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. Author manuscript; available in PMC: 2023 Feb 9.
Published in final edited form as: Community Ment Health J. 2018 Feb 9;54(8):1136–1145. doi: 10.1007/s10597-018-0242-z

Community Mental Health Providers’ Beliefs About Addressing Weight Loss Among Youth Clients with Serious Emotional Disturbance and Overweight/Obesity: An Elicitation Study

Thomas L Wykes 1, Katelynn A Bourassa 1, Andrea E Slosser 1, Christine L McKibbin 1
PMCID: PMC9911299  NIHMSID: NIHMS1867607  PMID: 29427055

Abstract

Youth with Serious Emotional Disturbance (SED) have high rates of overweight/obesity. Factors influencing mental health provider intentions to deliver weight-related advice are unclear. This study used qualitative methodology and Theory of Planned Behavior (TPB) constructs to examine these factors. Community mental health providers serving youth with SED were recruited via convenience sampling and an online provider list. Participants completed an open-ended TPB-based questionnaire online. Content analysis identified thematic beliefs. Twenty-one providers completed the questionnaire. Providers identified behavioral beliefs (e.g., client defensiveness), normative beliefs (e.g., medical professionals), and control beliefs (e.g., limited resources) that impact decisions to provide weight-related advice. Knowledge of factors that may influence providers’ delivery of weight-related advice may lead to more effective healthy lifestyle programming for youth with SED.

Keywords: Serious emotional disturbance, Youth, Obesity, Community mental health, Intervention

Introduction

The prevalence of youth overweight and obesity in the United States has tripled since the late 1970s, with overweight affecting 31.8% (Ogden et al. 2012) and obesity affecting 17.0% of youth between the ages of 2 and 19 years (Ogden et al. 2016). Unfortunately, this public health “epidemic” (p. 6; Wang and Beydoun 2007) has a disproportionate impact on youth affected by Serious Emotional Disturbance (Cook et al. 2014; Gracious et al. 2010; Hasnain et al. 2008; Jerrell et al. 2010; Katon et al. 2010). The term Serious Emotional Disturbance (SED) was created by the Substance Abuse and Mental Health Services Administration (SAMHSA) and refers to individuals less than 18 years of age who meet criteria for a DSM-based (e.g., American Psychiatric Association 2013) disorder which results in significant functional impairment (SAMSHA, 1993 as cited in Center for Behavioral Health Statistics and Quality 2016, pp. 1–2). Developmental and substance use disorders are excluded from the SED classification (SAMSHA 1993 as cited in Center for Behavioral Health Statistics and Quality 2016). Importantly, studies have suggested that elevated body mass index (BMI) among youth with SED is maintained across time (Rofey et al. 2009) and that childhood obesity may be associated with medical and psychiatric comorbidities (e.g., Halfon et al. 2013; Sanders et al. 2015).

A variety of factors likely contribute to elevated rates of overweight/obesity (OW/OB) among youth with SED, such as psychotropic medications and psychiatric symptoms. A number of studies have shown significant weight gain among youth due to the use of antipsychotic, antidepressant, and mood stabilizing medications (Jerrell 2010; Pringsheim et al. 2011). These data are particularly concerning because the number of youth receiving these medications has increased dramatically in recent years (Comer et al. 2010; Cooper et al. 2006; Olfson and Marcus 2009). Psychiatric symptoms may also contribute to the development of youth OW/OB through their impact on dietary and physical activity behaviors. Some authors have suggested that impulsivity, inattention, poor emotion regulation, and poor behavioral self-regulation may lead to unhealthy eating behaviors and/or obesity (Davis 2010; Puder and Munsch 2010). Hyperactivity and impulsivity have also been linked to physical inactivity in youth (Khalife et al. 2014). Thus, youth with SED constitute a vulnerable population that faces high rates of OW/OB, likely as a direct result of the treatment and behavioral sequelae associated with their psychiatric disorders. As many youths with SED present for treatment in community mental health settings (Merikangas et al. 2011), it has been suggested that community mental health clinics may be an ideal setting to provide structured weight loss interventions to address OW/OB in this population (Barlow 2007).

Before developing programs to address OW/OB in youth with SED served in community mental health settings, it is important to understand attitudinal factors that contribute to community mental health providers’ decisions to engage in weight loss treatment practices. The Theory of Planned Behavior (TPB; Ajzen 1991) has been widely used to understand the decision-making processes of a variety of healthcare providers (e.g., Godin et al. 2008). For example, the TPB has recently been used to investigate weight management practices for youth by providers in academic medical center settings (Frankfurter et al. 2017) and primary care provider intention to provide information on physical activity for health (Behrens and Harbour 2014). Therefore, it may be useful for understanding decision making among community mental health providers.

This theory provides a framework for understanding the psychological factors that contribute to an individual’s intention to perform a specific behavior in a given context (i.e., Behavioral Intention; Ajzen 1991). According to the model, behavioral intentions are the direct antecedents of a given behavior. Behavioral Intentions may be predicted by the following three “Direct Attitude” variables: Attitude Toward the Behavior, Subjective Norm, and Perceived Behavioral Control. These variables correspond to and are driven by specific beliefs, known as “Salient Belief” constructs (Ajzen 1991). Specifically, Attitude Toward the Behavior is determined by a set of specific beliefs regarding the possible outcomes of performing the behavior (i.e., Behavioral Beliefs). The Subjective Norm construct is influenced by specific beliefs regarding the opinions of important others such as colleagues or supervisors (i.e., Normative Beliefs). Finally, the Perceived Behavioral Control construct is determined by a set of specific beliefs regarding ability to control elements of the performance of the behavior (i.e., Control Beliefs). See Fig. 1. Despite the widespread, successful use of the TPB in studying provider intentions and behaviors across a variety of settings, few if any studies have applied this theory toward the decision-making processes of community mental health providers serving youth with SED and OW/OB.

Fig. 1.

Fig. 1

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Depiction of the Theory of Planned Behavior (TPB), (Adapted from Ajzen 2006)

We designed the present study to identify the Salient Beliefs related to the three major TPB constructs pertaining to providing weight-related lifestyle advice to youth clients with SED and OW/OB (or to parents on their behalf). A more thorough understanding of these Salient Beliefs can guide the development of TPB construct measures for use with community mental health providers serving youth with SED and OW/OB. Results may also inform assessment and intervention strategies that reflect integration of mental and physical health for this population.

Methods

Design

Qualitative methods were employed to elicit Salient Beliefs regarding the provision of weight-related lifestyle advice to youth clients with SED and OW/OB (or to their parents on their behalf).

Sample

A group of community mental health providers who serve youth with SED was recruited for this study. All providers were recruited from mental health centers meeting the following criteria: (a) offer primarily mental health treatment (i.e., not primarily substance abuse treatment), (b) offer services to youth, and (c) provide internet-based contact options for a director, other administrative staff member, or general office. Inclusion criteria for providers were: (a) age 18 or older, (b) work as a mental health provider (e.g., licensed professional counselor, psychiatric nurse, clinical social worker, clinical psychologist, psychiatrist), (c) work in an eligible center serving youth clients with SED, and (d) provide informed consent.

Measures

Sociodemographics

A sociodemographic form was used to collect basic information about personal and professional characteristics of participating community mental health providers (e.g., age, occupation, years in practice).

TPB Salient Belief Elicitation Questionnaire

Using published guidelines (Ajzen 2006; Francis et al. 2004), a questionnaire comprising nine open-ended, qualitative questions addressing the three Salient Belief constructs (i.e., Behavioral Beliefs, Normative Beliefs, and Control Beliefs) was created for this study. Questions targeting Behavioral Beliefs addressed perceived advantages and disadvantages of engaging in the behavior; questions targeting Normative Beliefs addressed perceived normative referents (e.g., people who would approve or disapprove of engaging in the behavior); and questions targeting Control Beliefs addressed perceived factors that enable or prevent engagement in the behavior. Questions are included in Table 1.

Table 1.

Elicitation survey items

Item
1. What do you believe are the advantages of providing weight-related lifestyle advice to your youth [patients with SED who are overweight/obese (or to their parents on their behalf)]?
2. What do you believe are the disadvantages of providing weight-related lifestyle advice to your youth […]?
3. What else comes to mind when you think of providing weight-related lifestyle advice to your youth […]?
4. Please list individuals or groups who would approve or think you should provide weight-related lifestyle advice to your youth […]
5. Please list the individuals who would disapprove or think you should not provide weight-related lifestyle advice to your youth […]
6. Sometimes when we are not sure what to do, we look to see what others are doing. Please list the individuals or groups who are most likely to provide weight-related lifestyle advice to their youth […]
7. Please list the individuals or groups who are least likely to provide weight-related lifestyle advice to their youth […]
8. Please list any factors or circumstances that would make it easy or enable you to provide weight-related lifestyle advice to your youth […]
9. Please list any factors or circumstances that would make it difficult or prevent you from providing weight-related lifestyle advice to your youth […]
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Procedure

Recruitment and Data Collection

Recruitment was conducted using two methods. Participants were initially recruited through convenience sampling. A list of community mental health and substance abuse treatment centers in Colorado, Nevada, New Mexico, Utah, and Wyoming was available from a prior study of community mental health services in the Western states. These lists were reviewed to identify sites that met eligibility criteria, resulting in a total of 50 sites across Colorado (n = 9), Nevada (n = 4), New Mexico (n = 11), Utah (n = 11), and Wyoming (n = 15). The second recruitment approach utilized the National Council for Behavioral Health’s online provider list. The lists for Arizona, Washington, and Montana were reviewed for eligible centers. A total of 45 eligible sites were identified across Arizona (n = 28), Washington (n = 15), and Montana (n = 2). Data collection was limited to these states because several studies have shown regional differences in obesity, obesity screening, and health behaviors in both youth and adult samples (Le et al. 2014; Park et al. 2015; Stalter et al. 2011; Turner and Chaloupka 2012). Contact options for these sites included emailing center directors or other members of the administrative staff, or sending emails to general contact addresses. Each contact attempt comprised an email with a description of the study and a link to the online survey, with a request to forward the message to relevant providers associated with the site.

All measures were administered through an online survey-hosting service (i.e., Qualtrics 2015). Upon clicking the survey hyperlink, prospective participants were taken to a screening page to assess inclusion criteria. Those who did not meet inclusion criteria had their participation immediately terminated. Informed consent was obtained from all individual participants included in the study. Study measures were administered following receipt of informed consent. The survey took 10–15 min to complete and completers were automatically entered into a raffle for one of five $20 Amazon gift cards.

Data Analysis

Descriptive statistics (e.g., mean, percentage of sample) were employed to summarize sociodemographic characteristics. Per existing guidelines (Ajzen 2006; Francis et al. 2004), responses to the items addressing Salient Belief scales were evaluated using content analysis. Content analysis is a process for reducing a body of text into a set of key concepts, and typically includes two raters working together through four analysis steps (Elo and Kyngas 2008; Stemler 2001). Two raters (TW and KB) performed the content analysis.

Analysis of responses proceeded across four steps. In the first step, the raters individually reviewed participant responses for prominent and recurrent words and/or concepts and created categories of words and/or concepts based on similarities in meaning (i.e., content categories). In the second step, the raters compared their lists of content categories and reconciled discrepancies in the lists (including combining and/or renaming some categories). Next, the raters separately re-evaluated the text to identify all instances of responses that corresponded to the content categories on the agreed-upon list (i.e., the “coding” process). Finally, the raters separately created lists to indicate how many times each of the categories were referenced in the original text, and compared their results for reliability by tabulating how often they agreed in their coding of the text. The raters met to discuss and reconcile differences in coding, and an agreement rate of 100% was achieved. The number of times each content category was referenced in the text was taken as an indicator of how significant that category was in the data.

All study procedures were approved by the University of Wyoming Institutional Review Board. The authors do not have any conflicts of interest to disclose, and all authors accept responsibility for this manuscript.

Results

A total of 21 community mental health providers participated in this study. A majority was female, had a Master’s degree, and was employed as a Licensed Professional Counselor (LPC). Participants were located in Colorado (n = 7), Washington (n = 6), Arizona (n = 5), and Wyoming (n = 3). See Table 2 for a summary of participant sociodemographics. The content analysis resulted in a total of 242 separate words or phrases across 20 content categories. See Table 3.

Table 2.

Study sample characteristics (n = 21)

Characteristic M (SD) n (%)
Age 37.33 (11.02) –
Years in practice 8.16 (9.24) –
Female gender – 20 (95.24)
Primary role
 Licensed professional counselor – 11 (52.38)
 Social worker – 4 (19.05)
 Nurse – 2 (9.52)
 Psychologist – 1 (4.76)
 Marriage and family therapist – 2 (9.52)
 Psychiatrist – 1 (4.76)
Education level
 Master’s – 13 (61.90)
 Doctoral – 2 (9.52)
 Bachelor’s – 2 (9.52)
 Othera – 4 (19.05)
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a

Four participants provided information about their licensure rather than their education level: two nurses and two social workers

Table 3.

Content categories extracted through content analysis, with number of references (n = 21)

Construct and content category Number of
references		 Illustrative quote
Behavioral Beliefs 65 –
 Integrating physical and mental health 21 “Exercise improves overall mood and energy levels as well as positive self-thoughts.” [PP 19]
 Defensiveness/sensitivity 12 “Some clients find that they feel judged by the weight information.” [PP 6]
 Conveying knowledge to clients 11 “They will have the tools to live a physically and emotionally healthy life.” [PP 14]
 Overall lifestyle and health improvement 7 “Improved lifestyle.” [PP 3]
 Role of family 4 “Many families can’t afford healthier foods.” [PP 10]
 Alliance rupture 4 “Many persons get defensive about the topic of weight, so bringing this up might interfere with rapport so that the youth or parents might be discouraged about engaging in treatment for the SED…” [PP 9]
 Not my job, role, or setting 4 “I think it would be great but I believe in a community mental health setting most of my clients are struggling with bigger issues, such as low SES and the serious behavior problems are more immediate.” [PP 20]
 Therapist hypocritical 2 “I need to walk the walk if I am going to talk the talk.” [PP 8]
Normative beliefs 99
 Medical professionals 42 N/A
 School staff 21 N/A
 Mental health providers or staff 21 N/A
 Supervisors/administrators 6 N/A
 Government/national organizations 5 N/A
 Parents 4 N/A
Control beliefs 78
 Resources 29 “Evidence-based information to pass along or curriculum to address in group settings.” [PP 15]
 Knowledge and/or training 15 “Taking some type of training to learn about how to address these issues with youth patients.” [PP 4]
 Parental support or resistance 12 “Having consistency and support from the parents is always helpful.” [PP 6]
 Client cooperation or resistance 12 “When client identifies that they are unhappy with health or another lifestyle related concern.” [PP 17]
 Therapist lifestyle 5 “Discomfort w/ making health recommendations that I haven’t completely incorporated in my life.” [PP 16]
 Stability of client mental health 5 “When their mental health and behavior are under control then we can address these other issues.” [PP 5]
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Behavioral Beliefs

There were eight categories related to Behavioral Beliefs, with a total of 65 supporting words or phrases. The strongest category to emerge, with 21 separate references, was the Integration of Physical and Mental Health (as an advantage of providing weight-related lifestyle advice). Participants described the benefits of physical health on mental health and well-being. For example, responses included:

“Physical and mental/behavioral health are intimately related and influence one another in both directions.”

[Participant (PP) 9; Social Worker]

“Exercise improves overall mood and energy levels as well as positive self-thoughts.”

[PP 19; Marriage and Family Therapist]

The concern of clients exhibiting Defensiveness and Sensitivity in reaction to the clinician providing weight-related lifestyle advice was expressed, with 12 references identified in the content analysis. For example, responses included:

“Some parents may not like to hear the information being provided.”

[PP 4; Licensed Practical Nurse]

“Some clients find that they feel judged by the weight information.”

[PP 6; Licensed Professional Counselor]

“It may affect their self-esteem and self-confidence.”

[PP 14; Social Worker]

Four clinicians expressed concerns about the effects of addressing weight and healthy lifestyle on the therapeutic alliance (Alliance Rupture). For example, responses included:

“Many persons get defensive about the topic of weight, so bringing this up might interfere with rapport so that the youth or parents might be discouraged about engaging in treatment for the SED…”

[PP 9; Social Worker]

“Patients may feel stigmatized or shamed. Depending on how the issue is handled, it might disrupt the relationship or therapeutic alliance.”

[PP 8; Psychiatrist]

Another important concern, expressed by four providers, was that addressing weight and lifestyle advice may not be within the clinician’s scope of practice (Not my Job, Role, or Setting). For example, responses included:

“But I also find that focusing on weight is not helpful since clients are generally not seeking counseling for weight concerns.”

[PP 6; Licensed Professional Counselor]

“I think it would be great, but I believe in a community mental health setting most of my clients are struggling with bigger issues, such as low SES and the serious behavior problems are more immediate.”

[PP 20; Licensed Professional Counselor]

Normative Beliefs

There were six categories related to Normative Beliefs, with a total of 99 supporting words or phrases. The strongest category to emerge, with 42 separate references, was Medical Professionals (as a normative referent). Participants overwhelmingly viewed medical professionals as people who would approve of their engagement in the behavior. For example, responses included: “Primary care doctors” [PP 20; Licensed Professional Counselor], “Healthcare providers” [PP 2; Licensed Professional Counselor], and “Primary care/family physicians who want to coordinate care” [PP 9; Social Worker].

Another strongly endorsed category, with 21 references, was School Staff. Participants viewed school staff members as people who would approve of their engagement in the behavior. For example, responses included: “The schools” [PP 2; Licensed Professional Counselor], “Teachers” [PP 8; Psychiatrist], and “Educational sector” [PP 6; Licensed Professional Counselor]. The category of Mental Health Provider or Staff also had 21 separate references. For example, responses were identified such as “Other therapists” [PP 2; Licensed Professional Counselor], “Counselors” [PP 6; Licensed Professional Counselor], and “Psychiatrists” [PP 13; Social Worker].

Control Beliefs

There were six categories related to Control Beliefs, with a total of 78 supporting words or phrases. The strongest category to emerge, with 29 references, was Resources. This included responses describing Resources as a factor or circumstance that could either enable or prevent engaging in the behavior. Responses also included references to both provider resources and family resources. For example, responses included:

“Evidence-based information to pass along or curriculum to address in group settings.”

[PP 15; Licensed Professional Counselor]

“Having brochures and information on paper for patients to be able to take something home to refer to when needed.”

[PP 4; Registered Nurse]

“Economic means to live the lifestyle we are proposing.”

[PP 8; Psychiatrist]

Another prominent category, with 15 separate references, was Knowledge and Training.

For example, participants responded with contents such as “Taking some type of training to learn about how to address these issues with youth patients” [PP4; Registered Nurse], “Trainings regarding specific interventions or evidence-based therapy models” [PP 16; Licensed Professional Counselor], and “Lack of knowledge” [PP 14; Social Worker].

Two important, closely-related categories were Parental Support or Resistance, and Client Cooperation or Resistance. Both categories had 12 separate references. Thus, a total of 24 references related to support/cooperation or resistance as factors affecting engagement in the behavior. For example, responses for Parental Support or Resistance included content such as “Having consistency and support from the parents is always helpful” [PP 6; Licensed Professional Counselor], “Parents and family culture that are not open to changing the patterns within the family” [PP 5; Licensed Professional Counselor], and “Parent resistance” [PP 8; Psychiatrist]. Responses related to Client Cooperation or Resistance comprised content such as “When client identifies that they are unhappy with health or another lifestyle related concern” [PP 17; Licensed Professional Counselor], “If they make it clear up front they will not talk about it” [PP 21; Marriage and Family Therapist], and “Child resistance” [PP 8; Psychiatrist].

Discussion

This study was among the first, to our knowledge, to elicit mental healthcare providers’ salient beliefs regarding provision of weight-related advice to youth clients with SED and OW/OB. Given that obesity may be associated with a myriad of health complications (e.g., Halfon et al. 2013; Sanders et al. 2015) and that youth are likely to carry OW/OB into adulthood (Simmonds et al. 2016), it is particularly important to integrate overall health and wellness care for this high-risk population. Results of an open-ended questionnaire suggested that behavioral beliefs, normative beliefs, and control beliefs may impact community mental health providers’ intentions to provide weight-related lifestyle advice to their youth clients.

Several important behavioral beliefs were identified that would influence the provision of weight-related lifestyle advice. Mental health providers cited the integration of physical and mental health as an important advantage of providing this type of advice to their youth clients. Despite the espousal of possible benefits of physical health for mental health, providers described how concerns about client defensiveness and sensitivity to discussion about weight, alliance ruptures, and the belief that the provision of this type of care is beyond the scope of a mental health provider may impede the provision of healthy lifestyle advice. These findings are consistent with beliefs reported by community mental health providers serving adults with serious mental illness, such that community mental health providers frequently espoused the belief that weight-related concerns are better managed by other professionals with support for behavior change offered by mental health providers (McKibbin et al. 2014). These findings are also noted in recent descriptive analyses detailing the implementation of the SAMHSA Primary and Behavioral Care Integration (PBHCI) grants program. This program supported the integration of primary care services into community behavioral health settings for adults with serious mental illness (Scharf et al. 2013). Scharf and colleagues found that four of the grantees reported experiencing staff conflict related to the program and lack of staff buy-in. The present paper suggests some potential concerns which may hinder or help the achievement of staff buy-in.

Normative beliefs about those who would and would not support the role of a mental health provider in weight management were also elicited. Mental health providers identified medical professionals, school staff, and other mental health providers or staff as individuals whose beliefs are important. Support from medical providers may be particularly important, as the provision of weight-related advice from both medical and mental health providers is consistent with the SAMHSA recommendations for care integration (SAMHSA 2013). Furthermore, this may suggest a willingness to coordinate care with other professionals. Additionally, school staff and other providers (e.g., psychiatrists, counselors) were thought to be supportive of efforts of mental health providers to engage in weight-related intervention with youth clients with SED and OW/OB. In their review of obesity in Canadian youth, Ball and MacCargar (2003) emphasized the importance of the collaboration of professionals from multiple system levels (e.g., community, school, family) for the prevention of overweight and/or obesity. Therefore, the perception of community mental health providers that supportive others exist in multiple settings may increase the integration of care for youth with SED and OW/OB.

Finally, control beliefs were elicited that could both inhibit or encourage engagement in the provision of weight-related lifestyle advice. The most prominent control beliefs elicited were related to the resources available to providers and families of youth with SED and OW/OB. For example, providers identified a need for evidence-based resources related to weight management techniques to engage in this type of service provision. However, few healthy lifestyle programs targeted to the unique needs of this population exist (see Nicol et al. 2016b for a modified family-based obesity intervention for youth prescribed antipsychotic medication). Providers also described the importance of obtaining training and/or education on how to provide weight-related advice to and/or implement weight management interventions with their clients. Surprisingly, this finding is not unique to mental health providers, but rather is consistent with barriers to obesity management experienced by pediatric primary care providers (Findholt et al. 2013; Spivack et al. 2010). To meet the need for resources and education related to obesity management, mental health providers may benefit from evidence-based resources for traditional weight-related interventions for youth with OW/OB as well as specific training on how to adapt these materials for youth with SED and OW/OB.

The resources available to the families of youth clients were also identified as potential barriers or facilitators to weight management for this population. For example, providers identified the necessity of families to have the economic resources to implement advice to live a healthier lifestyle. This is consistent with prior research showing that families of youth with SED and mental health providers who care for this population identify economic resources as important factors for engagement in healthy lifestyle behaviors, such as consuming fruits and vegetables (Bourassa et al. 2016). Therefore, providers should be aware of the resources available to their clients and assist them in obtaining the resources necessary to enact the recommended lifestyle modifications. Finally, providers noted that support and engagement from the client and/or the client’s family served as a facilitator to incorporating weight management practices into mental health treatment. This is consistent with motivational barriers to obesity management described by primary care providers who serve youth clients without SED (Findholt et al. 2013; Spivack et al. 2010). To illustrate further, a survey study of barriers to and preferences for weight-loss treatment for youth prescribed antipsychotic medication found that while most caregivers reported moderate to high levels of motivation for weight-management services, few engaged in these services when offered (Nicol et al. 2016a). As the need for parental involvement in healthy lifestyle interventions for youth with SED may be greater than in interventions for youth without SED, increasing parental motivation for and adherence to interventions may be necessary to improve outcomes for this population.

Little is known about the role of mental health providers in healthy lifestyle interventions, as illustrated by a recent literature review on behavioral interventions for adults with OB. In their review, Prost et al. (2016) reported that little information regarding the impact of interventionist background on health outcomes is provided in randomized controlled trials of behavioral interventions for this population. The findings of the current study fill a gap in the literature by beginning to elucidate the perceived role of community mental health providers in the weight management of their clients with SED and OW/OB. Furthermore, these results suggest that improving the overall health and wellness of youth with SED and OW/OB requires education and intervention at the provider, family, and individual levels.

Limitations

The findings of this study should be interpreted within the context of its limitations. First, this study consisted of a small sample of community mental health providers in the Western United States, and therefore, may not generalize to providers in other parts of the country or other healthcare settings. Additionally, most respondents were female and Licensed Professional Counselors, and the beliefs that influence provision of weight-related advice to youth clients may differ across types of mental health providers. Furthermore, the limited number of participants in disciplines other than Licensed Professional Counseling precluded our ability to analyze discipline-specific responses to providing weight-related advice to youth clients with SED. Second, as suggested by Khanna et al. (2009), providers’ intentions to address a problem of interest (e.g., OW/OB in the current study) may be impacted by the prevalence of that problem in their geographical area. The rates of OW/OB in each participating state were not considered in this study, and may represent an additional limitation. Third, the true response rates to the survey, as well as the demographic characteristics of the non-responders, are unknown. As the survey link was provided to a main contact at community mental health centers for further distribution to providers, and as the survey platform did not allow for collection of information related to the number of survey views regardless of completion, the overall response rate was unable to be calculated. Therefore, differences among completers and non-completers cannot be determined. Finally, although this study may contribute to a better understanding of the decision-making process of providers of youth with SED and OW/OB, it is limited in its ability to predict the actual engagement of these providers in the behavior of providing weight-related advice. While beliefs elicited in this study contribute to understanding of the cognitive constructs that inform Behavioral Intentions, additional complexities arise regarding the translation of Behavioral Intentions to Engagement in the Behavior. For example, within the TPB, Perceived Behavioral Control is not only related to Behavioral Intention, but may also be related to Engagement in the Behavior independently of the Behavioral Intention (Ajzen 1991). Contingent on contextual factors and the accuracy of control beliefs, providers’ Perceived Behavioral Control regarding the provision of weight-related advice to youth with SED may play a more direct role in actually carrying out this behavior, beyond what is explored by this study.

Future Work

This study makes important contributions to the literature on provider decision-making. The findings have implications for modeling the factors that influence intention to provide weight-related lifestyle advice and may assist in the development of strategies to modify provider beliefs to improve the overall health and wellness of youth with SED and OW/OB. Nicol et al. (2016a) reported that families who were referred for weight-loss treatment by a provider were more likely to engage in these services than families who were not referred by a provider. While it may be beneficial for providers to encourage participation in and/or provide healthy lifestyle interventions, the results of this study suggest it is important to understand the beliefs that lead to the provision of weight-related lifestyle advice. Furthermore, results suggest that it is necessary to develop more targeted education and training opportunities for providers themselves. Prior research suggests that completion of training in the provision of health-related counseling may be associated with provider behavior when treating adults and youth with serious mental illness (Chwastiak et al. 2013; Hetrick et al. 2010). For instance, Hetrick and colleagues developed a tailored intervention framework to address psychiatrists’ barriers to metabolic monitoring in a first-episode psychosis clinic (Hetrick et al. 2010). Many of the barriers to metabolic monitoring included providers’ beliefs about the consequences, as well as the necessity and client capability of monitoring (Hetrick et al. 2010); therefore, eliciting the beliefs unique to the provision of weight-related advice in a community mental health context could inform the development of appropriate and targeted programming for community mental health providers who serve youth with SED. Future work is also needed to elucidate the beliefs of specific types of community mental health providers (e.g., psychiatrists) regarding their involvement in weight management, as their clinical roles may be more or less conducive to engaging in this type of service provision. While the psychiatrist included in our study did identify advantages of providing structured weight-related lifestyle advice to patients and their families, this same provider also identified common concerns of relationship rupture, should the topic not be approached with sensitivity. Additionally, some research suggests that provider characteristics may be associated with the provision of health-related counseling to clients with mental illness (e.g., Chwastiak et al. 2013). While not assessed in this study, it may be important to assess personal characteristics of providers in addition to attitudes. Future work should also seek to understand the contexts in which Perceived Behavioral Control may or may not be independently associated with actual engagement in the provision of weight-related advice. Moreover, elicitation of important beliefs impacting this desired behavior can assist in the development of a formal, theory-based measure to assess the impact of salient beliefs on the provision of weight-related lifestyle advice by community mental health providers. Future work should be done to develop and test the psychometric properties of such a measure to examine TPB constructs as well as examine the role of TPB constructs in predicting behavioral intention. Eliciting and targeting providers’ beliefs related to the provision of weight-related advice to clients with SED and OW/OB may be a foundational step to designing more targeted and acceptable healthy lifestyle interventions for this unique population.

Footnotes

Conflict of interest The authors declare that they have no conflict of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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