Childhood obesity is a significant health concern throughout Europe( Reference Pigeot, Barba and Chadjigeorgiou 1 ). An important initial step in the process of preventing and tackling childhood obesity is raising awareness among parents that their child is overweight( Reference Barlow and Dietz 2 , Reference Elder, Zyzla and Harris 3 ), as without parental involvement and support, the potential impact of interventions to reduce obesity is limited( Reference Daniels, Arnett and Eckel 4 , Reference Skouteris, McCabe and Swinburn 5 ). Past work suggests that fewer than half of parents of overweight children correctly recognise their child as such( Reference Parry, Netuveli and Parry 6 ), with some studies estimating this to be as low as 30 %( Reference Jones, Parkinson and Drewett 7 ).
An example of how parental awareness can be raised is provided by the UK National Child Measurement Programme (NCMP), a nationwide school-based monitoring programme introduced in the UK in 2006( 8 ). The scheme was introduced as a surveillance programme to provide robust data to monitor national trends in childhood weight on entry to primary school (aged 4–5 years) and again in Year 6 (aged 10–11 years). The NCMP calculates BMI centiles using the UK 1990 Growth Reference charts, and uses surveillance thresholds (85th and 95th centiles) for national comparison and clinical thresholds (91st and 98th centiles) for individual feedback( 9 ).
As the process identifies children whose weight raises a concern, it is ethical practice to intervene by providing feedback to parents on their child's weight along with an offer of support to those willing to receive it. Given that the provision of tailored information may have greater impact than generic health messages( Reference Kreuter and Wray 10 ), it was anticipated that the programme would also help health professionals to engage with families for whom a child's weight may be an issue. However, this has not always been the case, and one factor that may have limited the effectiveness of the NCMP is the negative reaction that some parents have to receiving the feedback that their child is overweight( Reference Grimmett, Crocker and Carnell 11 , Reference Statham, Mooney and Boddy 12 ).
Negative parental reactions to initiatives that attempt to engage with parents on the issue of childhood obesity (e.g. angry phone calls) are not limited to responses to the UK system( Reference Davidson and Birch 13 ). Negative responses are reported only for a small minority of parents( Reference Grimmett, Crocker and Carnell 11 – Reference Davidson and Birch 13 ); however, dealing with them may be distressing for the staff involved and may lead to services ceasing to provide this feedback to parents. For example, in a 2011 survey of over 200 local UK NCMP leads, one-third of staff involved in the provision of feedback did not consider the benefits of providing this information to outweigh its negative impacts( Reference Statham, Mooney and Boddy 12 ). However, while telling a parent that their child is overweight may well lead to short-term distress, there is no evidence that it has a negative effect on parents or children over the long term. Conversely, there is evidence that providing feedback about a child's weight can bring positive changes in contributory parental behaviours, such as feeding patterns( Reference Grimmett, Crocker and Carnell 11 ) and engagement in active play( Reference Skouteris, McCabe and Swinburn 5 ). As such, it is important that the practice continues.
While the views of health professionals as to the benefits and challenges of providing feedback to parents on a child's weight are well documented( Reference Grimmett, Crocker and Carnell 11 , Reference Statham, Mooney and Boddy 12 , 14 ), little research is available directly exploring parents’ views. Secondary information from school nurses suggests that many parents are concerned that discussing weight with their child will trigger an eating disorder( Reference Statham, Mooney and Boddy 12 ), and audits suggest that parents opt out of initiatives to weigh children in school to avoid weight-related teasing( Reference Jain, Sherman and Chamberlin 15 ). Developing a deeper understanding of parents’ feelings and perspectives through first-hand accounts is an important step in designing a more acceptable approach to the provision of this feedback and thus one that is more likely to lead to parents’ active participation in tackling overweight in childhood( Reference Grimmett, Crocker and Carnell 11 ).
The aim of the present study was to investigate the factors behind parents’ negative reactions to receiving information that their child is overweight or very overweight (clinically obese) through the UK NCMP in south-west England during 2012. The objectives were to identify whether parents agreed with the judgements made on their children, what they objected to about the experience of receiving this information, and to explore how the way in which this information is communicated could be improved.
Methods
Design
The study adopted a mixed methods design( Reference Johnson and Onwuegbuzie 16 ). As the purpose of the study was to explore and better understand the perspectives of a subgroup of parents, rather than to record generalisable findings, the primary data were qualitative. However, it was considered useful to explore the prevalence of some key beliefs among the sample (e.g. whether parents accepted that their children were overweight) and conduct comparisons between the responses of parents of overweight v. very overweight children. Therefore, a number of quantitative (closed) questions were included to inform the interpretation and context of qualitative findings. This mixed approach stems from a pragmatist research perspective, which is driven by the research question rather than adherence to any particular epistemology standpoint( Reference Denscombe 17 ).
Recruitment
The sample frame included all parents whose children were identified as overweight or very overweight (clinically obese) as part of standard NCMP procedures in one NHS (National Health Service) primary care trust in England, during spring and summer of 2012. The population within the catchment area is predominantly white British, living in both rural and urban areas. While levels of deprivation are generally below the national average, there are pockets of deprivation with a small number of neighbourhoods featuring in the most deprived 10 % nationally. The NCMP process involves the school nurse team first contacting parents to inform them that the programme is taking place and providing them with an opportunity to opt out on behalf of their child. Weight and height measurements in light clothing, without shoes, are then collected by school nurses within school for all participating children, and the child's weight and BMI centile relative to children of the same age are reported in a letter to parents. Parents whose children are identified as very overweight (i.e. above the 98th centile) also receive a telephone call from a school nurse prior to receipt of the letter, to provide an opportunity for the result to be discussed in person. The term ‘very overweight’ is used in place of the medical term ‘obese’ when communicating this information to parents to reduce potential upset given the stigma associated with obesity. Therefore, for clarity, ‘very overweight’ will be used in the remainder of the present paper. The letter also provides information on local services and physical activity and dietary initiatives available to support and assist parents in responding to the information.
Approximately two weeks after receiving the NCMP letter, parents were mailed a further letter inviting them to take part in the research study and enclosing an open-response questionnaire. Responses were returned to an independent research address in a freepost envelope or could be completed online. To encourage open responses, parents were reassured that their feedback would remain anonymous and would directly feed into changes in the service. However, this meant we could not identify non-responders for follow-up. In order to encourage greater participation parents were provided with an incentive in the form of entry into a draw for a £25 shopping voucher. The study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects/patients were approved by the Department for Health Ethics Committee, University of Bath.
Questionnaire design
The survey was designed through collaboration between the lead author, a public health commissioner (third author) and the school nurse team (Appendix). The survey comprised five sections: (i) parents' agreement/disagreement with the assessment of their child's weight status and their previous awareness of this; (ii) parents’ planned responses to receiving the letter; (iii) barriers to addressing their child's weight; (iv) ways in which the primary care trust/local authority could help them to make positive changes; and (v) how the process of providing feedback through the NCMP could be improved. The questionnaire comprised a series of closed questions (e.g. ‘Do you agree with the assessment that your child is overweight?’) followed by an open comment box for eliciting the reasons behind these responses.
Analysis
Qualitative responses to open questions were analysed using a combination of conventional and summative qualitative content analysis( Reference Hsiu-Fang Hsieh and Shannon 18 ). Conventional content analysis is appropriate to answer research questions in which researchers wish to avoid using preconceived categories and which is inductive in nature (i.e. not driven by a large body of existing research or theory)( Reference Kondracki and Wellman 19 ). In the present study, two independent researchers familiarised themselves with the response forms of all participants, reviewing all unabridged written comments which they then coded inductively into indicative categories. The codes generated were compared between the two researchers and consolidated into overarching themes. Differences in categorisation/interpretation were resolved through discussion; the aim of this process was not to arrive at a definitive answer, but to ensure that all themes and attributions presented were justified by the data. Summative content analysis( Reference Hsiu-Fang Hsieh and Shannon 18 ) was used to enhance understanding of the issues that emerged by: (i) exploring the prevalence of beliefs within the sample to provide a degree of scale for the findings; and (ii) facilitating a comparison of the representation of themes between groups (e.g. overweight v. very overweight, agreement v. dispute of NCMP judgement).
Results
In total forty-five responses were received from 313 parents whose children were identified as overweight (n 128) or very overweight (n 185) in the target area (a 14 % response rate). Twelve responses were received from parents of very overweight children and thirty-three from parents of overweight children (see Table 1).
Table 1 Summary of quantitative survey responses among parents who received letters informing them that their child was overweight or very overweight through the UK National Child Measurement Programme in one local authority in south-west England, spring/summer 2012
Fewer parents of overweight children agreed with the judgement made than parents of very overweight children (n 16 v. n 9 respectively; 48 v. 75 %), although the difference was not significant (χ 2 = 2·36, P = 0·12). Reasons commonly cited for this included: believing BMI to be an invalid measure of body fat (particularly for children who had started puberty or who were believed to have a muscular body type); considering that a child did not ‘look’ visibly overweight (when compared with other children or family members); believing that a judgement could not be made on a single measurement occasion; and believing that lifestyle behaviours (i.e. diet and exercise) should be taken into account (Table 2).
Table 2 Reasons for lack of parental concern at child's weight status among parents who received letters informing them that their child was overweight or very overweight through the UK National Child Measurement Programme in one local authority in south-west England, spring/summer 2012
The majority (n 22, 92 %) of respondents who did accept that their child was overweight felt that the judgement on their child, and the need for health services to get involved, was unwarranted. Quotes illustrating parents’ rationales for their position are presented in Table 2. Most consistently, parents appeared to believe that if a child is physically active and eats a healthy diet then there can be little or no independent risk to their health as a result of being overweight. Moreover, there was a tendency for parents to rate their child's health favourably compared with underweight or healthy-weight children who had poor diets/physical activity levels. This suggests that parents do not subscribe to health professionals’ implied assumption that being overweight is an important health issue in its own right.
Content analysis
Only two respondents were open to receiving help from the school nurse or NCMP team and considered the process of being informed to have been helpful. The remaining parents did not want external help in reducing their child's weight, for reasons ranging from the belief that no one outside the family could or should help (e.g. ‘I realise that healthy eating and awareness of weight issues is a subject that parents should deal with at home, and establish good habits’), through to the belief that any external input represented unwarranted interference (e.g. ‘We are helping our daughter develop a healthy attitude to eating and exercise and resent the interference from the Nanny State’). Consistent with this, the majority of parents would not support the introduction of health-service interventions designed to help them to control their child's weight, and felt that any service introduced specifically to reduce childhood obesity (e.g. extended opportunities for physical activity) should be open to all children, not only those identified as being overweight or very overweight.
Despite not wanting external assistance, all but one parent who agreed that their child was overweight were planning to make changes to their child's lifestyle themselves as a result of receiving the NCMP letter (e.g. encouraging physical activity, reducing portion size). It was notable that not all parents proposed to involve their child in this process; eight of nineteen parents had changed their child's home food or activity environment without making this clear to their child or telling them why.
Excluding children from being involved in lifestyle changes reflected a wider-held concern for many parents that discussing weight with their child would be harmful either to the child's self-esteem or because it risked triggering eating disorders (e.g. ‘Discussing this with a 10-year-old is hard. I fear that by going down the overweight road with children is heading towards the dreaded anorexia/bulimia route’). For these parents, fear of harm was the primary reason why they objected to receiving feedback on their child's weight at all. A number of parents reported that their child had read the letter themselves and that this had been a distressing experience for them (e.g. ‘Thanks to your letter my child now thinks she looks disgusting and looks at the calorie content of everything she puts in her mouth’). Parents’ responses inferred that they perceived the risk of eating disorders to be far greater than the health consequences of being overweight or very overweight. Furthermore, although some parents acknowledged that their children had already suffered bullying or teasing because of their weight, they still avoided actively engaging them in talking about weight or attempting to lose weight for fear of upsetting them further (e.g. ‘Slight nervousness about making him too aware of diet etc. – don't want him to be aware he's overweight as already bullied by children’). This provides some indication of the scale of parents’ concerns in relation to eating disorders, as it suggests that their fears of the anticipated, but as yet unknown, negative effects of talking about weight with their child outweighed fears of the harm that their child was already experiencing through weight-related bullying and teasing.
Some parents’ responses also suggested that they objected to being informed that their child was overweight as they felt this inferred a criticism of their parenting skills. The majority of parents felt that they already knew what a healthy lifestyle should involve and already provided this for their child (e.g. ‘I feel this is a very unhelpful exercise…. I am not an uneducated person and I know what's good for her’). As such, they interpreted the NCMP letter as feedback that they had failed to effectively act on this knowledge (e.g. ‘Reading through the questionnaire, I am again made to feel bad as I have not ticked the boxes to say I am going to put my daughter on a diet. If there was a box to say “Are you going to continue feeding your child a healthy diet and encourage her to exercise?” I would tick that…. Yes, the letter did upset me as I felt judged and unable to reply to anyone as to why I perceive her weight to be where it is’). The degree of anger and defensiveness contained in many responses may therefore reflect parents’ responses to a perceived criticism of their parenting, along with disappointment at not living up to their expectations for themselves of being able to manage their child's weight.
Parents were asked for their views of how the NCMP letter could be improved to better communicate this sensitive information to them. Most comments reflected parents’ view that they should not have been contacted at all (for the reasons set out in the themes presented to this point), rather than expressing particular disagreement with how the information was communicated. However, a number of constructive suggestions were made, including requests for a better explanation of how to interpret BMI data (e.g. ‘I would like to see a weight range of where she would be for her height and age. BMI does not mean a bean to the normal person who stands on the scales at home. Plus it would help us to see where she should be, average weight wise’) and a desire for the provision of more individually tailored information (e.g. ‘I feel that a “standard” letter is not suitable in all cases – mine included. Although sections are applicable it would have been more help to know the level of concern based on her BMI being 1 point over a healthy weight’).
Discussion
The present study sought to explore parents’ first-hand accounts of the factors underpinning their negative reactions to being told that their child is overweight. In line with past work( Reference Grimmett, Crocker and Carnell 11 ), our interpretation of the results assumes that parents who were more upset by the receipt of the letter would be more likely to respond. As such the findings are not intended to be representative of all parents with overweight children, but to provide insight into the views of an important and often vocal subgroup of parents for whom the process is particularly distressing or unacceptable.
Two central themes emerged from comments collated in the present study: (i) lack of acceptance of the evidence and (ii) fear that taking action and talking to their child about his/her weight would be harmful. The two themes may not be independent, as some reluctance to accept the evidence may stem from fear that in doing so they would then have a duty to their child to take action, which they did not want or feel able to do. Responding to health promotion initiatives with denial or resistance is common, and is suggested to result from factors such as loss of faith in public services, distrust of health professionals( Reference Crossley 20 ), or feeling that there are too many health messages around that are perceived to be ‘telling’ people what they should or should not do( Reference Whitehead and Russel 21 ). Certainly our findings were consistent with this, in that parents demonstrated a clear lack of trust in school nurses’ ability to accurately assess their child's weight status. Denial that a child is overweight may also suggest a response to cognitive dissonance( Reference Festinger 22 ). Cognitive dissonance describes the discomfort that people feel when their actions are contradictory to their beliefs (e.g. continuing to overeat when you are aware that it causes you harm). To resolve the dissonance, a person can change his/her behaviour (i.e. eat less) or change his/her attitude or belief (e.g. reject the evidence that being overweight is harmful). In many instances, people are more likely to change their attitude than their behaviour, as it is easier to accomplish. Little or no work has been conducted on the importance of cognitive dissonance in the obesity domain, but further investigation of whether parental rejection of weight messages may be a result of this response may be worthwhile to better understanding of the mechanisms of effects, in order to improve our approach to working with parents.
A further consideration in understanding parents’ unwillingness to accept that their child is overweight may relate to a lack of belief in their ability to change it, i.e. their self-efficacy( Reference Bandura 23 ). According to social cognitive theory, both a lack of confidence to carry out an action, and a lack of confidence that executing a given action will result in a desired outcome, can undermine motivation( Reference Bandura 23 ). In the present study, a number of parents reported having previously tried and failed to bring about change in their child's lifestyle or to control their child's weight. These parents commented that they knew what a healthy diet or lifestyle should be and already provided it for their child (although whether parents typically judge this accurately is a subject of debate in the literature( Reference Parry, Netuveli and Parry 6 )). As such, it appears that parents had a low expectancy that changes they considered to be at an acceptable level would result in meaningful weight change. This is consistent with the few examples of past work to have measured parents’ self-efficacy and outcome expectancies towards influencing their children's diet, which have shown a positive impact of these factors on parent behaviour( Reference Lohse and Cunningham-Sabo 24 ).
Both themes may also reflect a general lack of understanding of the degree of health risk associated with childhood obesity that is independent of lifestyle factors. This finding is consistent with past work in other countries, although published work has largely been reported only for pre-school children( Reference Genovesi, Giussani and Faini 25 , Reference Campbell, Williams and Hampton 26 ). Parents of overweight children commonly show bias in believing their children to be more active and eating a healthier diet than healthy-weight children( Reference Goodell, Pierce and Bravo 27 ), and extrapolate from this that paediatric growth charts are not relevant for their child( Reference Genovesi, Giussani and Faini 25 , Reference Boutelle, Neumark-Sztainer and Story 28 ). Our study suggests that these beliefs, representing a so-called optimism bias, are retained through to primary school age. However, we note that even within the scientific community, BMI is not universally accepted as a means of establishing health risk in children or adults, so parents’ questioning of this metric is entirely reasonable( Reference Flegal and Ogden 29 ).
Parents’ fear that addressing weight issues with their child may be harmful is a logical concern and indeed being overweight in childhood is linked to the development of disordered eating patterns( Reference Neumark-Sztainer 30 ), which in a small minority of cases can lead to eating disorders( Reference Hayden-Wade, Stein and Ghaderi 31 ). These concerns may link to parents’ self-efficacy and outcome expectancies, in terms of their having low confidence that they could bring about a positive change in their child's weight while avoiding a psychologically or physically harmful outcome. However, there is no evidence to show that the process of children talking about weight with their parents acts as the trigger for this, rather than, for example, the responses overweight children encounter from others outside the home every day( Reference Puhl and Latner 32 , Reference Berge, Wall and Loth 33 ). Being overweight is associated with poorer well-being indices (e.g. self-concept and body-esteem)( Reference Davidson and Birch 13 ) regardless of whether it is acknowledged and discussed. Despite a number of parents being aware that their child was being teased or bullied because of his/her weight, it was striking that they showed greater concern for the possible future risk of eating disorder than for how being overweight was currently affecting their child's well-being. While parents may be attempting to protect their child through not discussing the child's weight, other studies show that lack of action still has the potential for harm. For example, increased parental concern about weight status without subsequent action was associated with increased negative self-evaluations in 5-year-old girls, independently of the child's initial weight status( Reference Davidson and Birch 13 ). Such findings suggest that health professionals should be mindful of the potential negative outcomes for children's health and well-being when raising awareness to parents and should consider how to ensure sufficient steps are taken to mitigate these risks( Reference Ikeda, Crawford and Woodward-Lopez 34 ).
A further factor that may deter parents from believing their child is overweight, and that has been shown to undermine self-efficacy for change, is the stigma associated with obesity( Reference Puhl, Luedicke and Peterson 35 ). While focusing conversations with parents on children's behaviours (i.e. physical activity and healthy eating) rather than weight itself has been forwarded as one means of minimising stigma( Reference Jain, Sherman and Chamberlin 15 ), this is not without challenges; in the present study most parents considered that their child had a healthy diet and was already sufficiently active for health. While previous research suggests that parents’ perceptions in this respect are often inaccurate( Reference Parry, Netuveli and Parry 6 , Reference Jones, Parkinson and Drewett 7 ), they would be unlikely to be motivated towards change unless these perceptions changed too. One approach to tackling this may be for schools to engage parents and children in monitoring their diet and physical activity levels against recommended standards, in order to provide parents with more objective information with which to make more informed judgements.
Negative outcomes from raising parental awareness are not inevitable, however; past research provides examples of ways in which parents can respond to childhood overweight to reduce weight and enhance well-being. For example, more authoritative parenting styles, in which parents play a guiding role but discuss and explain decision making, has been associated with improved obesity outcomes for adolescents (e.g. lower BMI, increased fruit and vegetable consumption)( Reference Clark, Goyder and Bissell 36 ). Conversely, instigating changes in children's lifestyles without their involvement, such as restricting food intake, may be associated with further weight gain rather than weight loss as children commonly react against changes being imposed on them without their involvement (i.e. find ways to eat more)( Reference Golan and Crow 37 ). The finding in the present study that 40 % of parents who reported planning to instigate changes to their child's diet proposed to do so without involving their child is therefore of concern. A number of comments indicated that parents’ reluctance to discuss or address their child's weight stemmed in part from a lack of confidence that they would be able to make a positive change; these included the difficulty of discussing weight management with young children, motivating children who do not enjoy sport and exercise, and having tried and failed to make changes previously. If information and advice to help parents adopt approaches to help their child manage his/her weight that have been shown to be more effective (in terms of promoting both physical and mental health) could be provided in an acceptable format, this may help to boost confidence and promote better engagement with services or available advice.
Limitations
The scope of the present study is limited by its size, as only 14 % of the parents contacted responded to the survey. Due to ethical and data protection considerations participant responses remained anonymous, so we were not able to follow up non-responders. While the sample achieved may well reflect the majority of those who do object strongly to the information received (and thus, the target group of the present study), it is lower than in previous studies( Reference Grimmett, Crocker and Carnell 11 , Reference Statham, Mooney and Boddy 12 ). Therefore we cannot infer that the present findings generalise to other parents within or outside the research locality. Further, we did not record parent characteristics, such as socio-economic, age, ethnicity, lifestyle characteristics and parental styles, so cannot comment on or explore differences between parents from different backgrounds.
Past work confirms that parents’ characteristics and parenting styles can influence a child's weight( Reference Rhee, Lumeng and Appugliese 38 , Reference Elva, Arredondo and Elder 39 ) and so may logically also help to explain why some parents reject the information that their child is overweight, whereas others find it useful. For example, some of the comments received in the present study confirmed that parents had difficulty in interpreting the BMI data; it is likely that this would be more of an issue for parents who have achieved a lower level of education. Similarly, it would be expected that parents’ confidence or willingness to accept that weight is an issue and make changes to their home environment will differ according to family circumstances (e.g. parental weight, family eating/activity habits). Differences in parenting style are already widely recognised as important in determining a range of children's health behaviours; however, while parents and professionals largely agree that many of these (e.g. smoking, unprotected sex and alcohol use) put a child at risk, this shared view cannot be assumed for the behaviours underpinning a child's weight( Reference Dempsey, Zimet and Davis 40 , Reference Jackson and Dickinson 41 ). Models of parenting suggest that developing a better understanding of the goals parents have in relation to their children is important for health professionals, as failing to appreciate that parents’ and health professionals’ goals may be very different can result in poor engagement( Reference Jackson and Dickinson 41 ). The results of the present study suggest that there is a disconnect between the goals public health workers have for children (i.e. achieving a healthy weight) and parents’ goals for their children (e.g. freedom from concern about their weight, avoidance of eating disorders); acknowledging and addressing this difference may provide a useful starting point for more productive discussions. Theories of psychological reactance may also provide a framework for investigating the impact of parenting style on responses to weight-related information. It is proposed that the strength of reactance against health messages stems from the degree of threat a person perceives in that message( Reference Rains 42 ). Linking this to the work on parenting style, it may be that parents who exert greater control over their child's health and behaviour (i.e. adopt an authoritarian parenting style( Reference Rhee, Lumeng and Appugliese 38 )) feel more threatened by feedback that their child is overweight, as it is more likely to be perceived as a direct criticism of their approach to parenting in this domain and its efficacy. Extending research to explore how individual differences in parent characteristics influence how they respond to health messages about their child's weight in some of the ways discussed here would be useful to help health professionals to better design and target how they communicate with parents.
Conclusions and future directions
Overall, the findings point to three key aims for promoting more adaptive responses to feedback for parents that their child is overweight. First is to promote parents’ confidence and belief in the accuracy and appropriateness of the measurements on which the feedback is based. This could be improved by tailoring letters to account for pubertal development or by providing parents with a means of monitoring their child's growth (e.g. through an online resource). This latter approach would not only provide parents with a sense of control, but also meet their concerns that children are labelled as overweight through a single assessment. Second is to better inform parents of the importance for children of maintaining a healthy weight, independently of a healthy lifestyle. Finally, future work is warranted in reassuring parents that they can talk to their children about managing their weight without risking the development of eating disorders and in exploring how guidance could be developed to help them to do so.
Acknowledgements
Source of funding: This work was commissioned and funded by NHS Bath and North East Somerset. Members of this organisation provided input into the design of the study, the development of recommendations for practice and drafting of the manuscript. Conflicts of interest: The authors have no conflicts of interest to declare. Authors’ contributions: The paper and research design was conceived by J.L. and F.G. Data collection and analysis were conducted by F.B. and F.G. All authors contributed to the writing of the paper. Acknowledgements: The authors are grateful to the Bath and North East Somerset school nurse team for assistance in carrying out this project.
Appendix
National Child Measurement Programme Parent Feedback
Section 1: Receiving the news that your child is overweight
1. Did you receive a phone call ahead of the letter from the school nurse?
Yes 
No 
2. If yes, did you find this helpful?
Yes 
Unhelpful 
Neither 
Please comment
3. Do you agree with the assessment that your child is overweight?
Yes 
No 
Unsure 
If no , please tell us why:
If yes , were you already aware of this?
Yes 
No 
Unsure 
Section 2: What happens next?
1. Are you planning to make any changes as a result of receiving the letter?
Yes 
No 
Undecided 
If yes, what are you planning to do?
2. Have you started this already?
Yes 
No 
3. Are there any barriers preventing you from making any changes that you might want to make?
Yes 
No 
Not planning changes 
Are you able to say what these barriers are?
4. What would help you to overcome these barriers?
Section 3: What can we do to help?
1. If you could design the perfect service to help you improve your family's lifestyle what would it offer? (ideas welcome!)
2. Please tick any of the following elements that you think would be essential
Yes No
One-to-one support 
Telephone support 
Internet support 
Group-based support 
More physical activity opportunities 
More healthy eating activities 
Psychological/emotional support
3. Do you think this service should be free to all?
Yes 
No 
Section 4: General Feedback
1. If there was one sentence in the letter you would change what would it be, and what would you change it to?
2. Please use the space below to provide any other comments
Thank you for giving us this feedback.
