Join the Conversation! The Development and Preliminary Application of Conversation Cards in Pediatric Weight Management

The high prevalence of pediatric obesity indicates the need for effective approaches to help children with obesity and their families make healthy lifestyle choices and improve health outcomes. Health care professionals can encourage families to remain engaged in care and reduce the well-documented high degree of attrition from pediatric weight management programs by establishing rapport and a collaborative partnership with families. The manner with which health care professionals communicate with families about weight and health is critical, given the sensitivity of the subject and the finding that many families have had negative clinical interactions in the past.^,  There is value in developing clinical tools for health care professionals to use that are practical, interactive, and family-focused. The purpose of our study was to develop a deck of cards called Conversation Cards that can be used to facilitate conversations between health care professionals and parents of children treated for obesity. The idea for the cards stemmed from a United Kingdom–based project in which a deck of cards was created for adults living with diabetes. The cards contained phrases representing common challenges experienced by patients, and were used before clinic visits to help patients prioritize issues they wished to discuss with their health care professional.

This research included 3 interrelated phases. In phase 1, health care professionals (n = 13; pediatricians, nurses, dietitians, exercise specialists, and psychologists with expertise in pediatric obesity) and parents (n = 16 [12 women and 4 men; 31–51 years of age; 81% white]) of boys and girls diagnosed with obesity were recruited to participate in semi-structured focus groups or individual interviews. Four separate focus groups (2 for health care professionals and 2 for parents) were held. Data were collected from health professionals during focus groups exclusively. For parents who were interested in participating in this study but were unable to attend the focus groups because of other commitments, individual interviews were held (n = 2). Of the parents who participated in the focus groups (n = 14), 12 families were represented. The aims of the focus groups and interviews were to (1) explore elements of collaboration between health care professionals and parents and (2) describe common barriers faced by families when trying to make healthy lifestyle and behavioral changes. Sessions were audio-recorded and transcribed. A modified thematic analysis was used to analyze both the focus group and interview data by identifying key elements of collaboration as well as factors that hindered lifestyle and behavior changes in families. These findings were published and used subsequently to create the themes in phase 2.

In phase 2, the qualitative data from phase 1 were used to generate a preliminary deck of Conversation Cards, which our research team reviewed by for content, language, and clarity, and which were subsequently organized into 6 themes (communication, weight management, physical activity, nutrition, interpersonal relationships, and parenting). The card statements included common barriers and challenges encountered by families that prevented them from making healthy lifestyle choices and achieving weight management success. A subgroup (n = 20; 12 health care professionals and 8 parents) of participants from phase 1 then participated in an electronic version of the Delphi technique, administered through SurveyMonkey Pro (SurveyMonkey.com, LLC, Palo Alto, CA), to prioritize, consolidate, and refine the number of statements. The Delphi technique is a group-based, rank-ordering process that allowed us to reduce the number of cards and merge cards with similar statements. This process also informed decisions to eliminate cards with statements that were not perceived as common or salient. In the end, these steps resulted in a deck of 45 individual cards (from the original 130 cards) that could be held and manipulated easily. The Figure shows sample Conversation Cards.

In phase 3, health care professionals working in a multidisciplinary, pediatric weight management center used Conversation Cards and offered them to a convenience sample of parents (n = 11) during clinical appointments. Parents were chosen based on their availability to review and evaluate the cards; they were not involved in the earlier developmental phases of this research. Parents' perceptions of acceptability, likeability, relevance, and future uses were assessed by having participants complete a brief survey at the end of the appointment. The survey included both closed questions (eg, “On a scale of 0–10, how relevant were the card statements to your family?”) and open-ended questions (eg, “What did you like most about the cards?”).

From phase 3, piloting testing revealed several insights. First, it was feasible to incorporate the cards into day-to-day clinical practice. Offering the cards to parents while they waited for appointments, or as an initial task to complete during appointments, was straightforward and well-received by health care professionals and families alike. Second, parents were not limited in the number of cards they could choose from the 45-card deck; on average, they chose 16 cards (range, 5–30 cards), which highlights the breadth of issues with which parents identified. Almost all of the cards were chosen at least once (40 of 45; 89%). The 5 cards chosen most often included: “Having a goal helps us to stay motivated” (n = 9); “Our schedule makes it hard to exercise together as a family” (n = 8); “I think it's good for my child to be involved in discussions” (n = 8); “It is helpful to write down what we eat and the activities we do” (n = 7); and “I want to learn how to make healthy foods fun” (n = 6). Third, when parents were asked to rate the likeability and relevance of the card statements on a scale of 0–10 (a higher score equaled a more positive rating), favorable scores were provided (mean likeability score, 7.0 of 10; mean relevance score, 7.2 of 10). Fourth, there was universal agreement (11 of 11; 100%) among parents that the statements were easy to understand, and they were open to using the cards again during future appointments. Finally, parents offered positive feedback on their perceptions of and experiences with the cards, yielding the following comments: “Good activity to do while waiting in the waiting room”; “good way to generate ideas for discussion”; “better than going through a long list of questions”; “they're nice—and reminded me of a card game.”

Conversation Cards may offer health care professionals working in the management of pediatric obesity a practical, interactive, and tangible tool to help families identify and address barriers related to lifestyle change and weight management. These findings indicate that the cards were easily incorporated into clinical practice, parents selected a variety of cards that reflected a range of common issues, and parents liked the cards and found them relevant to their own experiences. No parent chose fewer than 8 cards, which highlights the high number of concerns parents have regarding weight management. It is unlikely that health care professionals will have enough time to address this number of issues during a single clinic appointment. Parents may therefore benefit from selecting 3 or 4 cards that reflect issues they find most challenging or that they are more able and willing to address. This guidance can reduce some of the complexities of pediatric obesity and weight management while attending to families' priorities at the time of the clinic visit. Given the difficulty that many health care professionals have in initiating conversations about obesity and weight management, Conversation Cards provide an opportunity to explore issues, many of which are complex and sensitive in nature, in a more neutral and family-focused manner. The cards are aligned with the tenets of motivational interviewing, which encourage health care professionals to roll with their clients' resistance to change, understand their motivations, listen actively, and empower them. The Conversation Cards may be a practical tool that can be incorporated into motivational interviewing–based sessions with families. In light of the small sample of parents included in this pilot study, our team is currently planning additional research to examine the impact of the cards on both health services and clinical outcomes in a broader, more diverse group of families.

This study was approved by the Human Ethics Research Board and supported, in part, by the Women and Children's Health Research Institute, both of which are based at the University of Alberta in Edmonton, Alberta, Canada. Dr. Ball was supported by a Population Health Investigator Award from Alberta Innovates–Health Solutions and a New Investigator Award from the Canadian Institutes of Health Research. Dr. Newton was supported by a Canadian Institutes of Health Research Career Development Award from the Canadian Child Health Clinician Scientist Program in partnership with the SickKids Foundation, Child and Family Research Institute (British Columbia), Women and Children's Health Research Institute (Alberta), and Manitoba Institute of Child Health. The authors thank Dr. Mary Jetha and Kathryn Ambler, Jill Avis, Lisa Tremblay, Anna Stephenson, Jessica Sweezie, Rhiannon Prince, and Tesia Bennett, for assistance with data collection.