Implementing a weight-specific quality-of-life tool for young people in primary health care: a qualitative study

Background Obesity is thought to be one of the most serious global public health challenges of the 21st century. The primary care setting is important in terms of the diagnosis, education, and management of obesity in children and young people. This study explored the views of primary care clinicians on the implementation of a quality-of-life (QoL) tool to help young people and their families identify the impact of weight on QoL. Aim To assess the acceptability and feasibility of implementing the Weight-specific Adolescent Instrument for Economic-evaluation (WAItE) QoL tool for young people aged 11–18 years in primary care. Design & setting Qualitative study in Northern England, UK Method One-to-one, semi-structured interviews were conducted with a purposive sample of primary healthcare clinicians working in practices located in areas of varying deprivation in Northern England, UK. Interview transcripts were coded and analysed using framework analysis in NVivo (version 10). Results Participants (n = 16 GPs; n = 4 practice nurses) found the WAItE tool acceptable for them and their patients, and believed it was feasible for use in routine clinical practice. It was important to primary care clinicians that the tool would provide an overall QoL score that would be easy for GPs and nurses to interpret, to help them identify patients most in need of specialist help. Conclusion This study has developed a platform for further research around QoL in young people who are overweight and obese. A future feasibility study will focus on implementing the tool in a small number of primary healthcare practices.


Introduction
Childhood obesity is one of the most serious global public health challenges of the 21st century, with an estimated 381 million people aged 0-19 years measured as overweight or obese by body mass index (BMI). 1 Young people who are overweight and obese are more likely to be overweight or obese in adulthood, and have a higher risk of illness, disability, and dying earlier. 2 These young people are also more likely to experience low QoL, owing to associated physical and mental health comorbidities, which can often extend into adulthood. 3 Primary care could play a pivotal role in addressing the needs of young people and families.
Puhl and Heuer's 4 literature review shows that the negative consequences of weight stigma affect one's mental health (for example, depression, low self-esteem, poor body image, and psychiatric disorders) as well as one's physical health (for example, maladaptive eating behaviours, exercise avoidance, and reduced motivation to lose weight). Information on QoL may also influence parental motivation to change behaviours and improve adherence with recommendations for behaviour change. Clinicians and patients find discussing obesity difficult for a range of reasons, namely owing to the sensitive nature of the topic and the very few effective treatment options available. 5 Tools to refocus sensitive conversations about weight on other health outcomes associated with weight, rather than the body itself, may aid dialogue. One example is Public Health England's stepby-step guide for primary care professionals to carry out conversations around weight with families of children and young people. 6 However, this approach is limited given that the guide focuses only on supporting the primary care professional as opposed to including young people and their families. Focusing discussion on the QoL of young people may help to complement this guide. The WAItE is a validated QoL tool that was developed from young people's views on aspects of their lives affected by weight -tiredness, walking, participation in sports, concentration, embarrassment, unhappiness, and being treated differently -and can be used to measure the impact of overweight and obesity on QoL. [7][8][9] This study aimed to explore the views of primary care clinicians about the feasibility and acceptability of administering the WAItE tool in clinical practice.

Method Design
One-to-one, semi-structured interviews were conducted with a purposive sample of primary care clinicians to elicit their views about different aspects related to the feasibility and acceptability of implementing the WAItE tool in routine clinical practice.

Participants
Participants were recruited from primary healthcare practices in northern England between June 2017 and December 2017. Relevant practices were identified using Public Health England's National General Practice Profiles, 10 according to clinical commissioning group location (groups of GPs who commission services for their local area). 11 The sample was stratified by percentage of patients aged <18 years and percentage classified as obese based on BMI (monitored by each practice according to the obesity Quality and Outcomes Framework [QOF]). 12 To ensure sample diversity, the deprivation scores of each GP practice location and the percentage of patients who were of working status were also used to stratify GP practices. Practices were recruited via an email to the primary healthcare practice manager inviting GPs and practice nurses to participate. Participants were also recruited via the Clinical Research Network, which distributed invitations to primary healthcare practices registered as research active.

Interview schedule
The interview schedule covered four topic areas developed by the research team drawing on key topics identified in the literature. Questions and prompts for each topic area assessed practitioner views on their: 1) experience working with young people who are overweight or obese; 2) beliefs about the link between weight and QoL in young people; 3) attitudes towards using QoL tools in primary health care; and 4) views about the feasibility of using the WAItE tool in their clinical practice.
The interview schedule was piloted with three healthcare clinicians for comprehension and underwent refinements accordingly.

Interview procedure
Participants were interviewed once at their work premises, own homes, or via telephone, according to their preferences. Interviews were conducted by two female researchers, both of whom are experienced qualitative researchers and qualified at PhD level. Interviews were audio-recorded and field notes were taken. Participants were provided with a paper copy of the WAItE tool to examine during the interview (a copy of the WAItE tool is available from the authors on request).

Data analysis
Interviews were transcribed verbatim and anonymised by a professional transcriber, and uploaded into NVivo software (version 10) to facilitate analysis. Framework analysis was conducted using a fivestep standard procedure. 13 In step one, the first three interview transcripts were selected for review, and key ideas and recurrent themes from each transcript were noted. In step two, a thematic framework was developed using the ideas and themes identified in step one and the four distinct topic areas in the interview schedule. In step three, the whole dataset was analysed by applying the thematic framework created in step two. The thematic framework underwent refinements over time in order to respond to emergent and analytical themes. During this process, judgments were made about meaning, relevance, and importance of each statement in relation to the interview as a whole, and with particular emphasis on common and divergent themes in the data. A standard procedure was used to assess and confirm data saturation (that is, the point at which no new themes emerge from the data) during this stage. 14 In step four, data within each theme were arranged in thematic charts, which allowed systematic comparisons between the views of subgroups of interest including clinician (GP or practice nurse), sex, and number of years working in clinical practice. In step five, associations, patterns, and emergent themes were systematically identified from the data.
The analysis plan was developed and monitored in regular discussions by the research team. An initial dataset was coded independently by one researcher (SM), and a subset of data was discussed with other members of the research team (YO, EH). The purpose was to cross-check interpretations of key themes emerging from the data and jointly agree the final coding frame to be applied in the analysis of the remaining data.

Ethical considerations
All participants provided informed, written consent before participation and received a £10 gift voucher after completing the interview. General Data Protection Regulation (GDPR) was followed for the collection, storage, and use of data. This study adhered to the Standards for Reporting Qualitative Research 15 and the consolidated criteria for reporting qualitative research (see Supplementary Appendix S1). 16

Results
Twenty participants (n = 15 female, n = 5 male) were interviewed, four of whom were practice nurses and the remaining participants were GPs. The interviews lasted between 19 and 81 minutes (see Table 1). The percentage of patients aged <18 years registered to the participants' primary healthcare practice ranged from 12.4-27.9% (England average: 20.7%), and the QOF reported obesity prevalence for both adults and children in each practice ranged from 6.81-18.12% (England average: 9.5%). Table 1 displays further details about the characteristics of participants and their practices.
Key themes emerged within each of the four topic areas from the interview schedule; however, it is beyond the scope of this article to discuss emergent themes from all topic areas. The most salient emergent themes for addressing primary care clinicians' views on the feasibility and acceptability of administering the WAItE tool in clinical practice are presented below. Themes were inclusive of all data and, therefore, represent the views of all participants. Divergent views within each theme are highlighted where they occurred. Supporting quotes for each theme are presented in Tables 2-4.

Experience of using QoL tools in clinical practice
Participants' experiences of using QoL tools in clinical practice varied. Some participants used QoL tools frequently in their practice, whereas others did not use them at all. Often participants would use one particular type of condition-specific QoL tool frequently in their practice (for example, a depression and anxiety QoL tool), but were not familiar with and not likely to use many other QoL tools.

Advantages and disadvantages of QoL tools
Participants perceived a number of advantages associated with using QoL tools in clinical practice such as the ability to start a conversation and explore a particular topic in detail; the possibility of using QoL tools to monitor improvement (or deterioration) in follow-up consultations; and to facilitate treatment decisions.
There were some divergent views about the accuracy and usefulness of QoL tools. For example, one GP participant believed that QoL tools may help to obtain more accurate information from the patient, while another GP participant believed that patients may not answer QoL tools honestly. In addition, one participant reported a concern about the length of time QoL tools take to complete, whereas another participant believed using QoL tools can save time.

WAItE design and content considerations
The focus on weight in the questionnaire Some participants perceived the questions in the WAItE questionnaire as not weight-specific enough, whereas other participants felt that the WAItE questionnaire was too weight-specific.

The length of the questionnaire
Many participants held positive views regarding the length of the questionnaire and how long it would take to complete it. The questionnaire was perceived to be long enough to capture important information.
The clarity and relevance of the questionnaire items Many participants perceived the questions to be simple and relevant for young people. Some participants perceived the questionnaire to be suitable for children of different ages and for children with developmental difficulties. However, some other participants felt that questions were not as clear as they could be, or that the questions might not be understandable to younger children, or patients with developmental difficulties.

The response scale
Some participants had positive views about the response scale, whereas others were uncertain about this aspect of the WAItE tool. Some participants were keen to see an overall score calculated from the responses to the questionnaire items.
Perceived challenges, benefits, and methods of implementing the WAItE tool

Using the WAItE tool during consultations
Concerns were raised that the use of the WAItE tool during a consultation may not be well received by patients and may hinder the rapport between patient and clinician. It was reported that it may depersonalise the communication with a patient by using a questionnaire rather than having a conversation. Another GP reported that the use of the WAItE tool over open questioning may limit the information gained from patients and overlook a GP's communication skills. However, other interviewees perceived the WAItE tool more positively and anticipated that it could help to start conversations with patients about their weight in a non-judgmental manner. Many of the GPs interviewed considered broaching the topic of weight during a consultation a challenge if a patient attended with a non-weight-related issue, and one GP reported that the WAItE tool could help solve this problem. By acting as a reminder to GPs to discuss a young person's weight during a consultation when a patient has sought treatment for an unrelated issue, it could help to enhance the consultation by potentially identifying underlying issues rather than just treating symptoms.
Encouraging clinicians to use the WAItE questionnaire Several potential facilitators were identified by the participants to aid the use of the WAItE in primary care. In order to encourage the use of the WAItE tool in routine clinical practice, it was suggested that recommending its use in a clinical guideline and embedding it within GPs' IT system would be beneficial. Several GPs discussed the importance of having services to refer young people to if the WAItE was to be used in general practice. The completion of the questionnaire alone was not considered sufficient.

Suggestions for future use of the WAItE in clinical practice
Clinicians provided suggestions for alternative modes in which the WAItE tool's future use could be facilitated in clinical practice, such as completing the WAItE tool electronically, having it on a poster in the waiting room, or even adding it to current electronic check-in systems.

Discussion Summary
Clinicians' use of QoL tools in practice varied. Participants reported that QoL tools are not routinely used in practice with this age group, although, some clinicians had used similar tools to the WAItE tool with patients. Those with experience of using QoL tools in practice reported the benefits of using them to explore a particular topic in detail and of having a structured way to assess patients' progress at follow-up. On the other hand, some participants believed patients did not like completing tools or questionnaires. In general, participants perceived advantages of the WAItE tool such as starting conversations about weight in a non-judgmental manner. Although, to be truly beneficial, it would be necessary to have effective and stigma-free services available to which patients could be referred. Furthermore, GPs proposed that the WAItE could help address a longstanding challenge of broaching the topic of weight with patients who are overweight when a patient presents with a non-weightrelated issue. Disadvantages of the tool were also expressed, such as completing and interpreting the results of the tool within the 10-minute consultation window, and potentially hindering the rapport between patient and clinician.

Strengths and limitations
The current study provides a novel exploration of the feasibility and acceptability of using a QoL tool specifically designed for young people who are overweight in a primary care setting. The importance of refocusing discussions on QoL to engage children and parents with treatment for obesity has been demonstrated in a UK-based study of childhood obesity, 17 which demonstrated that perceived improvements in the QoL of children motivated parents to enter their child into treatment. Furthermore, observed benefits in QoL during treatment motivated continued engagement with services. 17 The current study is novel in its approach of seeking the views of primary healthcare clinicians regarding the use of QoL tools with young people who are overweight and obese. The study explored GPs' and practice nurses' views in depth, reaching saturation in the data from participants in primary healthcare settings with varying deprivation. Furthermore, this study explored the use of QoL tools in an English NHS setting, whereas the majority of existing literature has explored QoL tools in a US-only context. However, the English focus prevents the generalisability of the findings to other countries and different healthcare systems.
The majority of the study sample were GPs, which limits the findings to a narrow selection of primary healthcare clinicians. In addition, the interview sample was limited in ethnic diversity with the majority of participants self-reporting as White British. Furthermore, the proportion of patients aged <18 years at the majority of the primary care practices involved in the study were below the UK average. This may have implications for interview participants' experiences discussing weight with young people.

Comparison with existing literature
There are a small number of existing tools that can be used to assess the impact of weight status on the QoL on young people such as IWQOL-Kids (Impact of Weight on Quality-of-life-Kids version), 18 Sizing Me Up, 19 and YQOL-W (Youth Quality of life Weight). 20 However, the applicability of these in the context of the UK primary care setting is limited. These tools are lengthy (all three have in excess of 20 questions), which may reduce completion rates and increase the time needed to complete. Furthermore, cultural factors play an important role in perceptions of weight and weight-related health consequences; hence, the generalisability of these tools to the UK population is unclear. 7

Implications for research and practice
A future feasibility study will focus on implementing the WAItE tool in GP surgeries. The ultimate goal is the implementation of the WAItE tool within healthcare services and in schools to improve QoL and management of overweight and obesity. Overall the impetus of the implementation of the WAItE tool is to improve clinical practice in the context of weight management for children and young people, and for children and young people to feel listened to in a non-stigmatising way.

Funding
Funding was received from NIHR School for Primary Care Research (Project No: 357, Funding round: FR 13). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Ethical approval
The study was approved by the Newcastle University Research Ethics Committee (reference number: 13118/2016; 24/03/17) and approved by the Health Research Authority (Newcastle, North Tyneside, South Tyneside and North Cumbria).

Provenance
Freely submitted; externally peer reviewed.