Table 3. Illustrative Quotes from Stakeholders
|
Core Components
|
1. A strong curriculum with illustrative examples of healthy behavior change
|
1a
|
"…and what she had in sodas. We eliminated them completely because she had sugar in little bottles. The portions of sugar in bottles, how much sugar sodas have, how they harm us." – Parent Adviser
|
1b
|
"Not just pointing pictures at the book, but having the physical food there and the key was, portion control, so seeing what a plate looked like… I was given a sample plate of the size that it should be.”
-Patient Adviser
|
1c
|
“I think the cooking demonstrations, also have to be about the recipes that would fit into what people are used to in terms of their heritage, and diet, and their diet heritage.”
-Pediatrician
|
2. A patient centered program with engaging materials and a participant tailored approach
|
2a
|
“In fact, in our program, they want us to say, "Do this, do this, do this. Go home and eat this. Don't eat that." They think that's what our program is going to be. It's not. Obviously it's not. We're not—it's not within our scope of practice, but furthermore, we are facilitators, and, you know, it's behavior change model, which is "What do you think you can do?” - Local YMCA program director
|
2b
|
"[What] I think is a key element to be successful, because if the patient[s] do not feel comfortable with the providers they, you know, will go to listen to you or they [don't make] many changes, you know. So I think the communication, engagement with the family is very, very important.” -Behavior Health Professional
|
2c
|
“we've really had to learn a lot in this first session of, like, we sort of had the child sitting with their parent, and as we're facilitating the first hour, what we found was that the parents were doing all the talking...” - Local YMCA program director
|
3. 3. A family-centered program where all members of the family are involved in behavior change
|
3a
|
“Certainly one of the things that was abundantly clear to me when I did that first program all those years ago was that you cannot just do a program to change youth obesity with just the children. That’s just never going to work. It can’t work because they don’t – it’s a family issue.” - Local YMCA program director
|
3b
|
“...one thing that is very, very helpful is pay attention to the interest of the family and support them and ask about the question that they had and in my case, one of the thing that is very helpful is connect the families with family partners or community support.” -Behavior health professional
|
3c
|
“So I think that there needs to be more focus on the parents and educating them because they’re coming from a family, you know, they’re in the same situation. So now they’re just another generation. So some parenting skills, limit setting, cooking, shopping, and menu planning.” - Dietitian
|
4. Group visits to help build a support system for participants
|
4a
|
“I think that group visits work better than individual visits just because of the support system, of you know, the parents with other parents—and also, the kids, as well. They don’t feel like, you know, they’re the only ones, you know? They have.. other kids with them that are going through the same things that they’re going through...So to have that group setting, where they can talk to each other, and the parents can talk about their frustrations, I think is the best scenario” -Community Health Worker
|
4b
|
“I think the special sauce is the relationships that they build with each other- and then sort of they feel responsible to each other, right? They need to have the readiness to be making these types of lifestyle changes, um, but at the same time, if this sort of power of this group and this group cohesion is helping them come back, then that’s a really good thing” -Local YMCA Program Director
|
4c
|
“I would've definitely wanted, being in a group setting. Especially [with] kids...around my own age; so you can relate to them a lot...” -Patient Adviser
|
5. The inclusion of high-quality core personnel such as a community health worker, a physician, a behavior health clinician and a dietitian
|
5a
|
“not just a medicalized approach. I think many of the tertiary care kind of programs around childhood obesity do have a team approach of different specialists. You’ve got the doc; you’ve got the psychiatrist; you’ve got the nutritionist. So I think holistic, in nature and working” – National YMCA Representative
|
5b
|
“I would say, number one, having someone who really knows the community and knows the culture of our patients.... Because if you can't understand our culture and our community, then whoever tries to teach is not going to get any parent to do anything.”
-Community Health Worker
|
5c
|
“Be compassionate with people because some of the patients, especially the parents sometimes they come with long faces because of different issues.” -Dietitian
|
Determinants of implementation and dissemination
|
Cosmopolitanism
|
6. Partnerships of clinic and community organizations
|
6a
|
"Neither one of us can do this work alone... clinical needs us, and we need clinical. Whether the partnership is around a referral source, or if it's …collaborative programming. I think we need each other” -Local YMCA Program Director
|
6b
|
“If an accountable care organization is a group of community provider settings, heavily toward that structure, then the setting of care, at which the care if provided, may be much more effective and appropriate in a community setting because you're there.”
-Medicaid Official
|
6c
|
" I think , to make it work better especially in my community , either the schools after school when you find a place like the nurse's office where the doctor can travel to , the different neighborhoods in the community , to access more people. Buildings where people can go to , where they can get the services because it makes it all difficult to try to get everyone to one central location, , compared to going to different- one-one day go to one location, the other day go to another location. Which would make it easier, for patients, they get out of school and then go straight to the program. They don’t physically have to leave the building" -Patient Adviser
|
6d
|
" I think with this new wave of quality improvement, and controlling costs. I think that might be the next phase where we try to establish firmer relationships with effective community resources of the YMCA, so I could see that down the line." Internal Medicine Physician /Chief Medical Officer
|
External Policies and Incentives
|
7. Sustained funding for the program with insurance reimbursement
|
7a
|
“I think it's very important that health insurance be providing reimbursement for different doctor's offices or community health centers. Because… it would create a priority, for different organizations to provide these services. If they can't find the funding they won't be able to put more into it.” -Patient Adviser
|
7b
|
‘” the other piece of that is,... those accountable care organizations are going to focus on the people who are in the emergency room, you know, who are, you know, in the ICU, who are, you know, massive users of healthcare dollars. And our patients with diabetes, right? ...Our kids with obesity, you know, they're invisible, right?” -Pediatrician
|
7c
|
“I think you always have to show cost savings, unfortunately. And some years you have to show them more than others, and some year—you always have to argue that.” – MassLeague Representative
|
7d
|
"I mean, like, health insurance is, I mean, beyond, so, but they should, this is the kind of thing they should be funding, because, all things relative, it’s not that expensive, and it’s such an investment.”-Pediatrician
|
8. Supportive External policies
|
8a
|
“It’s going to be critically important, obviously, to manage chronic diseases as inexpensively as possible, and certainly it is cheaper to have a community health worker touch base with a family than it is to have a nurse or to have, you know, the provider . . . ACO models are probably going to incorporate, you know, more aggressive case management and we’ll probably utilize people that are at least referred to as community health workers down the road. And so I think that insurers will pay attention that because I think they’re an inexpensive way to kind of in a culturally appropriate, linguistically appropriate way, to have health-related education to people who have chronic diseases.” -Pediatrician
|
8b
|
“I think is important, and making sure it's evidence-based, which I think goes part and parcel with the cost …efficiency and quality equation, but then, going that step further to say, "Let's not look at it as a one-year, how much did you save," but I think, in the long run” -Medicaid Official
|
8c
|
" I think in schools, I think that we need just policy change in the- and change the way kids spend their days" -Local YMCA program director
|
Identifying and Developing Solutions to Patient Barriers
|
9. Barriers
|
Transportation
|
9a
|
"It's tough I think for them to get here, for families to actually come get into the clinic…They might take the bus, which is just a lot for them….They might not have the money to get here" -Dietitian
|
9b
|
“There’s no transportation option. So Mom or Dad, you know, or whomever that the guardian or parent is, don’t have transportation. They don’t have a car.” -Local YMCA Program Director
|
Childcare
|
9c
|
“With the families having a lot of children, and these kids having a lot of siblings and lack of babysitters, they’re coming here and having to bring them all…” Community health worker
|
Time Constraints
|
9d
|
“So if there—if there were, like, extended hours or just hours that are later on after school which would allow parents to bring their kids to the doctor to get, you know, the education that they need.” -Patient Adviser
|
9e
|
. “The only problem with the weight clinic, for me, personally, was just—it was very time-consuming for the patients…” -Community Health Worker
|
Tertiary Care Centers are Often Where Programs are Occurring
|
9g
|
“So that access for those programs are an issue, and when you have a disease that has, you know, has a 40 percent prevalence rate in our community, there is no way that those patients can all be seen at tertiary care centers. It's just not possible.” -Pediatrician
|
Cost
|
9i
|
So anything with a cost, unfortunately parents tend to shy away from. The YMCA is very expensive for them, even with the financial-assistance contract.” Community health worker
|
9k
|
“I did a presentation to the providers, and the first question out of their mouth is "Is it free?" And if it's not free they cannot envision their patients being able to take advantage of the program.” -Local YMCA Program Director
|
9l
|
“but I think you should do something like that, or to help with obesity, or free groups to do exercise, or for people that don’t have resources like me.” – Parent Adviser
|
9m
|
“I think their food insecurity piece is always the biggest challenge, and so how does that play into the work that you’ve been doing?” Pediatrician
|
Language
|
9o
|
“Just being able to speak the same language that the family has, and not just talking to just me as the patient, but just talking to the family, it’s a family effort... So it was very difficult for them to go, and not always having a translator or someone who spoke Spanish available” -Patient Adviser
|
9p
|
“There’s that lag in time of their response and it actually does kind of affect the process not being able to kind of – having that gap in there. It takes twice as long to kind of get back to them with whatever you want to say.” -Pediatrician
|
9q
|
“Language and culture is the other barrier that we encounter a lot. In a perfect world, we would have in-person interpreters for all these visits. That probably wouldn’t happen, so we would need to—we would as much as we can, schedule it ahead of time, and if we can’t, we would use the interpreter line.” Pediatrician
|