How can children, adolescents and adults who are overweight or obese be motivated to participate in health programs?

The World Health Organization (WHO) sees obesity as one of the greatest challenges for public health in the 21st century. The Austrian Institute for Health Technology Assessment (AIHTA) has now examined group programs offered in Austria, Germany, and Switzerland for children, adolescents, and adults with either overweight or grade 1 obesity, as well as numerous international literature sources.

From the results, the researchers have derived various strategies that can lead to better accessibility of the target groups when designing programs and consequently to a higher motivation to participate.

According to the WHO, adults with a body mass index (BMI) of 25 or more are considered overweight, while experts speak of obesity above a BMI of 30. Obesity is considered one of the main risk factors for non-communicable diseases such as type II diabetes, cardiovascular diseases, chronic lung diseases, and depression. Data from Austria shows that around a quarter of children and adolescents and more than half of adults are currently overweight or obese—and the trend is rising.

For treating overweight and obesity, health insurance companies offer, for example, multimodal group programs. These consist of several elements—nutrition, exercise and behavioral therapy—and usually last several months. In a recent study based on international literature, the AIHTA analyzed the barriers to participation in group programs and how programs can be designed to better reach target groups and retain them in the programs.

For the programs researched in German-speaking countries (20 for children and adolescents, 14 for adults), there were often no publicly available evaluations and little information on their strategies for recruiting and motivating potential participants.

Frequent difficulties reaching target groups

According to study leader Inanna Reinsperger, there is generally little scientifically validated information on how the providers of these programs reach their target groups and what methods are used to recruit program participants. An analysis of 16 international studies has shown that several active and passive recruitment methods are usually used.

Active strategies such as referrals by doctors combined with routine examinations or direct letters with information about the program are combined with passive approaches to the target groups, such as posters, flyers, and information in (social) media.

The studies report on numerous barriers at different levels. At a societal level, for example, these include the perception of overweight and obesity as well as associated stigmatization. Barriers among potential participants include a lack of motivation for treatment, underestimation of the extent of obesity, and, among adolescents, fear of bullying and discrimination.

According to Reinsperger, the focus for children is very much on organizational barriers. In addition, the parents of children and adolescents who are overweight tend to be difficult to recruit for the programs due to a lack of psychological pressure, whereas this is somewhat easier in the case of obesity.

Strategies for reducing barriers

As strategies for reducing these barriers, the study authors Sarah Wolf and Inanna Reinsperger recommend not only training recruiters in culturally and weight-sensitive communication but also targeting hard-to-reach groups such as socially disadvantaged people and people with a migration background directly in the socio-cultural settings relevant to the target group—preferably through people with a similar background and (multilingual) information material in easy language.

In general, it should be noted that the time and location conditions should be tailored to the potential participants. For example, a certain degree of flexibility in the schedule and an easily accessible location with public transport connections and sufficient parking facilities can lead to an increased willingness to participate. Support with childcare and transportation also increases the possibility of program participation for families.

In addition, the focus should be on positive messages and the benefits of a healthy lifestyle for the participants rather than just weight reduction: "If a person is only overweight and otherwise healthy, an intervention aimed at weight loss is not necessary or may even be harmful, for example, because it can lead to weight cycling and subsequently to a higher weight in the long term," Inanna Reinsperger points out.

Guidelines only recommend lifestyle interventions in the overweight range (i.e., BMI between 25 and 30) if there are other risk factors or illnesses that could be improved by weight reduction.

Increasing motivation to participate

Another challenge is to retain participants for the entire duration of the program, i.,e. to achieve good program adherence. Early program discontinuation often occurs, which means that the hoped-for goals, such as weight reduction or improvement in quality of life, are not achieved in the long term.

The AIHTA researchers examined eight literature reviews on this issue. These reviews showed that, for example, overly high expectations (e.g., rapid weight loss), a lack of motivation on the part of parents, and several previous diet attempts in adults have a negative impact on the willingness to participate in the program in the long term.

According to the study authors, motivation to participate could be increased by an orientation event before the program and by setting realistic goals at the beginning. In addition, involving the participants (co-designing) in the design of the—preferably varied—program content helps to improve adherence.

The AIHTA researchers have also identified a good relationship with a trained support team, which, at best strengthens the program participants with motivating feedback, as crucial for long-term motivation to participate.

While strengthening self-confidence and involving the family has a positive effect on participation in programs for children and young people, programs for adults may benefit from financial incentives—for example, vouchers for other courses or the reimbursement of a deposit if a certain number of program meetings are attended. In any case, the co-payments sometimes incurred in the various programs should be subsidized for socio-economically disadvantaged people.

In conclusion, study leader Inanna Reinsperger explains that the group programs examined for children, adolescents and adults with overweight and obesity only focus on individual behavior. Ideally, however, obesity should be considered in terms of the "Health in All Policies" approach—as also called for by the WHO—and health-promoting infrastructures should be created: for example, an exercise-friendly design of living environments and access to affordable and high-quality food.