Keys to Achieving Clinically Important Weight Loss: Perceptions of Responders and Nonresponders in the Clinic and Community Approaches to Healthy Weight Trial

Abstract

Background:

Despite modest mean body mass index (BMI) improvements in pediatric weight management interventions (PWMIs), some children are more and less successful in achieving a healthier weight. We sought to understand key behavior modifications and strategies used to overcome barriers that led to success or nonresponse.

Methods:

Using a semistructured guide, we conducted interviews in English and Spanish to explore the perspectives of caregivers whose children responded (BMI z-score change of greater than or equal to −0.2 units over 1 year) or did not respond (≥5% increase in % of the 95th percentile for BMI over 1 year) to a PWMI. Interviews were recorded, transcribed, and then coded using the framework approach. Researchers met regularly to review coding, content, and emerging themes.

Results:

We reached thematic saturation after interviewing the caregivers of 14 responders and 16 nonresponders and identified 7 themes as key elements of a positive response: (1) positive parenting approach; (2) application and practice of new information; (3) higher agency for change; (4) management of unmet social needs through creative solutions; (5) promoting mindful eating; (6) family alignment on health behaviors; and (7) mitigation of weight stigma.

Conclusion:

The effectiveness of PWMI may be enhanced by incorporating curricular elements that specifically promote the approaches identified among responders in this study. Similarly, lessons can be learned from nonresponders, so clinicians can identify and help early on when behaviors associated with nonresponse are seen.

Clinical Trial Registration number: ClinicalTrials.gov: NCT03012126.

Introduction

In the United States, ∼22.4% of children 2–19 years old have obesity, which has further increased during the COVID-19 pandemic.¹ Childhood obesity rates remain high, and racial and ethnic, as well as socioeconomic, inequities appear to be widening.² Childhood obesity is associated with both short- and long-term adverse outcomes,^3–6 including hyperlipidemia, diabetes, and hypertension^5,7–9; and with higher morbidity and mortality in adulthood.¹⁰ Children who have obesity tend to continue to have obesity as adults, and, once present, adult obesity is hard to treat.^11–13

Most clinically based randomized controlled trials (RCTs) to improve a child's body mass index (BMI) have had limited success.^14–16 Despite modest mean BMI improvements in childhood obesity RCTs, there are children within these interventions who are more successful in getting to a healthier weight (responders). One approach to improving the effectiveness of interventions is to identify and explore the characteristics of responders to form hypotheses about what may be driving their success.

This methodology has been used to identify characteristics and behavior change components of students who have successfully curbed binge drinking behaviors and led to a prediction model for binge-drinking and more effective interventions.¹⁷ It has also been used in identifying best practices in diabetes care by primary care practices¹⁸ and to identify the characteristics among pregnant adolescents that predict a healthy infant birth weight.¹⁹ In previous studies, our team conducted focus groups with children and parents to better understand what mattered most to children who were “positive outliers” in improving their BMI; we found positive relationships with family and friends facilitated success.

Other themes included parent modeling, consistency, and creativity in overcoming resistance; notably, however, the families interviewed for providing insight into their children's motivations leading to successful obesity management were not enrolled in a weight management intervention.^20,21 Examining the behavioral changes made by responders and the socioenvironmental factors that influence these behaviors can provide critical information to develop effective obesity interventions. There are no other studies to our knowledge that qualitatively examined caregivers to uncover characteristics of response or nonresponse in an intensive pediatric weight management intervention (PWMI).

In this study, we explored the perspectives of primary caregivers (parents, grandparents, and legal guardians) of children who responded or did not respond to a PWMI delivered at either a Healthy Weight Clinic (HWC) at a federally qualified health center (FQHC) or a modified Healthy Weight and Your Child (M-HWYC) program in a local Young Men's Christian Association (YMCA). We sought to understand key behavior modifications and strategies used to overcome barriers that led to their children's success or nonresponse.

Materials and Methods

Sampling

For this study, we recruited caregivers of children who previously participated in a PWMI delivered as part of an RCT—the Clinic and Community Approaches to Healthy Weight Trial. Participants were randomized to either the HWC delivered at two FQHCs or to M-HWYC at two YMCAs. The 407 participants in the trial were 6.0 to 12.9 years old at referral, with BMI ≥85th percentile, and had a caregiver who could read and speak English or Spanish. Recruitment started in December 2016 and data collection ended in September 2019.²²

We recruited caregivers of children in the study after they completed the 1-year intervention and their child had both baseline and 1-year BMI measurements obtained for this qualitative study. Caregivers of children who responded (BMI z-score change of greater than or equal to −0.2 units over 1 year, as defined by the US Preventive Services Task Force definition of clinically important weight loss) or did not respond (≥5% increase in % of the 95th percentile for BMI over 1 year, based on data of cardiometabolic differences observed in the POWER study for children) were recruited as they finished the intervention on a rolling basis.^23,24

The Massachusetts Department of Public Health Institutional Review Board approved the study protocol.

Recruitment and Enrollment

Study staff sent recruitment letters explaining the study and offering an opt-out telephone number to the eligible children's caregivers. One week after the letters were mailed, study staff called caregivers to explain the study, confirm their child's eligibility, obtain consent, and set a time for the interview. Forty-three met the criteria of responders during the timeframe we were conducting qualitative interviews before we met thematic saturation. Of these 43, 2 declined, 18 were unable to be reached, 9 were scheduled, but did not show up for their interview appointment, and 14 completed the interviews. Sixty-eight met the criteria of nonresponders; of these, 3 declined, 42 were unable to be reached, 7 were scheduled to be interviewed, but did not show up, and 16 completed the interviews.

Qualitative Protocol

Our study team of pediatricians and public health researchers created an interview guide through an iterative process. To help inform the guide, we completed an evaluation of prior studies investigating caregiver perspectives related to obesity to help identify context and mediating mechanisms around improvement or lack of improvement of BMI. Specific questions from the guide included suggested follow-up questions to provide a more complete exploration of the topics being discussed. We completed half-hour interviews over the phone. We provided caregivers with a $50 gift card as an incentive for interview participation.

Three bilingual clinical research coordinators were trained in qualitative methods by Drs. Kuhlthau and Fiechtner, in addition to formal qualitative training methods for study staff at Massachusetts General Hospital. The clinical research coordinators used the structured interview guide to conduct recorded English- and Spanish-speaking interviews. To ensure consistency and depth, two interviewers were present during all interviews. The interview guide (Supplementary Table S1) included exploration of what healthy lifestyle changes the family tried and then moved on to what the caregiver thought worked and did not work. Questions focused on why caregivers thought the healthy lifestyle change worked or did not work, how caregivers made the change, what motivations and barriers caregivers faced, and how caregivers got around such barriers.

The interview probed at what happened when the child was outside of the caregiver's care, what helped to continue the change, how their neighborhood affected the change, what additional neighborhood or financial resources would have helped, and what role either the HWC or the M-HWYC program played in the change.

Analysis

The audio recordings of all interviews were transcribed by the independent company Landmark Associates. The seven-member analysis team individually read the transcripts before discussing them together in meetings with the rest of the team. The transcripts were discussed repeatedly to recognize emerging themes and important topics. A list of themes was created and representative quotes were collected. After determining the developed themes and refined definitions, the transcript texts were coded using the framework approach and analyzed in NVivo 10.0.²⁵ Researchers met frequently to use the spreadsheet of coded quotations to prompt further dialog, draw connections between themes, and finalize interpretation of the data. Meetings were held biweekly, and analysis was considered complete when no new theme was generated from transcript review and discussions. Quantitative results are presented as the percentage of responder and nonresponder caregivers whose qualitative responses represented a theme.

Results

The caregiver-child dyad presented various parent and household characteristics, as well as child characteristics (Table 1). We reached thematic saturation after a total of 30 participants were interviewed, of which 14 were responders and 16 nonresponders. We determined we had reached data saturation when we began to hear repetitive comments, with limited novel data and no further generation of themes. We identified seven themes as key elements of a positive response: (1) positive parenting approach; (2) application and practice of new information; (3) higher agency for change; (4) management of unmet social needs through creative solutions; (5) addressing signs and symptoms of disordered eating behaviors; (6) family alignment on health behaviors; and (7) mitigation of weight stigma. Examples of direct quotes are included (Table 2).

Table 1.

Sociodemographic Characteristics of the Caregiver/Children Dyad

	Responder (N = 14)	Nonresponder (N = 16)
Parent and household characteristics	Mean (SD) or N (%)	Mean (SD) or N (%)
Relationship to child
Mother	14 (100.00%)	12 (75.00%)
Father	0 (0%)	2 (12.50%)
Grandparent	0 (0%)	2 (12.50%)
Language of interview
English	6 (42.86%)	6 (37.50%)
Spanish	8 (57.14%)	10 (62.50%)
No. of people in household	4.79 (1.67)	3.94 (1.61)
Income
$20,000 or less	7 (50.00%)	11 (68.75%)
between $20,000 and $70,000	5 (35.71%)	4 (25.00%)
More than $70,000	0 (0%)	0 (0%)
Don't know	2 (14.29%)	1 (6.25%)
Child characteristics
Age at baseline, years	9.16 (1.92)	9.14 (1.73)
Sex, female	6 (42.86%)	4 (25.00%)
Race/ethnicity
Hispanic/Latino	13 (92.86%)	15 (93.75%)
Non-Hispanic White	0 (0%)	0 (0%)
Non-Hispanic Black	0 (0%)	1 (6.25%)
Non-Hispanic Asian or other	1 (7.14%)	0 (0%)
BMI z-score slopea	−0.44 (0.22)	0.24 (0.13)
Time between first and last BMI measure, yearsb	1.29 (0.30)	1.32 (0.47)

^a Calculated as the average change from baseline to 12 months.

^b Calculated as the time difference from baseline to 12 months.

BMI, body mass index; SD, standard deviation.

Table 2.

Responder and Nonresponder Sample Quotes

Theme	Status	Quotes
Positive parenting approach	Responder	“It's not easy, but if you're willing to do it, you have to look at it in a positive way and be consistent with it. Because if you don't be consistent with it, none of it's going to work.” –Mother of 8-year old “She used to tell me these things about feeling chubby and she told me that, ‘no, I don't like being like this,’ and I told her, ‘you are pretty the way you are, but if you don't like it then let's have healthier eating and let's do more exercise, eat less, so then we can be well.’”—Mother of 10-year old
	Nonresponder	“I tell him, ‘no, son, you need to walk. You cannot be sitting all day, because you are going to get more fat,’. He cries when someone tells him like that.”—Mother of 9-year old “Sometimes, he sees his siblings drinking soda. I tell him not to drink it, but sometimes they give it to him, and he drinks it. More than anything, I tell him not to drink it, because he is going to get diabetes.”—Mother of 9-year old
Application and practice of new information	Responder	“[The school] …was planting vegetables and they asked for our collaboration. We went, and that's where I got the idea to begin to plant. I do it in containers, in planters. I liked the idea, and I get a lot of tomatoes and cucumbers and a lot of peppers, and now I love it. My daughters do too. Practically the whole summer they eat fresh vegetables. It gives my daughters more incentive to eat healthier.”—Mother of 9-year old “On YouTube you can find a lot of ideas. I also received a lot of calls from [the PWMI] program, where they gave me some examples. In the beginning I used to buy a lot of cookies, sodas, juices. They also gave me a lot of feedback about healthy things. You can give them that, but you have to limit it, because it has a lot of calories and a lot of sugar.”—Mother of 12-year old “So, those things that they have like a journal that you bring home and you have homework like every week and you have to stick with that… write what they do try and what they didn't try and what worked, what didn't work? That actually helped a lot.”—Mother of 13-year old
	Nonresponder	“I learned some new things, how to apply them to him—so that he could understand the reason for the changes. It was difficult for him to understand that. Why was I making these changes, and why wasn't I buying that, why the salads, why the vegetables?”—Mother of 12-year old
Higher agency for change	Responder	“I was trying to make the changes, but when my mother passed is when I really … went into it. I'm real serious about it now. I really got to make these changes big time, especially with [name of child].”—Mother of 9-year old “There comes a point when you have to take care of your health. I could have had a cardiac arrest, and who would take care of my children? I had to do it not only for my children, but also for myself—to teach them that exercising is good, that eating healthy is good. When the doctor said that the child was too obese, these are the complications that could happen. He alerted me, and not only that, but he also gave me a measure of strength, because when he introduced me to YMCA and the programs that can help the kids, it gave me the strength to be able to kick start that change.”—Mother of 12-year old
	Nonresponder	“Junk food is cheaper than vegetables and fruits.”—Father of 8-year old
Managing unmet social needs through creative solutions	Responder	“I have four pepper plants there. Oh my God, they have so many, and they help me. I think maybe people don't really want to put in the effort to do it. If they go to the program—they gave us that idea … I get lots of vegetables practically the entire summer.”—Mother of 9-year old “Well, the main change I found out in my food shopping, I'm saving more money. It's not coming up as much as it usually does. Less of the soda, less of the junk food, the cakes, the cookies, the stuff like that … so it is a big change of my money situation.”—Mother of 9-year old
	Nonresponder	“I see children here [at government housing]. [But] I don't allow my daughter to be outside by herself. I don't permit it. She is either with her dad or with me.”—Mother of 10-year old “We weren't able to fix [physical activity] very much, because we don't have a car. We don't have a lot of income. We have a very limited income, so I didn't have transportation.”—Grandmother of 12-year old
Addressing signs and symptoms of disordered eating behaviors	Responder	“He didn't like lettuce, and I said okay. I introduced it little by little, because you can't force a child to eat something he doesn't like. Try it like this—with different dressing flavors to see which one they liked better…The same goes for fruit—its texture, how it feels in their mouths, that depends, and trying different techniques. Cooked, uncooked, to see what they like best.”—Mother of 12-year old
	Nonresponder	“Of course, I hide food in my room. All the good snacks and stuff, I hide them in my room.” “If I buy a box of candy bars, even if I hide it from her, she will find it.”—Mother of 10-year old
Family alignment vs. disparate family health behaviors	Responder	“I started with 10 to 15 minutes outside, and of course whenever [the children] do it—for me spending so much time outside because I have so much stuff to do … it's a bit more of a sacrifice for working parents. However, those 10 to 15 minutes you're outside with [the children] are worth it—especially after eating—because they're not just lying there watching TV, but jumping around, getting excited. They're already burning the calories they ate.”—Mother of 12-year old “Only [child's name] was in the program, because my other daughter is very skinny…but all three of us went. Sometimes my husband would go too. [The sibling] learned a lot too. What I liked the most was that both of them went, so both of them learned and both of them practiced it, because it's easier.”—Mother of 9-year old “For me, it was like, if I did it, she would do it, too. I also had to lose weight because I was overweight. I motivate her. She sees me working out, so she does the same. Sometimes she is the one who starts, ‘Mom, let's work out,’ and she's the one who motivates me.”—Mother of 12-year old
	Nonresponder	“I have to be the one to be stern because the dad won't. Do you know what I mean? He thinks that if he lets her do whatever she wants … and play on the phone all day, she'll be happy.”—Mother of 10-year old “At my house, the most … that [someone] was drinking [soda] was me. I'm guilty … He's more aware of healthy conscious. He says, ‘Mom, you know that we can't be drinking that because we need to lose weight, and I like sports, so if I have overweight on me, I'm not going to be able to run around a lot.”—Mother of 8-year old
Mitigation of weight stigma	Responder	“I think when you tell a child, ‘you're fat, you need to lose weight,’ he doesn't get motivated. I think motivation is, ‘Look at this sport, let's go to the park and jump or let's play this game.’”—Mother of 12-year old
	Nonresponder	“No, I tell him, ‘Do not do that, because it is not good for you. You do not understand. It is your problem if you get fat. Fat children cannot run or play.’ I talk to him that way, but he says, ‘That is fine. That is fine. I will not do it.’ He does not do it often, though.”—Mother of 9-year old

PWMI, pediatric weight management intervention; YMCA, Young Men's Christian Association.

Positive Parenting Approach

Nearly half (43%) of caregivers of responders had responses demonstrating positive parenting approaches. Caregivers of responders thoughtfully encouraged their children and emphasized consistency in their parenting approach. They, for instance, discussed with their children that healthy food provides more energy, and healthy food was linked with the ability to play with peers.

Nearly half (44%) of caregivers of nonresponders had responses focused on negative health consequences of unhealthy behaviors as motivation for change. For example, caregivers of nonresponders reported threats of becoming “more fat” and mentioned delivering warnings of developing diabetes from drinking soft drinks.

Application and Practice of New Information

Caregivers of responders (36%) had responses about applying and practicing new information, such as having their child help them grow vegetables in potted plants at home after the child had been exposed to planting healthy food at school. Caregivers of responders also mentioned practicing new ideas from YouTube and the HWC or M-HWYC program. Through these resources, they found feedback about calories and sugar in cookies, soda, and juices. Other caregivers of responders encouraged their children to keep a journal of what healthy eating strategies they tried. The caregivers asked their children to clarify in the journal which strategies seemed helpful and which did not seem helpful.

Caregivers of nonresponders (31%) described new knowledge about what healthy lifestyle changes were associated with improvement in BMI; however, their responses did not elaborate on how they applied or shared with their children the information they learned from the HWC or M-HWYC program at home.

Higher Agency for Change

Half (50%) of caregivers of responders had responses notable for high agency for change. These caregivers spoke about understanding actions to improve healthier eating and exercise were within their own control. Some caregivers noted feeling empowered after receiving the recommendation from doctors to enroll in the M-HWYC.

Half (50%) of caregivers of nonresponders had responses aligned with lower agency for change, likely due to external reasons. One caregiver of a nonresponder mentioned they thought cheaper, unhealthy food was simply more attainable. Some caregivers reported feeling powerless.

Management of Unmet Social Needs Through Creative Solutions

Caregivers of responders (29%) reported creative solutions when discussing unmet needs. For example, when faced with the obstacle of accessing healthier, affordable fresh food, caregivers of responders talked about the efforts to grow their own vegetables. Similarly, while acknowledging financial stressors, caregivers of responders found a cost saving opportunity by reducing soda, cake, and cookie purchases, and thereby allocating more funds for healthier foods.

Caregivers of nonresponders (38%) had limited discussion of alternative options while reporting obstacles such as access to transportation and other social determinants of health such as financial security.

Addressing Signs and Symptoms of Disordered Eating Behaviors

Caregivers of responders (14%) described behaviors that are protective against disordered eating such as embracing mindful eating and expanding the child's palate. For instance, caregivers reported introducing healthy new foods like lettuce and fruits slowly. Sometimes they would offer vegetables cooked and uncooked to determine what was preferable. They would try different fruits to see if certain textures were more appealing. Children of these caregivers had the opportunity to be attentive to food and diversify their palates.

Caregivers of nonresponders (38%), however, had responses demonstrating symptoms of disordered eating. These caregivers would be prescriptive with dietary change and hide certain foods like snacks and sweets from the child, but maintain them for others in the household.

Family Alignment on Health Behaviors

More than half of caregivers of responders (57%) mentioned alignment among family members on family-based and weight-sensitive approaches for healthy lifestyle changes. Caregivers reported including their whole family in the PWMI-related efforts, even though only one of their children was the primary participant. They mentioned it seemed easier when working on healthy weight initiatives together. Furthermore, caregivers found their children were best motivated to make healthy lifestyle changes when the caregivers themselves were also focused on making healthy lifestyle changes. Seeing each other increase physical activity inspired and benefited each person mutually.

Sixty-three percent of caregivers of nonresponders discussed varying levels of inconsistent family alignment. Sometimes one caregiver felt as though the other caregiver was not contributing to healthy lifestyle changes, which impeded progress. Other caregivers said they were unable to maintain some of the healthy lifestyle choices themselves.

Mitigation of Weight Stigma

Caregivers of responders (14%) mentioned efforts to reduce weight stigma. Conversations with their children did not emphasize problems with weight, but instead focused on the joyful elements of movement. Conversations centered around playing in the park, for instance. When fun through physical activity was discussed as the primary goal, rather than weight loss, caregivers noticed it was easier to motivate their children to be active.

Caregivers of nonresponders (25%) displayed more weight stigma, and they would allude to their child's clothing and physique, using descriptions that could be negative and shaming. These caregivers would call their children “fat” and be explicit on limitations they were facing physically.

Discussion

We explored the behaviors and strategies of the primary caregivers of children who responded and did not respond to a PWMI delivered at either an FQHC or YMCA to better understand what factors were associated with either their children's success or nonresponse. Overall, positive parenting practices, application of new information, a higher agency for change, managing unmet social needs through creative solutions, promoting mindful eating, maintaining family alignment, and mitigating weight stigma proved to be critical change-promoting elements found in this study. Although we noticed differences between responders and nonresponders, the implication of these results needs to be contextualized in the complex realities of health care inequities.

We believe these findings are relevant to clinical and community practice, for both clinicians and caregivers. Identifying barriers and helping caregivers acquire the tools to promote their child's success will be crucial for all families to have the best chance of success. For the caregivers who express that unhealthy, cheaper food is the only financially viable option for the family, clinicians can offer a connection to resources that can ameliorate this burden such as Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment, and refer to local food pantries. Clinicians can also review with caregivers mindful eating behaviors (observing taste, texture and smells of foods, eating at the table, without screens, and not locking or hiding food) and indicators of disordered eating to identify these symptoms early.

Although, to our knowledge, there is no other study that has qualitatively examined caregivers' reasons for response or nonresponse in an intensive PWMI, this study does contain elements consistent with current literature. Most broadly, this study reaffirms nurturing family environments can impact their child's behavioral choices and health outcomes.²⁶ Studies show positive parenting with thoughtful encouragement has positive impacts on children's weight.^27,28 Responders in this study have caregivers who embraced mindful eating and expanding the child's palate, which align with other studies that show involving children in food preparation is associated with better weight-related outcomes.²⁹ Nonresponders in this study, however, had symptoms of disordered eating, consistent with other studies showing restriction and pressure to eat foster unhealthy weight outcomes.²⁹

A notable feature of this study was caregivers of responders showing family alignment and learning together, which aligns with literature demonstrating family-based interventions are effective for child weight management.³⁰ Similarly, modeling healthy eating behaviors, such as a child witnessing a caregiver eat a healthy snack, has positive health outcomes for the child.²⁹ Caregivers of nonresponders in this study who were unable to maintain some of the healthy lifestyle choices for themselves may have limited the opportunity for the child to feel as though they had shared understandings and goals, even if the child was engaged and interested in making healthy lifestyles choices for themselves. Mitigation of weight stigma, a behavior of caregivers of responders, is sometimes grouped into positive parenting as actions without harsh psychological control in literature.²⁹

Strengths of the study design include intentional eligibility criteria, based on objective electronic health records, to differentiate responders and nonresponders of a PWMI. Interviews were conducted in English and Spanish and the participants were from families of lower income and Hispanic ethnicity, populations inequitably impacted by obesity. Further, the study is transparent and replicable. The study is not without limitations, however. Nonresponders may have faced more health inequities and barriers out of their control than responders, as it is certainly possible nonresponders had lower incomes (among other factors) than responders.

Nonresponders' experiences should be viewed in the context of health inequity, instead of attributing some barriers that may be out of their control to choice. Selection bias may have played a role, as there is a possibility the most motivated responders and the least successful nonresponders may be more inclined to speak about their experiences. As our team met biweekly on a rolling basis to determine themes, those interviewed first had more of an impact on the data. In addition, the participants were primarily Hispanic and from lower-income families, and for this reason may not be generalizable to other groups.

Conclusion

This novel study identifies behavior and strategies utilized by caregivers of children responding and not responding to a PWMI, which can inform future PWMIs and allow clinicians to better tailor care to this patient population. Knowledge of the successful elements of a positive response to a PWMI, specifically those that include behaviors and strategies that are modifiable and facilitated by an informed caregiver, can be paramount to a child and their family's success.

The results can be used to help motivate caregivers to participate in a family-centered approach to their child's healthy eating and exercise. We have incorporated these findings in our current dissemination and implementation package of the HWC.^31,32 Clinicians should encourage positive behaviors and, as early as possible, identify and intervene on behaviors associated with nonresponse and help offer solutions for external barriers such as food insecurity. The findings from this study can inform further investigation into these behaviors and strategies to continue to develop best practices of care. In sum, the results from this study can lead to increased effectiveness of the PWMI to ensure children and their families can overcome barriers to health behavior change.

Impact Statement

Caregivers of children who responded and did not respond to the intervention hold answers to improving pediatric weight management intervention effectiveness. Responder families highlighted the energy healthy food provides, advanced individual practice like growing vegetables, embraced mindful eating, and discussed family-based and weight-sensitive approaches. Nonresponders used threats, had lower agency for change, and hid food.

Authors' Contributions

Mr. C.F. drafted the first article and was mentored by Dr. L.F. Dr. D.S.V., Ms. I.C., Ms. G.O.’C., Dr. M.S., Ms. F.N.M., Dr. K.K., and Dr. L.F. created the interview guide and analyzed the data. Ms. I.C., Ms. F.N.M., and Ms. G.O.’C. conducted the interviews. Ms. M.P., Dr. E.M.T., and Dr. L.F. helped conceptualize the study and obtained funding. Ms. M.L. and Dr. C.R. performed the quantitative analysis. All authors reviewed and edited the final article.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control, Agency for Health care Research and Quality, the National Institutes of Health, or any other funders. The funders/sponsors did not participate in the work.

Funding Information

This study was supported by the Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion (Award no.: U18DP006259). Dr. Fiechtner is supported by grant number K23HD090222 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr. Sharifi was supported by grant K08 HS024332 from the Agency for Health care Research and Quality. Dr. Taveras was supported by grant K24DK105989 from the National Institute of Diabetes and Digestive and Kidney Diseases, and is supported by grant K24HL159680 from the National Heart, Lung, and Blood Institute.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

Supplementary Table S1