Table 5.

Implementation Facilitators and Challenges

Facilitators

Recruitment  • Promotions to families who have already identified their need for child weight management support, for example, those:   o With children who have a BMI-for-age above the 97th percentile and/or having experienced a triggering situation or event   o Talking with family physicians/pediatricians or going online to look for programming   o Contacting their local recreation centres or providers to look for physical activity or nutritional programming – or going to events looking for information on these topics   o Connecting with (former) MEND parents  • Promotions to intermediaries in contact with multiple families with eligible children, for example, those:   o Who are family physicians or pediatricians, in schools, in recreation centres or other physical activity or nutrition advice providers   o By mail/email out, webinar, newsletter and/or at a conference  • Promotions which use a multi-pronged and coordinated approach (at the neighbourhood/community, municipal and provincial levels) are well-branded, use key messages which resonate well, are boosted by champions, are ongoing, are synchronized with other schedules (e.g., for newsletters) and are sufficiently funded.  • Using a combination of promotions which are more widespread, though with lower levels of conversions (e.g., posters/flyers and social media), and promotions which have a narrower spread but have higher levels of conversion (e.g., referrals).  • Program delivery elements which encourage recruitment include – program content, ability to meet eligibility criteria (e.g., age, BMI and/or risk factors criteria), convenience of location, free (no cost), timing/schedule, inclusion of siblings.  • Knowing your communities - what works in one community may not work at all in another.

Delivery  • An overall approach which combines nutrition, exercise and psychology. One which is group-based (providing discussion, support, interpersonal connections/friendships and culturally diverse). One which is family-based – involving parents (or other caregivers) as well as children.  • Highly qualified, skilled, motivated, enthusiastic, well-prepared staff with strong community connections. Staff continuity - enabled where the organizational staffing structure is not based on short-term contracts. Strong centralized training, responsive external support for staff (i.e. Regional Coordinators) and the sharing of resources among facilitators/teams.  • Program sessions on nutrition and healthy eating as well as engaging physical activity sessions, especially games. Activities which are interactive, hands on, (age-) appropriate and fun.  • Delivery elements and logistics such as good venue facilities and spaces. Accessible session times and program lengths. Establishing and communicating clear expectations around behaviour. Using specific retention strategies (emails between sessions, follow up with families with poor attendance, promote future sessions in current sessions, fun/engaging sessions). Having committed/engaged families.

Outcomes  • Short-term outcomes:   o families that are satisfied with the program and making lifestyle changes while they are in it   o statistically significant positive changes in measures consistently achieved across all four evaluation time periods

Challenges

Recruitment  • Connecting with communities when there is:   o Lack of community size/awareness/interest and/or   o Lack of program staff time and/or available promotional materials  • The BMI eligibility criterion and the challenges faced by delivery team staff and partners around what language to use when speaking with parents about their child’s weight  • Program delivery elements (twice a week, inconvenient locations or session times)  • Lack of clear and direct communication with sites about provincial level recruitment activities so that site staff are aware of these activities and can leverage them through complementary local promotions.

Delivery  • A disconnect in the overall approach among stakeholders as to whether the program should be treated as a medical intervention program or a community healthy living program. This results in some confusion and communication challenges between partners, and can contribute to difficulty recruiting participants.  • The effects of programs not running – on facility bookings, staff turnover, smaller group dynamics (as a result of low attendance).  • Within programs – participant behavioural issues, broad age groupings, the strong facilitation skills required, content issues (e.g., weight-focused language, multicultural content needs, lack of cultural relevance for First Nation families, recent/updated nutrition content needs and/or more time on physical activity relative to classroom time), twice a week delivery (rather than once a week delivery) and data collection issues (missing or un-entered data and the high number of questionnaires).

Outcome  • Long-term outcomes – the lack of follow up or maintenance activities means nothing is in place after the program. Thus, there is no way to support changes over time and/or to confirm long- term impacts e.g., the extent to which recreation passes are being used, whether changes made continue or whether new changes are being made.