11 stakeholders were recruited to this study. Stakeholders were all female and included Hearty Lives weight management programme workers (n = 2), School nurses (n = 3), dieticians (n = 2), Hearty Lives manager (n = 1), Public Health Consultant (n = 1), PE and School Sport Partner Manager (n = 1), Health advisor (n = 1). A further 10 school nurses were contacted but did not take part. Two had retired or left the trust, eight did not respond. Interviews were on average 52 minutes (36–74 min). Three interviews were completed face-to-face, the remainder over the telephone (n = 7). One stakeholder emailed text responses to the interview guide. Analysis led to the development of three main categories (professional support, tailoring and intervention content) that relate to what stakeholders consider important for future weight management programme design and delivery. Sub-categories within these categories are highlighted in bold throughout the text. All categories and sub-categories can be seen in Fig. 1. Transcribed quotations can be seen in Table 1.
Stakeholders commented on the importance of qualified and experienced weight management professionals with a mix of skills including physical activity, nutrition and psychology. Stakeholders felt that experienced staff instilled confidence in adolescents and parents.
Stakeholders felt that adolescents engaged better with ‘cool’ and relatable professionals, especially youth workers. Non-judgemental characteristics were important with adolescents and when speaking to parents/carers about their child’s weight. Stakeholders recognised that adolescents’ value being treated like an adult. Building rapport and trust with adolescents increased engagement in weight management programmes.
The consensus among stakeholders was that adolescents valued the peer support that came with attending a group programme. This made adolescents feel like they were not the only ones struggling with their weight, leading to new bonds and friendships. Stakeholders commented on how self-conscious adolescents with obesity feel in school Physical Education classes; exercising with others of a similar size made adolescents feel more comfortable.
The importance of family support was highlighted by all stakeholders. It was felt that without family support, behavioural changes would be limited and that educating the whole family facilitated longer sustainable lifestyle changes. Stakeholders spoke about the difficulty of engaging with some parents and found adolescents took more responsibility and were more motivated if their parents/carers were engaged. Some stakeholders felt the defensive nature of some parents was a barrier. If the parent was defensive, the adolescent was less receptive to making changes.
Stakeholders highlighted the importance of staff having the skills to be flexible and individually tailor sessions, depending on the adolescent’s mood on the day, as well as tailoring to the family’s needs. Adolescents need different support and resources compared with younger children. Stakeholders felt incentives were important, but that they must be appropriate to the adolescent age group. The consensus was that this was harder than finding appropriate incentives for younger children. Adolescents also have different needs to adults, for example, they are generally concerned with short-term outcomes and not with the risk of poor health in the long-term.
Variety in terms of delivery mode of weight management programmes was spoken about in depth by all stakeholders. Many praised the home setting of the Hearty Lives programme because of its ability to tailor to each family, and to reach families who might not otherwise engage. However, although the benefits of 1-2-1 programmes were recognised, particularly in a home setting, several stakeholders felt that this option was not sustainable or time-efficient in the current Public Health financial situation. Groups on the other hand offered a more cost-effective approach and were a good way to increase adolescents’ self-esteem. Both dieticians interviewed felt 1-2-1 programmes in clinic settings were not effective, mainly because of infrequent appointments, and formal atmosphere. Nonetheless, most stakeholders felt that the best option was to offer both group and 1-2-1 options accommodating the differing needs of adolescents and families wanting support.
Stakeholders recognised that adolescents felt embarrassed and lacked confidence prior to attending weight management programmes. Suggestions to ease these prior fears included a taster session. This was mainly linked to the physical activity element of a weight management programme, whether this be taking part or viewing the session. Stakeholders suggested a promotional video for potential participants to watch, on a website or social media, which could include interviews with previous participants. In addition, stakeholders emphasised the importance of an induction session for adolescents prior to a programme starting.
Stakeholders spoke about the importance of focusing on health within a weight management programme, even if weight loss was the adolescent’s motivation for initiating attendance.
Stakeholders felt that most adolescents, either didn’t mind, or liked having anthropometric measurements taken. Some were interested in logging changes in their Body Mass Index (BMI). Adolescents seemed to like modern technology that could calculate their BMI. Stakeholders noted the importance of making sure measurements were taken in an informal, sensitive and discreet manner, with no pressure placed on the individual.
One of the most well supported sub-categories within this analysis was the importance of ensuring all weight management programmes for adolescents include support around emotional wellbeing, confidence and self-esteem. Stakeholders commented on how fragile adolescents were in terms of their self-esteem and confidence. With adolescence being a period of life with changing emotions and potential pressures, stakeholders suggested mental health support must be prioritised. Stakeholders felt that staff involved in weight management programmes and those who knew the adolescent well, should support their emotional well-being, rather than referring them on to external organisations. However, stakeholders were not comfortable speaking to adolescents about mental health without specific training. Stakeholders spoke about how body conscious adolescents were. They felt appearance was more important to adolescents, particularly girls, than their health.
Stakeholders spoke about the benefit of goal setting with adolescents. Stakeholders felt that adolescents were generally receptive to this and there was a sense of pride when a goal was achieved. It was important that these goals were SMART (Specific, Measurable, Achievable, Realistic and Time-bound) and although the priority should be on letting the adolescent decide the goal, stakeholders suggested this should be done with support from their parent/carer. An important factor in effective goal setting was that goals were reviewed regularly by a professional and progress monitored. Stakeholders acknowledged that small changes might be all that is manageable for some families.
Stakeholders spoke of the importance of nutrition and physical activity education to improve knowledge. This was not only essential for adolescents, but also their parents. Stakeholders felt it was important for adolescents to understand the reasoning behind promoted health messages. This may help adolescents to take more responsibility for their health and weight. Stakeholders felt that parents should also receive education on parenting skills. Cooking skills for both parents and adolescents was deemed important as well as opportunities to try new foods, again highlighting the importance of family involvement.
The consensus amongst stakeholders was that adolescents need to take responsibility for their health and weight, but this should be shared responsibility with parents. Some stakeholders felt that adolescents do not realise it is their responsibility so incorporating this learning into an intervention could be promising.
Stakeholders’ general impression was that adolescents with obesity enjoy taking part in physical activity when completed as part of a weight management programme. This was felt to be a significant aspect of any weight management programme, kick starting engagement with physical activity. Stakeholders spoke of the importance of physical activity being fun. Helping adolescents to recognise that options for physical activity can include more than just sessions in the gym. Activity must be tailored to the individual and not begin too strenuously. It should be affordable, free or subsidised. Accessibility was also noted as an important factor to encourage attendance. Stakeholders spoke about how adolescents feel in terms of poor confidence and body image, which leads to embarrassment when taking part in physical activity, particularly swimming. One criticism of the Hearty Lives programme was that it did not directly provide physical activity as part of the programme. Gender specific sessions were felt to be a good option if resources were available and several stakeholders commented on the competitive nature of some adolescents. A healthy level of competition, whether this was with family or friends, was motivating, reiterating the need for peer and family support.
Stakeholders spoke of the importance of using practical, hands-on activities when educating adolescents as part of a weight management programme. Visual and interactive activities, which were more creative than typical didactic teaching was favoured. Stakeholders were very positive about including interactive cooking activities within a weight management programme.
All stakeholders spoke about incorporating technology into a weight management programme. Email, text, WhatsApp or other apps were suggested as useful tools to support and motivate both parents/carers and adolescents throughout a weight management programme and for longer-term support. Apps were suggested as a good way to gain feedback on a programme, as adolescents would feel more comfortable completing a form online, rather than on paper, highlighting their ability to use online or digital technology with ease.
Stakeholders agreed that online support really should be part of a weight management programme, not alone, but paired with face-to-face support. Stakeholders commented on the use of social media platforms as a way of supporting and promoting weight management programmes. Websites were also recommended but stakeholders commented on the need for commitment from staff to keep these up-to-date and continue promoting them. It seems stakeholders felt the idea of using technology, in principle, was something they should do, but were not currently doing well. The negative impact of social media in terms of poor body image was noted.
Most professionals commented on the need for longer-term support for adolescents taking part in weight management programmes. Hearty Lives was a 6-week programme with 12 months follow-up support at 3 monthly intervals; however the initial programme and follow-up period was felt to be too short to ensure new habits were solidified. Stakeholders commented on integrating long-term support into other services. Examples included free gym or leisure centre passes for completers, or linking more with schools, including after school activity clubs.