An emotionally loaded subject – parents experiences when CHC-nurses introduce a conversation related to their child being overweight

An emotionally loaded subject – parents experiences when CHC-nurses introduce a conversation related to their child being overweight | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An emotionally loaded subject – parents experiences when CHC-nurses introduce a conversation related to their child being overweight Marie Fridolfsson, Anna Olsson, Jenny Ericson, Catrin Borneskog This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4014139/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted 13 You are reading this latest preprint version Abstract Background Children with a raised BMI are a major public health challenge in the world that can cause serious consequences for children's physical and mental health. Child health care nurses' responsibility is to promote health and prevent ill-health in children, but because being overweight is stigmatized CHC-nurses find it difficult to talk to the parents about concerns over the children's weight, in fear of losing their trust. Aim The purpose of this study was to describe parents' experiences when CHC-nurses introduced a conversation relating to their child’s weight and the effect on it's health. Method This study was conducted via semi-structured interviews with nine parents and the data was analyzed using qualitative content analysis. Results The result showed that being overweight in childhood is a sensitive topic, and this is presented as four categories Coping with the information about the child’s weight, A desire to protect the Children from the potential consequences a conversation about health and weight might lead to, Feelings and thoughts about the parenting role and The relationship with the nurse influence the experience. This is a sensitive topic for the parents, who have a hard time accepting the situation and place the blame on themselves, and the nurse’s approach and relationship with the parents is of great importance for the outcome of the conversation. Conclusions Parents seem to have another perspective on health and weight than the healthcare providers, and both parents and CHC-nurses might benefit from an increased understanding of one another's view. Parents need to gain knowledge about how healthcare providers assess children's growth, and the CHC-nurses need to be aware about how to be responsive to the parents and allow them time to process the information. The focus should be on healthy lifestyle choices regardless of weight Children Child health care nurse Experience Overweight Parents Qualitative Introduction Being overweight and obesity in children have increased worldwide during the last 40 years. It can be seen as a result of socio-cultural and societal changes associated with urban development, such as a sedentary lifestyle and easy access to energy-dense food (Hadi et al., 2020; World Health Organization [WHO], 2021). Being overweight increases the risk for cardiovascular diseases, cancer and type 2 diabetes. Being overweight in childhood is associated with an increased risk of fractures, hypertension, insulin resistance and obesity in the future, as well as disability and premature death (WHO, 2021). Overweight children suffer from depression, loneliness, exclusion, discrimination, and low self-confidence, as well as getting bullied (Powell et al., 2018). Being overweight is stigmatized and those affected are often assigned negative attributes such as being lazy, clumsy, unintelligent, undisciplined, and having poor hygiene (World Obesity Federation, 2022), even among preschool children (Hutchison and Muller, 2018). In Sweden all children up to six years old are offered health check-ups at publicly financed Child Health Care (CHC) centers where CHC-nurses work to promote children’s health and support their families. Nearly 100% of the families attend, and during routine check-ups CHC-nurses assess children’s development and track their growth and give customized advice to the families when needed (Tell, 2023). Giving support to families with overweight children can be considered difficult by CHC-nurses (Mäenpää and Vuori, 2021; Sjunnestrand et al., 2019). They find it hard to identify and assess overweight in children (Isma et al., 2013) and are afraid to hurt the parent’s feelings (Castor et al., 2021), parents tend to feel offended when informed about their child’s overweight, and doubt whether it’s true (Eli et al., 2022; Hardy et al., 2019). The conversation can be perceived as either empowering or provoke resistance depending on how the subject is approached (Eli et al., 2022). Parents seem to underestimate their children's weight status (Suligowska and Buczny, 2022; Wang et al., 2022) as well as the risks associated with being overweight in childhood (Gainsbury and Dowling, 2018; Tschamler et al., 2018) and many think that it will resolve by itself (Suligowska and Buczny, 2022; Ziser et al., 2021). Studies investigating the weight stigma indicate that parents often feel judged and blamed for their children being overweight (Gorlick et al., 2021; Lee et al., 2022) and some fear that taking actions to lose weight might affect the children negatively (Eli et al., 2022). Being overweight in childhood is a growing issue with major health consequences. As a CHC-nurse, the tasks include working to promote health and prevent ill-health in children, but it is perceived as difficult to talk about a child being overweight with the parents. There is a fear that the conversation will damage the caring relationship and there is a concern regarding how the information will be received. Thus, an increased understanding of the parents' perspective on the conversation concerning the child's weight is needed so that these conversations can be carried out as well as possible. Aim The aim of this study was to describe parents' experiences of when CHC-nurses introduce a conversation related to their child being overweight. Method Participants Participants were recruited through advertising in social media (Facebook) during September and October 2022. The advertisement sought parents who had experienced a conversation about their child being overweight with their CHC-nurse within the past two years and while their child was between 2 and 5 years old. Those wanting to participate were asked to announce their interest via email, and a total of 15 parents responded. An information letter about the study as well as an informed consent form was emailed, and parents were asked to send the signed consent back to the research team if they still wanted to participate. Five ( 5 ) stopped responding or dropped out and one ( 1 ) was excluded due to not meeting the inclusion criteria, resulting in a total of nine ( 9 ) participants in this study. Data collection A semi-structured interview guide was created and tested in a pilot interview, that led to some adjustments. The interviews were carried out continuously during the recruitment period and the first question asked to all participants was "Tell me what the CHC-nurse did say about your child's weight?" followed by the follow-up question "How did it feel?". All the interviews were conducted in Swedish via Zoom and lasted between 14 and 29 minutes. The two first authors took turns leading the interviews. Audio recordings were made of the interviews, and they were later transcribed using Microsoft Word's transcription function. Directly after each interview the two first authors listened to the audio-files while reading and correcting the transcriptions. When all interviews were transcribed, they were individually listened to and read through again by the two first authors to make sure everything was transcribed correctly. Some of the participants were contacted again to follow up some questions. The pilot interview was not included in the data. Analysis The material was analyzed using qualitative content analysis with an inductive approach, by Elo and Kyngäs (2009). After reading the transcriptions multiple times the two first authors individually coded the transcriptions. Each interview was labelled with a number (Interview xx) and units of text and quotations were coded with as many words as possible. Every quote, text unit and code were labelled with the same number as the interview it originated from. The codes were compiled, compared, and sorted into groups with similar meaning. A digital whiteboard was used to move the codes around to get a clearer view on where they belonged. Every group was given a headline that represented the content. When all the codes were sorted and divided into categories, generic categories were created. The quotes from the interviews were used to support the interpretations of the text and the quotes that are presented in the results are labelled with each interviewee’s number. Ethics This study was designed according to the requirements of the Helsinki declaration and approved by the research ethics committee at Dalarna University, Sweden. After receiving oral and written information about the study, participants signed the letter of informed consent. Participants were guaranteed confidentiality and informed they could withdraw from the study at any time without giving any reason to do so. The information was repeated verbally at the start of every interview. Result Coping with the information about the child’s weight The information about their children being overweight came as a shock for many parents, particularly those who had previously struggled to achieve desired weight according to the growth chart. Those, whose children had always been on the heavier side, felt surprised when it was suddenly presented as a problem. The conversation awoke many feelings, and parents described it as tough to accept and difficult to hear. Many felt angry, irritated, or defensive and one dismissed the information completely. Others felt sad and one said that she went home and cried afterwards. Many highlighted the sensitivity of the subject and when parents were overweight themselves, they expressed that their own experiences made it extra sensitive and difficult to hear. Several parents found it difficult to take the situation seriously and the health care system's perspective on overweight was described as obsolete and outdated. They described that there is too much faith in the BMI-scales and the growth charts, which they felt did not take aspects such as muscle mass into account, and therefore had too much impact in the assessment of the child. The question whether the extra weight was fat, or muscles occurred frequently, and since the overweight was not an obstacle in the children's lives, some questioned whether being overweight was actually a health concern. He weighs a lot, yes, but is it that unhealthy in his case? Does he have that, like, unhealthy overweight that leads to, like, diseases? (Parent 6). Some parents dismissed or questioned the information since their child was, to them, not visibly overweight, and many used alternative words to describe their children's weight status, such as big, heavy, chubby, rounded, and solid. Some parents said that children grow unevenly, and they consider it normal for a child to first gain weight and then grow taller. Many explained that their children looked like their relatives, and that it is not surprising that they have this kind of physique. They questioned whether their lifestyle habits actually could affect their children's weight situation, due to the genetic nonadjustable composition. Many also believed that the weight would resolve by itself in time. A desire to protect the Children from the potential consequences a conversation about health and weight might lead to The parents stated that today's cultural norms promote being as thin and fit as possible and children are affected by this both directly and indirectly. They expressed a desire to not expose their children to this and to attempt to counteract this by different means. Some avoided talking in terms such as tall, short, fat, and thin, while others used the words but without attaching any value to them. Others tried to attribute positive values ​​to words like “fat” so it would not be considered something negative. One parent expressed that they focus on what the body can do and what it is good at instead of how it looks. The parents did not wish to value what they eat and explained that if they discuss food with their children, it is about which food is good for you and will make you strong and healthy, not what is bad or should be avoided. As far as possible they use value-neutral words regarding food and exercise, and they avoided talking about weight and food together. ... ” If you eat too much of this you will get fat”, and I was like, that isn’t something that a 3–5-year-old needs to hear about, like, even if it is true... (Parent 4) Many parents feared that these conversations would affect the children negatively and cause eating disorders. Some parents highlighted that they are aware that being overweight is unhealthy and they understood why the CHC-nurse raised the issue. However, the fear of eating disorders and that the child would connect food and weight in a negative way was described as outweighing the risks of being overweight. ... I think that being overweight is absolutely not good, it’s harmful, but anorexia actually kills... (Parent 9) The parents worried that the children's participation in the conversation might make them lose their self-esteem and change the way they look upon themselves and their abilities. They feared that their children would develop unhealthy body images, start thinking about their body size or start identifying as overweight. I don’t want my little girl to start thinking about whether her body is too fat or not... (Parent 9) One parent stated that children understand that being overweight is not considered a good thing, and most parents did not want their child to be present when addressing this subject. One parent wished that a lifestyle conversation should have been held at the child’s level of understanding. Some expressed a theoretical possibility of a child participating in this conversation, if it is done under the right conditions but most of them said that children are too young to be present. ... what made me most angry was the fact that she brought it up in front of my daughter, I mean she's 3 years old [...] children understand more than you think… (Parent 2) Some parents worried about the future and how others would treat their children because of them being overweight. Some feared that their child would be left out or feel that they did not belong, and others were concerned that the child would suffer from mental illness and poor self-esteem. One parent said that the CHC-nurse made her aware of the risk of abuse in school, and several parents feared that being overweight would lead to the child being bullied. Parents who were overweight in their own childhood felt particularly afraid about being bullied and explained that the treatment you receive varies greatly depending on your body shape. Feelings and thoughts about the parenting role Feelings of guilt and shame were expressed by some parents and the situation made them question their parenting skills. They were afraid to have done something wrong or to have made the wrong decisions, and one parent expressed that this situation made her feel like they have harmed their child. Several parents explained that they always try to do what is best for their children and it felt like a failure when that was not enough. One parent shared that she struggled with being overweight herself, and always had as a goal that her children should not get there, and now when they were, it felt like a failure, and even though she knows it was not an actual failure, the sensitivity in the subject made it feel more personal than it was. All but one parent expressed that they felt judged and criticized in their parenthood and one parent explained that every health check-up the child goes to feels like an assessment of you as a parent, and if something is not perfect it feels like criticism. …I think that the instinctive feeling is, or was for me at least, that I did not do a good job, and she judged me for that. (Parent 9) Some felt like the CHC-nurse jumped to conclusions regarding their habits and assumed that they did something wrong. Some said that the CHC-nurse showed no interest in what kind of lifestyle habits they had, and instead instantly pointed out what to do differently, which made them feel accused. Those presumptions were unwarranted for those who had never met that CHC-nurse before. It was the first time she met us, and sure, she does not know at all… then maybe you should not just assume that people eat junk food and sit still… (Parent 9). The parents not only expressed feelings of being judged by the healthcare system, but also a fear that other people would question how they took care of their children and what habits they had. ... it feels like people think you give them candy every day, and just eat unhealthy food and never exercise (Parent 1) One parent expressed that it is easy to have opinions about what other parents do, but when you find yourself in the same situation, it is not as simple as it seems. Some parents felt divided since they were responsible for their children's habits and therefore causing the problem and were now responsible to put it right. It was perceived as against the parental instinct to limit the child's food intake, and it felt difficult to justify this to the children. One parent felt conflicted since others had difficulties getting their children to eat at all while she cannot give her child more food when he asks for it. For those who were separated from the other parent, it felt difficult to respond to questions about the child's food and eating habits since they could not speak for the other parent. Many wished the other parent should have been contacted as well, even those cohabitating, since it was described as hard to pass on information and advice, especially if the parents had different opinions on what is right for the child. The relationship with the nurse influenced the experience The parents highlighted the importance of respectful healthcare encounters and to establish a good relationship with their CHC-nurse. Those who felt they were treated nicely found it easier to handle the situation while parents who had a bad experience wished for more support. Many expressed that the CHC-nurse was insensitive and plump while telling them about the child's being overweight, and some perceived the CHC-nurse as harsh and insensitive which made them feel as if they were caught off guard. Encouragement was described as important, and one parent said that it would have been nice to hear calming and reassuring words. Those who did receive reassurance such as ‘ it will probably even out’ said that even though it was comforting to hear, it felt like the CHC-nurse mitigated the problem or was afraid of stepping on her toes. Some parents expressed that the CHC-nurse seemed uncomfortable and had difficulties raising the subject, which made the conversation feel awkward. A neutral and matter-of-fact approach was appreciated by the parents, and it was preferred when the nurse was calm and educational. It felt positive when she showed understanding for the sensitivity of the subject and the CHC-nurse's responsiveness made it easier to receive the message. Sensitivity and humility were requested by most parents, and one described the CHC-nurse as not empathetic at all, which made her wish for better treatment. Whether the parents trusted the CHC-nurse or not was described as significant for the outcome of the conversation, and their trust was affected by the advice they got. Non-evidence-based advice affected their faith in the CHC-nurse in a negative way, and one parent found it questionable when they got advice to make more unlikable food to try to get their child to eat less. One parent expressed lots of faith in her CHC-nurse which affected the situation positively, and even though it was a delicate situation it was not perceived as a negative experience. She explained that they had the same CHC-nurse since the child was born which had created a trusting relationship between them, and if someone else had given the information, it would not have been received in the same way. ... she [the CHC-nurse] really understands the problem in a different way[...] it feels like, the doctors who come at these check-ups who just go in and point[...] it doesn't get personal then, it's like this "okay you're talking about a chart, but I'm talking about my child", it's a bit different. (Parent 8) It was described as difficult to have the conversation with a CHC-nurse they did not trust. One parent shared that she mistrusted the CHC-nurse since there was a history of being forgotten or double booked, and the room was empty and cold and there were no toys, so the child wanted to leave. Others lacked trust since they never met that CHC-nurse before, and one parent described that she felt unwanted during the entire appointment as the CHC-nurse sighed heavily in relation to every moment of the check-up. What support the parents were offered from the CHC-nurse varied greatly, some received dietary advice, follow-ups and lots of information regarding being overweight while others got none at all. It was perceived in different ways since some did not want any information at all while others wished for more. It was also described as difficult to receive advice on what measures to take while still being in shock. Some did not want either advice or follow-ups, although many were offered extra weight checks or a referral to an obesity unit, which they had different opinions on. Some went there with their children while others felt it was an overreaction from the CHC-nurse. ... that we would get a follow-up, because it could also be something medically wrong. Like this, yes, but it's also pulling the trigger all at once... (Parent 2) Discussion The results of this study indicated that talking about their child being overweight was a sensitive topic for the parents and many reacted with strong emotions, which confirms previous research (Eli et al., 2022). In accordance with other studies (Gainsbury and Dowling, 2018; Hardy et al., 2019) many parents struggled with acceptance, which could be explained by the fact that they did not consider their children being overweight and had their own ideas regarding how children grow. Genetics was believed to be a main cause for being overweight, which is consistent with previous research (Gainsbury and Dowling, 2018; Tschamler et al., 2018; Ziser et al., 2021), and there were questions whether it was possible to overcome genetic factors. Even though it is known that some children gain weight more easily, according to a large study (Heitkamp et al., 2021), the primary factors regarding treatment of being overweight were environmental, social and behavioral, rather than genetic. Some parents blamed themselves, felt guilty and questioned themselves, and some felt like they had harmed their children, which was similar to other studies (Gorlick et al., 2021; Hardy et al., 2019). However, most parents did not understand how it turned out this way for their children and felt there was nothing they could have done to prevent it. This differs from another study where fathers to a greater extent could see their own participation in how it came to this and what could have contributed to their children being overweight (Salemonsen et al., 2022). In light of this, CHC-nurses might benefit from having the genetic predisposition in mind, as well to have an individual approach and be careful not to blame the parents but help them make adjustment that suits the family. The parents wished to protect their children from the consequences of what a conversation about their being overweight might lead to. Many did not want the children to be present in the conversation at all, which agrees with another study (Eli et al., 2022). They feared it might negatively affect the children's self-esteem, cause unhealthy thoughts regarding food and weight or cause eating disorders. They wished to use neutral terms while speaking about weight and food and some would rather not speak about it at all while their child was present. This could be understood by the body positive movement (Cherry, 2020), where previous research shows that a body positive approach might have a good influence on children's self-image and their view on food and weight (Carbonneau et al., 2021). Even though a body-positive approach might benefit the children's self-image, in this case, it conflicts with the medical perspective where being overweight is, or might be, a health risk if not prevented (WHO, 2021). Many parents felt accused, questioned, and judged in the conversation regarding their child being overweight, and perceived it as criticism of their parenthood. This might be a result of the prevailing overweight stigma, where parents to children who are overweight are often exposed to associated stigmatization which is surrounded by presumptions regarding how they take care of their children (Gorlick et al., 2021). This shows the importance of the CHC-nurse being caring, respectful and responsive when raising the subject. Parents who know of and trust their CHC-nurse might find it easier to accept the situation than those who do not. The parents questioned the validation of the measuring tools since being overweight was not visible, and whether extra weight was unhealthy or not, can be considered an obstacle regarding the work preventing children being overweight and more generally obesity in society. These findings suggest that there seem to be a perception among parents that when talking about excess weight in childhood is about how the children looks, rather than the health risks associated. There might be a gap of knowledge, where CHC-nurses would gain by educating parents about the measuring tools and how children are expected to grow, preferably before a weight issue occurs. It might also be beneficial for both CHC-nurses and parents if the CHC-nurses, during conversations regarding being overweight in childhood and the associated risks clarify that the conversation has nothing to do with how the children look and the risks remains whether being overweight is visible or not. CHC-nurses might also benefit from using neutral terms regarding food and exercise to decrease the risk of the children's self-esteem being affected. Some parents felt like the CHC-nurse seemed uncomfortable talking about the subject which agrees with previous research (Castor et al., 2021). Others felt like she raised the subject without full concern for the sensitivity of the parent, which could be understood by Sjunnestrand et al (2019) where CHC-nurses felt like they had to raise the subject whether parents seem receptive or not. If some CHC-nurses feel uncomfortable, it might be one reason why parents in this present study had a negative experience. It is possible that raising the subject without responsiveness might hurt a caring relationship (Halldórsdóttir, 1996). Although, when there was a caring relationship and the parents trusted their nurse, the conversation was not perceived as negative, which agrees with previous research (Mäenpää and Vuori, 2021; Halldórsdóttir, 1996). It also appears that a caring relationship is not necessarily affected negatively by talking about being overweight in childhood, which was something CHC-nurses feared according to Sjunnestrand et al (2019). This result highlights the importance that CHC-nurses build a caring relationship with the parents. If the relationship is poor the parents might not be receptive to the information regardless of how or what the CHC-nurse does, therefore the whole purpose of guarding the child’s overall health through growth monitoring will have failed. This might lead to absence of changes in the family’s lifestyle habits. A caring relationship might be a prerequisite when it comes to talking sensitively about being overweight in childhood. If there is trust between the family and the CHC-nurse, the CHC-nurse does not need to be afraid to bring up the subject as the trust between them having been established will help to overcome any challenges that might arise during the conversation about the child’s weight. At the same time the CHC-nurse might benefit from showing understanding and sensitivity towards the parents' concerns and be careful regarding use of terminology and when and how to talk about children’s weight, and to ask open questions regarding lifestyle habits rather than just assume they do something wrong. Limitations This study has some limitations, first the parents were interviewed after being sought via social media. Since all participants volunteered to participate there could be a risk of sampling bias which might decrease the transferability since parents might have chosen to participate because they had strong feelings they wanted to express regarding the subject. However, similar studies where participants were recruited in different ways show similar results which strengthen the trustworthiness of the result. Second, nine parents were interviewed, and although a greater number might have enriched the result further and increased the credibility and transferability, more interviews would have contributed to more data than what was manageable considering the time limit when performing the study. During the last couple of interviews, the same kind of experiences were described and nothing new came up, hence, saturation was achieved, which is considered a strength. There was a pre-understanding regarding the subject since it was chosen partly because the two first authors had read discussions on social media where parents expressed negative opinions about the healthcare system with a particular focus regarding children and weight. This pre-understanding was not believed to have affected the interviews since all the questions asked were in line with the interview guide There are some strengths in the study. Firstly, since all the coding was done separately by the two first authors, and turned out to be similar it decreased the risk of preconception bias and contributed to the trustworthiness and credibility in the result. The person participating in the pilot interview read the result and expressed recognition, even though her interview was not included, this further strengthened the credibility of the study. Regarding transferability it is likely that parents recruited in other contexts might have shared similar experiences since the internet is a broad platform and except that all the parents in the study were mothers living in Sweden there were no other known significant common denominator. Another study where parents were recruited through the CHC show a similar result (Eli et al., 2022), which might strengthen the credibility in this study, and the findings to be transferable, at least in a Swedish context. Furthermore, a study from Australia got a similar result (Hardy et al., 2019) which suggests that it might be transferable to other western communities as well. Using quotes in the result contributed to enrich and also authenticate the results since the reader can make their own judgment of whether or not the quotes are correctly assessed. Clinical implications This study increases the understanding of the parental perspective on children being overweight, the knowledge can be used to facilitate the CHC-nurses' conversations about the child's weight. This may increase compliance to given advice on lifestyle changes, to promote future health for the child. Conclusion Based on the result of this study it seems like parents take the conversation about childhood overweight personally, and it could be perceived as being critical of their parental skills. In their perspective, the conversation was about how their children looked rather on their health, and since they did not consider their children being overweight, the conversation as well as the following measures seemed unnecessary. When CHC-nurses raised the subject, the parents felt judged, and they feared their children might get hurt in the process. This highlights the importance for CHC-nurses to be responsive towards when and especially how to talk about the subject, without blaming the parents or risk hurting the children's self-image or self-esteem. Parents need time to process the situation before receiving advice and it might be beneficial not to talk about weight when the child is present. Since the parents seem to lack knowledge regarding how children are supposed to grow and how the measuring tools work, it might be beneficial for CHC-nurses to introduce the growth charts as a routine from the start so the parents understand what it is for and how it is used, so they can see for themselves when something deviates. If parents understand why they have to take measures regarding their children's increased weight it might improve the compliance to the given advice. Focus should be on healthy lifestyle choices rather than weight. Declarations Acknowledgements We are grateful to the parents that participated in the study. Data availability Declaration The author confirms that all data generated or analysed during this study are included in this published article. Consent for Publication Not applicable Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Funding This study was funded by Dalarna University and did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References Carbonneau N, Hamilton L, Musher-Eizenman DR. From dieting to delight: Parenting strategies to promote children’s positive body image and healthy relationship with food. Can Psychol / Psychologie canadienne. 2021;62(2):204–12. https://doi.org/10.1037/cap0000274 . Castor C, Derwig M, Borg SJ, et al. 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BMC Fam Pract. 2013;14(1). https://doi.org/10.1186/1471-2296-14-143 . Lee KM, Arriola-Sanches L, Lumeng JC, et al. Weight stigma by association among parents of children with obesity: A randomized trial. Acad Pediatr. 2022;22(5):754–60. https://doi.org/10.1016/j.acap.2021.09.019 . Mäenpää T, Vuori A. Broaching overweight and obesity at maternity and child health clinics. Int J Nurs Pract. 2021;27(5):e12958. https://doi.org/10.1111/ijn.12958 . -n/a. Salemonsen E, Holm AL, Øen KG. (2022) Struggling with overweight or obesity in children – fathers’ perceptions and experiences of contributing factors, role and responsibility, International Journal of Qualitative Studies on Health and Well-being 17(1). https://doi.org/10.1080/17482631.2022.2093912 . Sjunnestrand M, Nordin K, Eli K, et al. Planting a seed - child health care nurses’ perceptions of speaking to parents about overweight and obesity: A qualitative study within the STOP project. BMC Public Health. 2019;19(1):1494–1494. https://doi.org/10.1186/s12889-019-7852-4 . Suligowska K, Buczny J. Obesity in polish children and parents’ perception of their Children’s weight status: The result of the SOPKARD-junior study. Int J Environ Res Public Health. 2022;19(8):4433. https://doi.org/10.3390/ijerph19084433 . Powell SB, Engelke MK, Swanson MS. Quality of life in school-age children with obesity. Pediatr Nurs. 2018;44(4):183–8. Tell J. (2023) Swedish Child Health Services. https://www.rikshandboken-bhv.se/metoder--riktlinjer/informationsmaterial-och-brevmallar---oversikt/swedish-child-health-services/ (accessed at 19 december 2023). Tschamler JM, Conn KM, Cook SR, et al. Underestimation of children's weight status: Views of parents in an urban community. Clin Pediatr. 2010;49(5):470–576. https://doi.org/10.1177/0009922809336071 . Wang J, Zhy D, Cheng X, et al. Maternal perception of child weight and concern about child overweight mediates the relationship between child weight and feeding practices. Public Health Nutr. 2022;25(7):1780–9. https://doi.org/10.1017/S1368980022000040 . World Health Organization. (2021) Obesity and Overweight. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (accessed 3 january 2023). World Obesity Federation. (2022). Weight stigma. https://www.worldobesity.org/what-we-do/our-policy-priorities/weight-stigma (accessed 3 january 2023). Ziser K, Decker S, Stuber F et al. (2021) Barriers to behavior change in parents with overweight or obese children: A qualitative interview study. Frontiers in psychology 12, Artikel 631678. https://doi.org/10.3389/fpsyg.2021.631678 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 03 May, 2024 Reviews received at journal 23 Apr, 2024 Reviews received at journal 12 Apr, 2024 Reviewers agreed at journal 03 Apr, 2024 Reviewers agreed at journal 02 Apr, 2024 Reviews received at journal 02 Apr, 2024 Reviewers agreed at journal 02 Apr, 2024 Reviewers agreed at journal 02 Apr, 2024 Reviewers invited by journal 02 Apr, 2024 Editor invited by journal 01 Apr, 2024 Editor assigned by journal 31 Mar, 2024 Submission checks completed at journal 31 Mar, 2024 First submitted to journal 04 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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It can be seen as a result of socio-cultural and societal changes associated with urban development, such as a sedentary lifestyle and easy access to energy-dense food (Hadi et al., 2020; World Health Organization [WHO], 2021). Being overweight increases the risk for cardiovascular diseases, cancer and type 2 diabetes. Being overweight in childhood is associated with an increased risk of fractures, hypertension, insulin resistance and obesity in the future, as well as disability and premature death (WHO, 2021). Overweight children suffer from depression, loneliness, exclusion, discrimination, and low self-confidence, as well as getting bullied (Powell et al., 2018). Being overweight is stigmatized and those affected are often assigned negative attributes such as being lazy, clumsy, unintelligent, undisciplined, and having poor hygiene (World Obesity Federation, 2022), even among preschool children (Hutchison and Muller, 2018).\u003c/p\u003e \u003cp\u003e In Sweden all children up to six years old are offered health check-ups at publicly financed Child Health Care (CHC) centers where CHC-nurses work to promote children’s health and support their families. Nearly 100% of the families attend, and during routine check-ups CHC-nurses assess children’s development and track their growth and give customized advice to the families when needed (Tell, 2023). Giving support to families with overweight children can be considered difficult by CHC-nurses (Mäenpää and Vuori, 2021; Sjunnestrand et al., 2019). They find it hard to identify and assess overweight in children (Isma et al., 2013) and are afraid to hurt the parent’s feelings (Castor et al., 2021), parents tend to feel offended when informed about their child’s overweight, and doubt whether it’s true (Eli et al., 2022; Hardy et al., 2019). The conversation can be perceived as either empowering or provoke resistance depending on how the subject is approached (Eli et al., 2022). Parents seem to underestimate their children's weight status (Suligowska and Buczny, 2022; Wang et al., 2022) as well as the risks associated with being overweight in childhood (Gainsbury and Dowling, 2018; Tschamler et al., 2018) and many think that it will resolve by itself (Suligowska and Buczny, 2022; Ziser et al., 2021). Studies investigating the weight stigma indicate that parents often feel judged and blamed for their children being overweight (Gorlick et al., 2021; Lee et al., 2022) and some fear that taking actions to lose weight might affect the children negatively (Eli et al., 2022).\u003c/p\u003e \u003cp\u003eBeing overweight in childhood is a growing issue with major health consequences. As a CHC-nurse, the tasks include working to promote health and prevent ill-health in children, but it is perceived as difficult to talk about a child being overweight with the parents. There is a fear that the conversation will damage the caring relationship and there is a concern regarding how the information will be received. Thus, an increased understanding of the parents' perspective on the conversation concerning the child's weight is needed so that these conversations can be carried out as well as possible.\u003c/p\u003e \u003cp\u003eAim\u003c/p\u003e \u003cp\u003eThe aim of this study was to describe parents' experiences of when CHC-nurses introduce a conversation related to their child being overweight.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eParticipants were recruited through advertising in social media (Facebook) during September and October 2022. The advertisement sought parents who had experienced a conversation about their child being overweight with their CHC-nurse within the past two years and while their child was between 2 and 5 years old. Those wanting to participate were asked to announce their interest via email, and a total of 15 parents responded. An information letter about the study as well as an informed consent form was emailed, and parents were asked to send the signed consent back to the research team if they still wanted to participate. Five (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) stopped responding or dropped out and one (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) was excluded due to not meeting the inclusion criteria, resulting in a total of nine (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) participants in this study.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eA semi-structured interview guide was created and tested in a pilot interview, that led to some adjustments. The interviews were carried out continuously during the recruitment period and the first question asked to all participants was \"Tell me what the CHC-nurse did say about your child's weight?\" followed by the follow-up question \"How did it feel?\". All the interviews were conducted in Swedish via Zoom and lasted between 14 and 29 minutes. The two first authors took turns leading the interviews. Audio recordings were made of the interviews, and they were later transcribed using Microsoft Word's transcription function. Directly after each interview the two first authors listened to the audio-files while reading and correcting the transcriptions. When all interviews were transcribed, they were individually listened to and read through again by the two first authors to make sure everything was transcribed correctly. Some of the participants were contacted again to follow up some questions. The pilot interview was not included in the data.\u003c/p\u003e\u003cp\u003eAnalysis\u003c/p\u003e\u003cp\u003eThe material was analyzed using qualitative content analysis with an inductive approach, by Elo and Kyngäs (2009). After reading the transcriptions multiple times the two first authors individually coded the transcriptions. Each interview was labelled with a number (Interview xx) and units of text and quotations were coded with as many words as possible. Every quote, text unit and code were labelled with the same number as the interview it originated from. The codes were compiled, compared, and sorted into groups with similar meaning. A digital whiteboard was used to move the codes around to get a clearer view on where they belonged. Every group was given a headline that represented the content. When all the codes were sorted and divided into categories, generic categories were created. The quotes from the interviews were used to support the interpretations of the text and the quotes that are presented in the results are labelled with each interviewee’s number.\u003c/p\u003e\u003cp\u003eEthics\u003c/p\u003e\u003cp\u003e This study was designed according to the requirements of the Helsinki declaration and approved by the research ethics committee at Dalarna University, Sweden. After receiving oral and written information about the study, participants signed the letter of informed consent. Participants were guaranteed confidentiality and informed they could withdraw from the study at any time without giving any reason to do so. The information was repeated verbally at the start of every interview.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eCoping with the information about the child’s weight\u003c/p\u003e\u003cp\u003e The information about their children being overweight came as a shock for many parents, particularly those who had previously struggled to achieve desired weight according to the growth chart. Those, whose children had always been on the heavier side, felt surprised when it was suddenly presented as a problem. The conversation awoke many feelings, and parents described it as tough to accept and difficult to hear. Many felt angry, irritated, or defensive and one dismissed the information completely. Others felt sad and one said that she went home and cried afterwards. Many highlighted the sensitivity of the subject and when parents were overweight themselves, they expressed that their own experiences made it extra sensitive and difficult to hear.\u003c/p\u003e\u003cp\u003eSeveral parents found it difficult to take the situation seriously and the health care system's perspective on overweight was described as obsolete and outdated. They described that there is too much faith in the BMI-scales and the growth charts, which they felt did not take aspects such as muscle mass into account, and therefore had too much impact in the assessment of the child. The question whether the extra weight was fat, or muscles occurred frequently, and since the overweight was not an obstacle in the children's lives, some questioned whether being overweight was actually a health concern.\u003c/p\u003e\u003cp\u003e \u003cem\u003eHe weighs a lot, yes, but is it that unhealthy in his case? Does he have that, like, unhealthy overweight that leads to, like, diseases? (Parent 6).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSome parents dismissed or questioned the information since their child was, to them, not visibly overweight, and many used alternative words to describe their children's weight status, such as big, heavy, chubby, rounded, and solid. Some parents said that children grow unevenly, and they consider it normal for a child to first gain weight and then grow taller. Many explained that their children looked like their relatives, and that it is not surprising that they have this kind of physique. They questioned whether their lifestyle habits actually could affect their children's weight situation, due to the genetic nonadjustable composition. Many also believed that the weight would resolve by itself in time.\u003c/p\u003e\u003cp\u003eA desire to protect the Children from the potential consequences a conversation about health and weight might lead to\u003c/p\u003e\u003cp\u003e The parents stated that today's cultural norms promote being as thin and fit as possible and children are affected by this both directly and indirectly. They expressed a desire to not expose their children to this and to attempt to counteract this by different means. Some avoided talking in terms such as tall, short, fat, and thin, while others used the words but without attaching any value to them. Others tried to attribute positive values ​​to words like “fat” so it would not be considered something negative. One parent expressed that they focus on what the body can do and what it is good at instead of how it looks.\u003c/p\u003e\u003cp\u003eThe parents did not wish to value what they eat and explained that if they discuss food with their children, it is about which food is good for you and will make you strong and healthy, not what is bad or should be avoided. As far as possible they use value-neutral words regarding food and exercise, and they avoided talking about weight and food together.\u003c/p\u003e\u003cp\u003e...\u003cem\u003e” If you eat too much of this you will get fat”, and I was like, that isn’t something that a 3–5-year-old needs to hear about, like, even if it is true... (Parent 4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMany parents feared that these conversations would affect the children negatively and cause eating disorders. Some parents highlighted that they are aware that being overweight is unhealthy and they understood why the CHC-nurse raised the issue. However, the fear of eating disorders and that the child would connect food and weight in a negative way was described as outweighing the risks of being overweight.\u003c/p\u003e\u003cp\u003e...\u003cem\u003eI think that being overweight is absolutely not good, it’s harmful, but anorexia actually kills... (Parent 9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e The parents worried that the children's participation in the conversation might make them lose their self-esteem and change the way they look upon themselves and their abilities. They feared that their children would develop unhealthy body images, start thinking about their body size or start identifying as overweight.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI don’t want my little girl to start thinking about whether her body is too fat or not... (Parent 9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e One parent stated that children understand that being overweight is not considered a good thing, and most parents did not want their child to be present when addressing this subject. One parent wished that a lifestyle conversation should have been held at the child’s level of understanding. Some expressed a theoretical possibility of a child participating in this conversation, if it is done under the right conditions but most of them said that children are too young to be present.\u003c/p\u003e\u003cp\u003e...\u003cem\u003ewhat made me most angry was the fact that she brought it up in front of my daughter, I mean she's 3 years old [...] children understand more than you think… (Parent 2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e Some parents worried about the future and how others would treat their children because of them being overweight. Some feared that their child would be left out or feel that they did not belong, and others were concerned that the child would suffer from mental illness and poor self-esteem. One parent said that the CHC-nurse made her aware of the risk of abuse in school, and several parents feared that being overweight would lead to the child being bullied. Parents who were overweight in their own childhood felt particularly afraid about being bullied and explained that the treatment you receive varies greatly depending on your body shape.\u003c/p\u003e\u003cp\u003eFeelings and thoughts about the parenting role\u003c/p\u003e\u003cp\u003e Feelings of guilt and shame were expressed by some parents and the situation made them question their parenting skills. They were afraid to have done something wrong or to have made the wrong decisions, and one parent expressed that this situation made her feel like they have harmed their child. Several parents explained that they always try to do what is best for their children and it felt like a failure when that was not enough. One parent shared that she struggled with being overweight herself, and always had as a goal that her children should not get there, and now when they were, it felt like a failure, and even though she knows it was not an actual failure, the sensitivity in the subject made it feel more personal than it was.\u003c/p\u003e\u003cp\u003eAll but one parent expressed that they felt judged and criticized in their parenthood and one parent explained that every health check-up the child goes to feels like an assessment of you as a parent, and if something is not perfect it feels like criticism.\u003c/p\u003e\u003cp\u003e \u003cem\u003e…I think that the instinctive feeling is, or was for me at least, that I did not do a good job, and she judged me for that. (Parent 9)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSome felt like the CHC-nurse jumped to conclusions regarding their habits and assumed that they did something wrong. Some said that the CHC-nurse showed no interest in what kind of lifestyle habits they had, and instead instantly pointed out what to do differently, which made them feel accused. Those presumptions were unwarranted for those who had never met that CHC-nurse before.\u003c/p\u003e\u003cp\u003e \u003cem\u003eIt was the first time she met us, and sure, she does not know at all… then maybe you should not just assume that people eat junk food and sit still… (Parent 9).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe parents not only expressed feelings of being judged by the healthcare system, but also a fear that other people would question how they took care of their children and what habits they had.\u003c/p\u003e\u003cp\u003e...\u003cem\u003eit feels like people think you give them candy every day, and just eat unhealthy food and never exercise (Parent 1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e One parent expressed that it is easy to have opinions about what other parents do, but when you find yourself in the same situation, it is not as simple as it seems.\u003c/p\u003e\u003cp\u003e Some parents felt divided since they were responsible for their children's habits and therefore causing the problem and were now responsible to put it right. It was perceived as against the parental instinct to limit the child's food intake, and it felt difficult to justify this to the children. One parent felt conflicted since others had difficulties getting their children to eat at all while she cannot give her child more food when he asks for it. For those who were separated from the other parent, it felt difficult to respond to questions about the child's food and eating habits since they could not speak for the other parent. Many wished the other parent should have been contacted as well, even those cohabitating, since it was described as hard to pass on information and advice, especially if the parents had different opinions on what is right for the child.\u003c/p\u003e\u003cp\u003eThe relationship with the nurse influenced the experience\u003c/p\u003e\u003cp\u003e The parents highlighted the importance of respectful healthcare encounters and to establish a good relationship with their CHC-nurse. Those who felt they were treated nicely found it easier to handle the situation while parents who had a bad experience wished for more support. Many expressed that the CHC-nurse was insensitive and plump while telling them about the child's being overweight, and some perceived the CHC-nurse as harsh and insensitive which made them feel as if they were caught off guard. Encouragement was described as important, and one parent said that it would have been nice to hear calming and reassuring words. Those who did receive reassurance such as ‘\u003cem\u003eit will probably even out’\u003c/em\u003e said that even though it was comforting to hear, it felt like the CHC-nurse mitigated the problem or was afraid of stepping on her toes. Some parents expressed that the CHC-nurse seemed uncomfortable and had difficulties raising the subject, which made the conversation feel awkward.\u003c/p\u003e\u003cp\u003eA neutral and matter-of-fact approach was appreciated by the parents, and it was preferred when the nurse was calm and educational. It felt positive when she showed understanding for the sensitivity of the subject and the CHC-nurse's responsiveness made it easier to receive the message. Sensitivity and humility were requested by most parents, and one described the CHC-nurse as not empathetic at all, which made her wish for better treatment.\u003c/p\u003e\u003cp\u003e Whether the parents trusted the CHC-nurse or not was described as significant for the outcome of the conversation, and their trust was affected by the advice they got. Non-evidence-based advice affected their faith in the CHC-nurse in a negative way, and one parent found it questionable when they got advice to make more unlikable food to try to get their child to eat less.\u003c/p\u003e\u003cp\u003eOne parent expressed lots of faith in her CHC-nurse which affected the situation positively, and even though it was a delicate situation it was not perceived as a negative experience. She explained that they had the same CHC-nurse since the child was born which had created a trusting relationship between them, and if someone else had given the information, it would not have been received in the same way.\u003c/p\u003e\u003cp\u003e...\u003cem\u003eshe [the CHC-nurse] really understands the problem in a different way[...] it feels like, the doctors who come at these check-ups who just go in and point[...] it doesn't get personal then, it's like this \"okay you're talking about a chart, but I'm talking about my child\", it's a bit different. (Parent 8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIt was described as difficult to have the conversation with a CHC-nurse they did not trust. One parent shared that she mistrusted the CHC-nurse since there was a history of being forgotten or double booked, and the room was empty and cold and there were no toys, so the child wanted to leave. Others lacked trust since they never met that CHC-nurse before, and one parent described that she felt unwanted during the entire appointment as the CHC-nurse sighed heavily in relation to every moment of the check-up.\u003c/p\u003e\u003cp\u003eWhat support the parents were offered from the CHC-nurse varied greatly, some received dietary advice, follow-ups and lots of information regarding being overweight while others got none at all. It was perceived in different ways since some did not want any information at all while others wished for more. It was also described as difficult to receive advice on what measures to take while still being in shock. Some did not want either advice or follow-ups, although many were offered extra weight checks or a referral to an obesity unit, which they had different opinions on. Some went there with their children while others felt it was an overreaction from the CHC-nurse.\u003c/p\u003e\u003cp\u003e...\u003cem\u003ethat we would get a follow-up, because it could also be something medically wrong. Like this, yes, but it's also pulling the trigger all at once... (Parent 2)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study indicated that talking about their child being overweight was a sensitive topic for the parents and many reacted with strong emotions, which confirms previous research (Eli et al., 2022). In accordance with other studies (Gainsbury and Dowling, 2018; Hardy et al., 2019) many parents struggled with acceptance, which could be explained by the fact that they did not consider their children being overweight and had their own ideas regarding how children grow. Genetics was believed to be a main cause for being overweight, which is consistent with previous research (Gainsbury and Dowling, 2018; Tschamler et al., 2018; Ziser et al., 2021), and there were questions whether it was possible to overcome genetic factors. Even though it is known that some children gain weight more easily, according to a large study (Heitkamp et al., 2021), the primary factors regarding treatment of being overweight were environmental, social and behavioral, rather than genetic. Some parents blamed themselves, felt guilty and questioned themselves, and some felt like they had harmed their children, which was similar to other studies (Gorlick et al., 2021; Hardy et al., 2019). However, most parents did not understand how it turned out this way for their children and felt there was nothing they could have done to prevent it. This differs from another study where fathers to a greater extent could see their own participation in how it came to this and what could have contributed to their children being overweight (Salemonsen et al., 2022). In light of this, CHC-nurses might benefit from having the genetic predisposition in mind, as well to have an individual approach and be careful not to blame the parents but help them make adjustment that suits the family.\u003c/p\u003e \u003cp\u003eThe parents wished to protect their children from the consequences of what a conversation about their being overweight might lead to. Many did not want the children to be present in the conversation at all, which agrees with another study (Eli et al., 2022). They feared it might negatively affect the children's self-esteem, cause unhealthy thoughts regarding food and weight or cause eating disorders. They wished to use neutral terms while speaking about weight and food and some would rather not speak about it at all while their child was present. This could be understood by the \u003cem\u003ebody positive movement\u003c/em\u003e (Cherry, 2020), where previous research shows that a body positive approach might have a good influence on children's self-image and their view on food and weight (Carbonneau et al., 2021). Even though a body-positive approach might benefit the children's self-image, in this case, it conflicts with the medical perspective where being overweight is, or might be, a health risk if not prevented (WHO, 2021). Many parents felt accused, questioned, and judged in the conversation regarding their child being overweight, and perceived it as criticism of their parenthood. This might be a result of the prevailing overweight stigma, where parents to children who are overweight are often exposed to associated stigmatization which is surrounded by presumptions regarding how they take care of their children (Gorlick et al., 2021). This shows the importance of the CHC-nurse being caring, respectful and responsive when raising the subject. Parents who know of and trust their CHC-nurse might find it easier to accept the situation than those who do not.\u003c/p\u003e \u003cp\u003eThe parents questioned the validation of the measuring tools since being overweight was not visible, and whether extra weight was unhealthy or not, can be considered an obstacle regarding the work preventing children being overweight and more generally obesity in society. These findings suggest that there seem to be a perception among parents that when talking about excess weight in childhood is about how the children looks, rather than the health risks associated. There might be a gap of knowledge, where CHC-nurses would gain by educating parents about the measuring tools and how children are expected to grow, preferably before a weight issue occurs. It might also be beneficial for both CHC-nurses and parents if the CHC-nurses, during conversations regarding being overweight in childhood and the associated risks clarify that the conversation has nothing to do with how the children look and the risks remains whether being overweight is visible or not. CHC-nurses might also benefit from using neutral terms regarding food and exercise to decrease the risk of the children's self-esteem being affected.\u003c/p\u003e \u003cp\u003eSome parents felt like the CHC-nurse seemed uncomfortable talking about the subject which agrees with previous research (Castor et al., 2021). Others felt like she raised the subject without full concern for the sensitivity of the parent, which could be understood by Sjunnestrand et al (2019) where CHC-nurses felt like they had to raise the subject whether parents seem receptive or not. If some CHC-nurses feel uncomfortable, it might be one reason why parents in this present study had a negative experience. It is possible that raising the subject without responsiveness might hurt a caring relationship (Halld\u0026oacute;rsd\u0026oacute;ttir, 1996). Although, when there was a caring relationship and the parents trusted their nurse, the conversation was not perceived as negative, which agrees with previous research (M\u0026auml;enp\u0026auml;\u0026auml; and Vuori, 2021; Halld\u0026oacute;rsd\u0026oacute;ttir, 1996). It also appears that a caring relationship is not necessarily affected negatively by talking about being overweight in childhood, which was something CHC-nurses feared according to Sjunnestrand et al (2019).\u003c/p\u003e \u003cp\u003e This result highlights the importance that CHC-nurses build a caring relationship with the parents. If the relationship is poor the parents might not be receptive to the information regardless of how or what the CHC-nurse does, therefore the whole purpose of guarding the child\u0026rsquo;s overall health through growth monitoring will have failed. This might lead to absence of changes in the family\u0026rsquo;s lifestyle habits. A caring relationship might be a prerequisite when it comes to talking sensitively about being overweight in childhood. If there is trust between the family and the CHC-nurse, the CHC-nurse does not need to be afraid to bring up the subject as the trust between them having been established will help to overcome any challenges that might arise during the conversation about the child\u0026rsquo;s weight. At the same time the CHC-nurse might benefit from showing understanding and sensitivity towards the parents' concerns and be careful regarding use of terminology and when and how to talk about children\u0026rsquo;s weight, and to ask open questions regarding lifestyle habits rather than just assume they do something wrong.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThis study has some limitations, first the parents were interviewed after being sought via social media. Since all participants volunteered to participate there could be a risk of sampling bias which might decrease the transferability since parents might have chosen to participate because they had strong feelings they wanted to express regarding the subject. However, similar studies where participants were recruited in different ways show similar results which strengthen the trustworthiness of the result.\u003c/p\u003e \u003cp\u003eSecond, nine parents were interviewed, and although a greater number might have enriched the result further and increased the credibility and transferability, more interviews would have contributed to more data than what was manageable considering the time limit when performing the study. During the last couple of interviews, the same kind of experiences were described and nothing new came up, hence, saturation was achieved, which is considered a strength. There was a pre-understanding regarding the subject since it was chosen partly because the two first authors had read discussions on social media where parents expressed negative opinions about the healthcare system with a particular focus regarding children and weight. This pre-understanding was not believed to have affected the interviews since all the questions asked were in line with the interview guide\u003c/p\u003e \u003cp\u003eThere are some strengths in the study. Firstly, since all the coding was done separately by the two first authors, and turned out to be similar it decreased the risk of preconception bias and contributed to the trustworthiness and credibility in the result. The person participating in the pilot interview read the result and expressed recognition, even though her interview was not included, this further strengthened the credibility of the study. Regarding transferability it is likely that parents recruited in other contexts might have shared similar experiences since the internet is a broad platform and except that all the parents in the study were mothers living in Sweden there were no other known significant common denominator. Another study where parents were recruited through the CHC show a similar result (Eli et al., 2022), which might strengthen the credibility in this study, and the findings to be transferable, at least in a Swedish context. Furthermore, a study from Australia got a similar result (Hardy et al., 2019) which suggests that it might be transferable to other western communities as well.\u003c/p\u003e \u003cp\u003eUsing quotes in the result contributed to enrich and also authenticate the results since the reader can make their own judgment of whether or not the quotes are correctly assessed.\u003c/p\u003e \u003cp\u003eClinical implications\u003c/p\u003e \u003cp\u003eThis study increases the understanding of the parental perspective on children being overweight, the knowledge can be used to facilitate the CHC-nurses' conversations about the child's weight. This may increase compliance to given advice on lifestyle changes, to promote future health for the child.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on the result of this study it seems like parents take the conversation about childhood overweight personally, and it could be perceived as being critical of their parental skills. In their perspective, the conversation was about how their children looked rather on their health, and since they did not consider their children being overweight, the conversation as well as the following measures seemed unnecessary. When CHC-nurses raised the subject, the parents felt judged, and they feared their children might get hurt in the process. This highlights the importance for CHC-nurses to be responsive towards when and especially \u003cem\u003ehow\u003c/em\u003e to talk about the subject, without blaming the parents or risk hurting the children's self-image or self-esteem. Parents need time to process the situation before receiving advice and it might be beneficial not to talk about weight when the child is present. Since the parents seem to lack knowledge regarding how children are supposed to grow and how the measuring tools work, it might be beneficial for CHC-nurses to introduce the growth charts as a routine from the start so the parents understand what it is for and how it is used, so they can see for themselves when something deviates. If parents understand why they have to take measures regarding their children's increased weight it might improve the compliance to the given advice. Focus should be on healthy lifestyle choices rather than weight.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe are grateful to the parents that participated in the study.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData availability Declaration\u003c/h2\u003e\n\u003cp\u003eThe author confirms that all data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003ch2\u003eConsent for Publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eDeclaration of conflicting interests\u003c/h2\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was funded by Dalarna University and did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarbonneau N, Hamilton L, Musher-Eizenman DR. 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(2021) Obesity and Overweight. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (accessed 3 january 2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Obesity Federation. (2022). Weight stigma. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.worldobesity.org/what-we-do/our-policy-priorities/weight-stigma\u003c/span\u003e\u003cspan address=\"https://www.worldobesity.org/what-we-do/our-policy-priorities/weight-stigma\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (accessed 3 january 2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZiser K, Decker S, Stuber F et al. (2021) Barriers to behavior change in parents with overweight or obese children: A qualitative interview study. \u003cem\u003eFrontiers in psychology\u003c/em\u003e 12, Artikel 631678. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2021.631678\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2021.631678\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children, Child health care nurse, Experience, Overweight, Parents, Qualitative","lastPublishedDoi":"10.21203/rs.3.rs-4014139/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4014139/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChildren with a raised BMI are a major public health challenge in the world that can cause serious consequences for children's physical and mental health. Child health care nurses' responsibility is to promote health and prevent ill-health in children, but because being overweight is stigmatized CHC-nurses find it difficult to talk to the parents about concerns over the children's weight, in fear of losing their trust.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThe purpose of this study was to describe parents' experiences when CHC-nurses introduced a conversation relating to their child\u0026rsquo;s weight and the effect on it's health.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis study was conducted via semi-structured interviews with nine parents and the data was analyzed using qualitative content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe result showed that being overweight in childhood is a sensitive topic, and this is presented as four categories \u003cem\u003eCoping with the information about the child\u0026rsquo;s weight, A desire to protect the Children from the potential consequences a conversation about health and weight might lead to, Feelings and thoughts about the parenting role\u003c/em\u003e and \u003cem\u003eThe relationship with the nurse influence the experience.\u003c/em\u003e This is a sensitive topic for the parents, who have a hard time accepting the situation and place the blame on themselves, and the nurse\u0026rsquo;s approach and relationship with the parents is of great importance for the outcome of the conversation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eParents seem to have another perspective on health and weight than the healthcare providers, and both parents and CHC-nurses might benefit from an increased understanding of one another's view. Parents need to gain knowledge about how healthcare providers assess children's growth, and the CHC-nurses need to be aware about how to be responsive to the parents and allow them time to process the information. The focus should be on healthy lifestyle choices regardless of weight\u003c/p\u003e","manuscriptTitle":"An emotionally loaded subject – parents experiences when CHC-nurses introduce a conversation related to their child being overweight","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-04 09:31:01","doi":"10.21203/rs.3.rs-4014139/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-03T09:39:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-23T20:42:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-12T06:05:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"acd9aa61-71d9-4f0a-a2cb-42e2d5b29695","date":"2024-04-03T13:23:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"0be2fecb-a50d-414c-94cd-35388733a8bc","date":"2024-04-02T16:24:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-02T13:29:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5644150d-5805-4f48-9962-7af1ad494987","date":"2024-04-02T13:06:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"b861735e-5e3c-4119-a8e5-a866dcc827b2","date":"2024-04-02T10:18:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-02T10:01:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-01T07:22:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-31T20:48:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-31T20:48:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-03-04T17:14:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ce43f043-4af5-49f2-abbd-1d2961adff91","owner":[],"postedDate":"April 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-25T16:00:14+00:00","versionOfRecord":{"articleIdentity":"rs-4014139","link":"https://doi.org/10.1186/s12889-024-20696-2","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-11-20 15:56:53","publishedOnDateReadable":"November 20th, 2024"},"versionCreatedAt":"2024-04-04 09:31:01","video":"","vorDoi":"10.1186/s12889-024-20696-2","vorDoiUrl":"https://doi.org/10.1186/s12889-024-20696-2","workflowStages":[]},"version":"v1","identity":"rs-4014139","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4014139","identity":"rs-4014139","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}