of childhood obesity was important reported positive attitudes and intention to implement recommended practices 23,26,31,33,39,47,54,55,58,62,73 . Motivated PCPs used approaches that facilitated implementation; these included using tactful language to discuss potentially sensitive topics, focusing on overall health and well‐being rather than on weight, framing having overweight as a societal issue, and using the BMI chart to raise the topic of weight, diet and feeding practices 25,26,31,35,39–41,53,54 .…”

“…Deficits in knowledge about childhood obesity 6,7,13,21,22,25,29,30,32 Lack of familiarity with guideline content 7,18,[21][22][23]30,31,48 Lack of skills (counseling, communication) 7,13,18,19,[21][22][23]37 Lack of obesity prevention training 2,7,11,13,18,[21][22][23]29,31 Psychological capability Uncertainty about identifying infants at risk of developing obesity 7,13,14,16,21,29,30,34,37,38,46 Disagreement with guideline content/usefulness 1,8,9,13,…”

“…Belief: risk of harm to relationship with family 1,6,10,11,13,[19][20][21]23,29,33,34,37,38,49,50 Social opportunity; Reflective motivation Beliefs, views, and assumptions about parents: Parents are resistant to advice, lack interest, not motivated 1,2,[5][6][7][8]10,11,13,14,16,18,[20][21][22]30,[33][34][35]37,38,40,42,48,50 Parents who are living with overweight are not concerned 6,7,18,19,21,30,37,50 Parents lack knowledge and skills to implement healthy weight advice 2,…”

Implementing guidelines for preventing, identifying and treating adolescent overweight and obesity—School nurses’ perceptions of the challenges involved

“…The nurses in this study revealed barriers or challenges at several levels: at the system level (implementation strategy, available resources, training and support, professional collaboration and referral options); at the individual school nurse level (perceived competence, attitudes and emotions); at the subject level (sensitivity of weight‐related issues); and at the professional level (scepticism about a BMI cut‐off of 25 as the starting point for interventions). In another Norwegian study, barriers to guideline implementation were identified at the individual nurse level (competence), the subject level (receptiveness of parents and children) and at the system level (resources, organisation, collaboration) (Nordstrand et al., ). In a Dutch study, the following barriers to implementation of a healthcare standard in childhood obesity were found: the sensitivity of the subject, lack of motivation on the part of the parents, previous negative experiences with lifestyle programmes, financial constraints and the lack of a multidisciplinary approach (Schalkwijk et al., ).…”

“…The Norwegian national guidelines appeared to be challenging to implement among staff in primary health care (Nordstrand, Fridlund, & Sollesnes, 2016;Riiser, Londal, Ommundsen, Misvaer, & Helseth, 2015). There is limited research on the implementation of guidelines to combat obesity; however, barriers to such interventions in primary health care have been reported (Quelly, 2014a;Regber, Marild, & Johansson Hanse, 2013;Steele et al, 2011).…”