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RESEARCH ARTICLE Open Access

Cultural adaptation of a children’s weightmanagement programme: Child weigHtmANaGement for Ethnically diversecommunities (CHANGE) studyMiranda Pallan1, Tania Griffin2* , Kiya Hurley1, Emma Lancashire1, Jacqueline Blissett3, Emma Frew1, Paramjit Gill4,Laura Griffith5, Kate Jolly1, Eleanor McGee6, Jayne Parry1, Janice L. Thompson7 and Peymane Adab1

Abstract

Background: Childhood obesity prevalence continues to be at high levels in the United Kingdom (UK). South Asianchildren (mainly Pakistani and Bangladeshi origin) with excess adiposity are at particular risk from the cardiovascularconsequences of obesity. Many community-based children’s weight management programmes have beendelivered in the UK, but none have been adapted for diverse cultural communities. The aim of the Child weigHtmANaGement for Ethnically diverse communities (CHANGE) study, was to culturally adapt an existing children’sweight management programme for children aged 4–11 years so that the programme was more able to meet theneeds of families from South Asian communities.

Methods: The adaptation process was applied to First Steps, an evidence informed programme being delivered inBirmingham (a large, ethnically diverse city). A qualitative study was undertaken to obtain the views of South Asianparents of children with excess weight, who had fully or partially attended, or who had initially agreed but thendeclined to attend the First Steps programme. The resulting data were integrated with current research evidence andlocal programme information as part of a cultural adaptation process that was guided by two theoretical frameworks.

Results: Interviews or focus groups with 31 parents in their preferred languages were undertaken. Themes arising fromthe data included the need for convenient timing of a programme in a close familiar location, support for those whodo not speak English, the need to focus on health rather than weight, nutritional content that focuses on traditionaland Western diets, more physical activity content, and support with parenting skills. The data were mapped to theBehaviour Change Wheel framework and Typology of Cultural Adaptation to develop an intervention programmeoutline. The research evidence and local programme information was then used in the detailed planning of theprogramme sessions.

Conclusions: The process of cultural adaptation of an existing children’s weight management programme resulted ina theoretically underpinned programme that is culturally adapted at both the surface and deep structural levels.

Trial registration: ISRCTN81798055, registered: 13/05/2014.

Keywords: Childhood, Overweight, Obesity, Weight management, Ethnicity, UK

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: [email protected] for Health, University of Bath, University of Bath, Bath BA2 7AY,UKFull list of author information is available at the end of the article

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BackgroundChildhood obesity is an ongoing public health problemin the United Kingdom (UK) with 20% of children aged11 years experiencing obesity [1]. South Asian childrenin the UK experience even higher obesity levels (26 and28% in 11 year old Pakistani and Bangladeshi childrenrespectively [2]), and are more vulnerable to the cardio-vascular consequences of adiposity both in childhood [3]and adulthood [4]. The last few decades have seen an ex-ponential increase in childhood obesity, and alongsidethis, a number of behavioural programmes to assist chil-dren and families in managing their weight have beendeveloped. More intensive, hospital clinic-based pro-grammes have been offered for children with severeobesity, but in the UK, there has also been a focus onthe development of community-based weight manage-ment programmes for children and their families, aimedat children with excess weight [5].Systematic reviews and meta-analyses indicate that

community-based weight management programmes forchildren result in a modest reduction in Body MassIndex (BMI) z-score (approximately 0.1 units 6 monthspost-intervention) [5, 6]. There is evidence that evenvery small reductions in BMI z-score can lead to lowercardiometabolic risk [7]. In the preadolescent age group,interventions that address both diet and physical activity,include behavioural elements, and involve parents havebeen shown to be the most promising [6, 8, 9].Cultural adaptation is the process of developing inter-

ventions, based on pre-existing programmes and mate-rials, that conform with the characteristics of thespecified cultural communities [10]. There are fewexamples of cultural adaptation of children’s weightmanagement programmes. Two USA-based RandomisedControlled Trials (RCT) which evaluated culturallyadapted interventions, one targeting Chinese Americanchildren aged 8–10 years [11] and the other a mixedpopulation of Hispanic, Black and White children aged8–16 years [12], have reported small to moderate sus-tained reductions in BMI z-score in the interventioncompared with the control groups. In the UK, one smallRCT (n = 72) has been undertaken to evaluate the effective-ness of a family-based behavioural treatment programme,developed in the USA, targeting children with obesity in anethnically and socioeconomically diverse community. Theprogramme was not culturally adapted and did not have asignificant effect on weight [13]. No culturally adaptedinterventions have previously been evaluated in the UK.Theoretical approaches have been lacking concerning

the process of cultural adaptation of both children’sweight management and health promotion programmesin general [14]. A theory-based approach to culturaladaptation of health promotion programmes is required,and the success of these adapted programmes needs to

be evaluated by directly comparing adapted with stand-ard programmes [15]. Retention of families in weightmanagement programmes is important, as evidence sug-gests that better programme attendance leads to moreweight loss [16]. Lower retention has been associatedwith certain programme characteristics (e.g. large groupsizes [17]) but is also more common among childrenfrom certain minority ethnic families [18, 19], thusfurther highlighting the need for cultural adaptation ofthese programmes so that they better meet the needs ofa wider range of families.The aim of the first phase of the Child weigHt mAN-

aGement for Ethnically diverse communities (CHANGE)study, was to culturally adapt a community weight man-agement programme for primary school aged children.The programme selected to be adapted was a locally devel-oped programme, incorporating elements of evidence-based child weight management programmes and takinginto account the characteristics of the local population.Routine attendance data from this programme showedthat it had poorer retention rates for children and familiesfrom Pakistani and Bangladeshi communities. Therefore,the purpose of the adaptation was to better meet the needsof families from Pakistani and Bangladeshi communi-ties, thereby increasing their retention rates within theprogramme. This paper reports the process of culturaladaptation and the resulting adapted programme.Participant acceptability of and retention in the adaptedprogramme has been evaluated in a subsequent feasibil-ity study, which has been reported separately [20].

MethodsSettingThe study took place in Birmingham, the second largestUK city with a population of 1.1 million. Forty-twopercent of all residents are from minority ethnic com-munities. Pakistani and Bangladeshi children comprise26% of the Birmingham population aged 0–15 years [21].At the time of the study a group-based child weightmanagement programme, First Steps, was availableacross the city. The programme was delivered as weeklyone-hour sessions over 5–7 weeks in community venues,covering nutrition education, physical activity promotionand the promotion of positive lifestyle behaviour changes.The programme was aimed at parents/carers; childrenattended only the first and last sessions to have theirheights and weights measured. All families resident inBirmingham with a child aged 4–11 years with excessweight (BMI over the 91st centile of the UK 1990 growthreference charts [22]) and able to participate in a group set-ting were eligible to attend the programme. Children couldbe referred to the programme by a health professional, thechild’s school, or families could self-refer. Children identi-fied as having excess weight through the National Child

Pallan et al. BMC Public Health (2019) 19:848 of 21

Measurement Programme (a surveillance programme toprovide data on weight indicators in primary school-agedchildren) were also referred to the programme.

Programme selected for adaptationFirst Steps was a children’s weight management programmedeveloped by the service providers, based on their previousexperience of delivering evidence-based programmes[23, 24], and tailored for the local population. GivenBirmingham’s cultural diversity, there was a focus onparental engagement with access to interpreters, andprogramme material had a high pictorial content andreferred to culturally appropriate foods. Despite this, Paki-stani and Bangladeshi families who started the programmewere less likely to complete it than families of other ethnici-ties (40% of Pakistani and Bangladeshi families completed itcompared with 65% of families from other ethnic groups).Data collected routinely at the first and last sessions indi-cated that children achieved an average reduction in BMIz-score of 0.1 at programme end. This is in line with re-ported differences in BMI z-scores between interventionand control groups in randomised controlled trials of be-havioural child weight management programmes [6]. Giventhe existing tailoring to the local population and evidenceof effect on children’s weight, the programme provided agood foundation on which to develop a further culturallyadapted programme, with the particular intention ofincreasing retention of families from Pakistani andBangladeshi communities in the programme.

Study designThe theoretical and modelling stages of the UK MedicalResearch Council (MRC) framework for the develop-ment and evaluation of complex health interventions[25, 26] guided the cultural adaptation process. Theadaptation process was informed by three main informa-tion sources: 1) data from a qualitative study exploringthe experiences and viewpoints of Pakistani and Bangla-deshi families who had participated in or who had ini-tially agreed but then declined to participate in the FirstSteps programme; 2) local information from the FirstSteps programme providers; and 3) existing children’sweight management literature. Two specific theoreticalframeworks were used in parallel in the adaptationprocess: a framework for the development of behaviourchange interventions, and a programme theory andadaptation typology to guide the adaptation of healthpromotion programmes for minority ethnic groups[15, 27]. An advisory panel comprising Pakistani andBangladeshi parents of primary school-aged childrenalso provided advice during the adaptation process. Ethicalapproval was received from the Edgbaston Local ResearchEthics Committee in July 2014 (14/WM/1036).

Qualitative study with Pakistani and Bangladeshi parentsCommunity Researchers from Pakistani and Bangladeshicommunities in Birmingham with qualitative researchexperience (AA; female and of Pakistani heritage, andMB and SK; both female and of Bangladeshi heritage)were recruited to assist the core research team (TG(research fellow in Public Health with mixed methodsresearch experience) and LG (lecturer in healthcare anthro-pology with extensive qualitative research experience); bothfemale and of white British heritage) in undertaking thisqualitative data collection. The Community Researchers didnot have pre-existing relationships with participants prior tothe study, but were able to communicate in Urdu, Bengalior Sylheti where necessary, and understand the culturalcontext of participating families.The First Steps programme provider (Birmingham

Community Healthcare NHS Trust) identified all Paki-stani and Bangladeshi families who had been invited totake part in the programme from September 2013 toJuly 2014. The families were categorised into either: (i)attended 60% or more of the First Steps programme(‘completers’); (ii) started the First Steps programme butattended less than 60% (‘non-completers’); or (iii) didnot attend the programme (‘non-attenders’). Parentsfrom completing families were invited to participate in afocus group (FG) at a community venue. FGs were thepreferred method of data collection as they explicitly usegroup interaction as a way of stimulating discussion[28]. However, we recognised that parents from non-attending and non-completing families may find itchallenging to attend a FG, and so they were invited toparticipate in a one-to-one interview, which gave greaterflexibility for them in terms of the timing and venue ofthe interview. Face to face interviews were preferred buttelephone interviews were offered if this was not possible.We aimed to recruit 15 ‘non-completers’ and 15 ‘non-at-tenders’ to participate in interviews, and to hold 3–5 FGswith ‘completers’, with a contingency of recruiting moreparticipants if data saturation was not felt to be achieved.All participants received a £10 shopping voucher follow-ing successful completion of the interview/FG.Parents were initially contacted by telephone and a

participant information pack was posted to those whoexpressed an interest in study participation. A furthertelephone call was made and if the parent agreed to par-ticipate, an interview or attendance at a FG was arranged.Parents who did not speak English were telephoned by aCommunity Researcher in their preferred language.Interviews took place in the participant’s home and

FGs at a convenient community location. Participantsgave written informed consent and completed a shortquestionnaire before the interview or FG commenced.The interviews and FGs were conducted either by a coreresearcher or Community researcher in the participant’s


preferred language. An additional researcher was presentas an observer at the FGs. Semi-structured interviewand focus group schedules, informed by literature andinput from the study Parent Advisory Panel, were usedto guide discussions. The research questions that wereexplored are shown in Table 1. Interviews and FGs wereaudio-recorded and transcribed. Community researcherstranslated and transcribed interviews and FGs that werenot conducted in English. A sample of translated tran-scripts was checked using the audio-recording by an in-dependent researcher with the relevant language skills.Data analysis was conducted using NVivo 10 (QSR

International Pty Ltd. Version 10, 2012) and was guidedby thematic analysis approaches [29]. Two researchers(TG and LG) reviewed 50% each of the transcripts inde-pendently and identified codes to apply to the data. Theresearchers discussed their coding and agreed on a finalcoding framework, which they then applied to all tran-scripts. Overarching themes were identified, which in-cluded commonalities and differences between the threeparticipant groups.

Information from the existing children’s weightmanagement serviceDirect observation of the First Steps children’s weightmanagement programme was undertaken by a re-searcher (TG) to assess structure, content, delivery andparticipant response. In addition, a series of consulta-tions were undertaken with the two service managersover a period of 3 months to enable an understanding ofthe existing infrastructure and processes. The managerswere also asked to identify any issues with the existingprogramme from their perspective.

Review of children’s weight management literatureA comprehensive guideline on managing overweight andobesity in children was published in 2013 by the UK Na-tional Institute for Health and Care Excellence (NICE)

[5]. Two evidence reviews were undertaken to supportdevelopment of this guideline, focusing on: 1) the effect-iveness and cost-effectiveness of interventions to managechildren’s weight [30]; and 2) the barriers and facilitatorsto implementing weight management programmes forchildren [31]. In addition a systematic review of behav-iour change techniques that are effective in influencingobesity-related behaviours in children was published in2013 [32]. These reviews, together with more recentevidence on effective children’s obesity interventions,informed the planning of the adapted programme to en-sure that it was coherent with established evidence.

Cultural adaptation processThe adaptation process was guided in parallel by two theor-etical frameworks: The Behaviour Change Wheel (BCW)by Michie et al. [27, 33] and the Typology of Cultural Adap-tation and Programme Theory of health promotion inter-ventions by Liu et al [15]. The BCW has been developedfrom 19 behaviour change frameworks and was used to en-sure the target behaviours, pathways to change, and adapta-tions made to address these were clearly articulated. Threetarget behaviours requiring change were identified; the firstwas programme attendance and the other two were behav-iours that directly influence weight (dietary intake andphysical activity). The capability, opportunity, motivationand behaviour (COM-B) model at the centre of the BCWenabled us to gain a theoretical understanding of the factorspreventing Pakistani and Bangladeshi families from adopt-ing the desired behaviours. This was achieved through themapping of qualitative data from parents onto the differentelements of the COM-B model (physical and psychologicalcapability, physical and social opportunity, and reflectiveand automatic motivation). From this understanding of thefactors influencing the target behaviours identified forchange we were able to select the relevant interventionfunctions (categories of mechanisms by which interventionsmay have their effects) from the nine outlined in the BCWthat correspond to elements of the COM-B model. This in-formed the detailed intervention planning.The second framework, the Typology of Cultural Adapta-

tion and Programme Theory proposed by Liu et al. [15], en-sured that appropriate cultural adaptations were consideredfor inclusion in the adapted intervention across all aspectsof the programme and at all stages of the programme cycle(i.e. conception/planning, promotion, recruitment, imple-mentation, retention, evaluation, outcome, and dissemin-ation). The 46-item typology has been constructed from asystematic review of health promotion programmes target-ing smoking, diet and physical activity, which have beenadapted for minority ethnic groups. The typology was usedto identify the most appropriate type of cultural adaptationsto address the themes identified in the qualitative data ob-tained from Pakistani and Bangladeshi parents.

Table 1 Research questions explored in phase 1 interviews andfocus groups with Pakistani and Bangladeshi parents ofoverweight and obese children

Research question

What are the participants’ experiences of the First Steps programme?

What are the barriers and facilitators to participating in and completingthe programme?

Which aspects of the structure, content and delivery of the programmeare perceived as problems?

What aspects of the structure, content and delivery of the programmeare valued?

What information, content or format would increase the appeal of theprogramme?

What might need to change about the current programme to ensureits cultural relevance?


Detailed intervention planningThe identified BCW intervention functions and thetypes of cultural adaptation provided the outline for thedetailed planning of the adapted programme. The localinformation from direct observation and the service pro-viders, and the relevant literature were used to furtherinform the process. Consideration was also given to theflexibility of programme delivery to ensure suitability forchildren of different ages. The planning process was it-erative to ensure that the final programme design wascoherent with: a) the identified intervention functionsand adaptation types; b) the qualitative data; c) local ser-vice information; and d) the children’s weight manage-ment literature. Figure 1 summarises the interventionadaptation methodology.

ResultsFindings from qualitative study with Pakistani andBangladeshi parentsIn total, 31 parents/carers participated in interviews and 12participated in FGs. All participants were Muslim, 36(84%) were Pakistani and 37 (86%) were female. Twenty-one participants were ‘non-attenders’, 9 were ‘non-com-pleters’ and 13 were ‘completers’. Participant characteristicsare shown in Table 2.Of the 31 interviews, 27 were conducted face to face

and 4 by telephone. Six interviews were in Urdu and 3in Bengali. Length of interviews ranged from 15 to 47min (average: 28 min). Once interviewees seemed tohave no further comments, interviews were drawn to aclose. Four FGs were completed. A further 3 were ar-ranged but no participants attended. Two of the FGswere attended by 4 participants with the remainder hav-ing 2 participants. Two FGs were conducted in Urdu.The FG length ranged from 35 to 50min.

Several themes emerged from the data. There was co-herence across the three groups on several themes, butsome themes were more prominent in some groups thanothers. Important logistical barriers to attending a familycommunity weight management programme were raisedby all participants. The majority of families reported thatto attend the programme it would need to be in a close,familiar location at a convenient time. Some parentswere concerned about children missing school and iden-tified weekends as the most convenient time to attend,whilst others felt that children could take time out ofschool to attend. In contrast, after school sessions werecommonly considered to be impractical due to many ofthe children attending religious classes at their localmosque at this time. This practice was also raised as abarrier to finding time for being physically active. Caringfor younger siblings was cited as a barrier to attending bysome parents, although it was also observed that youngersiblings were often brought along to the sessions. Lan-guage barriers to participation existed for some parentsfrom Pakistani and Bangladeshi communities who did notspeak English. These were highlighted as a problem bysome non-attenders at the initial recruitment stage. Onceparticipants attended the programme, language barrierswere less of an issue, particularly if interpreters werepresent (all participants were asked whether they requiredan interpreter prior to commencing the programme).Several English speaking participants discussed supportingother parents in the group who were struggling tounderstand.The focus of the programme being on weight and obes-

ity, rather than a positive focus on health was also a bar-rier. Some parents, particularly those who had notattended or completed the programme, considered thattheir child did not have a weight problem, or felt that theycould not do anything to address their child’s weight.

Fig. 1 Process of cultural adaptation of a child weight management programme


These families engaged less with the programme as itsfocus was on weight loss. However, data from these par-ents indicated that they recognised the value of healthylifestyles and wanted to encourage their children to adopthealthy behaviours. Some parents who did not attend orcomplete the programme also highlighted that childrenwere sensitive about attending for “weigh ins”.Another group of important themes related to the tar-

get audience, content and delivery of the programme.Most parents felt that a programme involving childrenin all the sessions would be of more value, as they feltthat children need to learn how to change their behav-iour first hand, and would respond more positively tomessages relating to behaviour change if they were givenby someone other than their parents. Interactivity withinthe programme was highlighted as important. Complet-ing participants spoke of the value of the interactive ele-ments of the programme. However, non-completingparticipants perceived that there was little interactivecontent and disliked the ‘classroom’ format of sessions.They also reported that they disliked receiving a highvolume of written information. Many of the participants

expressed that there needed to be much more physicalactivity content in the programme, particularly gettingthe children to participate in physical activities duringthe sessions. They identified a range of barriers to phys-ical activities in their daily lives which they thoughtshould be addressed through the sessions. The groupsetting and the ability to share ideas and experiencesamongst attending families was highly valued by manyparticipants who had attended the programme. Someparticipants who had not attended or completed theprogramme felt that they were not going to gain any-thing new from it, and that they already had a good ideawhat was ‘good’ and ‘bad’ for their children, particularlyin terms of their diet. This viewpoint differed in severalof the completing participants, who felt they had gainednew nutritional knowledge, and also advice on how toapply this in their daily lives. Although the First Stepsprogramme included references to South Asian foods,some parents felt that the nutritional content could bemade more relevant to their traditional diets, whilstother participants acknowledged the importance of alsotalking about Western foods, as their children’s diets

Table 2 Demographic characteristics of the 43 parents participating in the study

Completers Non-completers Non-attenders All participants

(n = 13) (n = 9) (n = 21) (n = 43)

Sex, n (%)

Male 3 (23.1) 2 (22.2) 1 (4.8) 6 (14.0)

Female 10 (76.9) 7 (77.8) 20 (95.2) 37 (86.0)

Age of child a, median (IQR) 11.0 (2.0) 11.5 (3.0) 11.0 (6.0) 11.0 (3.0)

Sex of child referred to the programme (n)a

Male 7 5 8 20

Female 7 5 14 26

Relationship to the child, n (%)

Mother 10 (76.9) 7 (77.8) 20 (95.2) 37 (86.0)

Father 3 (23.1) 2 (22.2) 1 (4.8) 6 (14.0)

Ethnicity, n (%)

Pakistani 12 (92.3) 8 (88.9) 16 (76.2) 36 (83.7)

Bangladeshi 1 (7.7) 1 (11.1) 5 (23.8) 7 (16.3)

Referral method, n (%b)

Doctor 0 (0.0) 2 (22.2) 1 (4.8) 3 (7.0)

School Nurse 2 (15.4) 0 (0.0) 3 (14.3) 5 (11.6)

NCMP 9 (69.2) 4 (44.4) 12 (57.1) 25 (58.1)

Hospital/dietician referral 1 (7.7) 1 (11.1) 2 (9.5) 4 (9.3)

Leaflet/self-referral 1 (7.7) 2 (22.2) 3 (14.3) 6 (14.0)

Method of discussion, n (%)

Interview 1 (7.7) 9 (100.0) 21 (100.0) 31 (72.1)

Focus group 12 (92.3) 0 (0.0) 0 (0.0) 12 (27.9)a1 completer, 1 non-completer, and 1 non-attender had two children who attended or were referred to the programmebPercentages may not sum to 100 due to rounding


encompassed both traditional and Western foods. Therewere mixed views regarding the cooking methods of trad-itional foods; some participants felt there was opportunityto learn about healthier cooking methods (e.g. using lessoil), but others felt that they would not change their cook-ing methods. There was also concern about children’s in-take of ‘junk’ foods, which they felt needed to beaddressed. Finally, several parents who had attended partor all of the programme expressed difficulty in ensuringtheir children adhered to the changes that they instigatedat home, especially in relation to food, and therefore, theyfelt they needed help with overcoming this issue.Apart from dietary and language factors and the time

spent attending religious classes, no other emergingthemes related explicitly to Pakistani and Bangladeshiculture. The more prominent issues identified in thedata were the difficulties and competing priorities whichfamilies had to face in their daily lives (e.g. juggling de-mands of siblings, busy family lives, and perceived safetyissues in local communities), and the impact of these onthe ability to undertake healthy behaviours. The emer-gent themes and examples of data to illustrate thesethemes are shown in Table 3.

Findings from review of children’s weight managementevidenceThe UK NICE guideline on managing overweight in chil-dren and young people (PH47) [5], published in 2013, pre-sented several evidence-based recommendations regardingchildren’s weight management service provision. The rec-ommendations were taken into consideration during thedetailed planning phase of programme adaptation to en-sure that the finalised programme was consistent with theguideline (see Table 4). The guideline, along with otherrelevant literature [5, 34], emphasised the importance ofparental involvement in child weight management pro-grammes, and the need for elements that address both dietand physical activity [35, 36]. Therefore, these importantaspects were included in the adapted programme. The be-haviour change techniques that have been identified as ef-fective in obesity interventions for children [32] (provisionof information on the consequences of behaviour to the in-dividual; environmental restructuring; prompting practice;prompting identification of role models or advocates; stressmanagement/emotional control training; and general com-munication skills training) were also considered for inclu-sion in the adapted programme.

Findings from the existing first steps programmeobservation and consultation with the managing staffA researcher (TG) observed two programmes, deliveredby different facilitators (all sessions of one programmeand two sessions of the other programme). Observationsbroadly concurred with the qualitative data. Particularly

evident were: the lack of interactive activities for partici-pants; the large volume of written information handedout; and the heavy focus on nutritional knowledge, withless emphasis on skills around food preparation and feed-ing practices, and little physical activity content. Goal set-ting was incorporated in the programme sessions but wasnot always well implemented. The programme managersalso identified that the didactic delivery and volume ofwritten information were problematic.

Application of the behaviour change wheel and culturaladaptation theoryThrough the mapping of the COM-B elements to thequalitative data, the intervention functions of enable-ment and education were identified as appropriate to ad-dress all target behaviours. Environmental restructuring,persuasion and incentivisation were identified as func-tions to address programme attendance, and trainingwas identified as a function to address physical activityand healthy eating. Modelling was also identified as away to address the physical activity behavioural target.From the parallel process of mapping the 46-item cultural

adaptation typology [15] to the qualitative themes, severaltypes of cultural adaptation and the stages at which theycould be applied in the programme cycle were identified.This process ensured that there was explicit considerationof how adaptations to the programme were culturally ap-propriate to the target population. The qualitative themes,mapped COM-B components, intervention functions, cul-tural adaptations and programme cycle stage, and corre-sponding NICE guideline recommendations are presentedin Table 4.

Detailed planning of the culturally adapted programmeFollowing application of the two guiding frameworks tothe qualitative data, specific adaptations were planned bytwo members of the research team (TG and MP). Thisplanning was also informed by the research evidenceand local programme information. Further consultationwith the programme managers took place at this pointso that they could comment on the feasibility of deliveryof the planned programme. The specific adaptations areoutlined in the right-hand column of Table 4. To furtherillustrate how the adaptation process was undertaken, anexample of the process is given in Additional file 1. Whenthe adaptation process was completed, the planned inter-vention programme was presented to the Parent AdvisoryPanel for feedback.

Final intervention designA summary of modifications made as a result of theadaptation process is provided below. The adapted inter-vention programme is reported in more detail using the


Table 3 Themes emerging from the interviews and focus groups with Pakistani and Bangladeshi parents, and quotes to illustratethe themes

Themes Completers Non-completers Non-attenders

Logistical issues with programme attendance

Close location If it’s closer, then it’s better becauseit saves time; because sometimeswe have to collect the children,and both mother and fatherneeded to attend, so we bothwent. (FG3 (conducted in Urdu),P2, male, Pakistani)

Well, it shouldn’t be too far away, it’sbetter if it’s closer because sometimesthe car isn’t available and then I couldwalk too. (154, female, Pakistani(interview conducted in Urdu))The reason why I couldn’t make it isbecause I’m not driving, so having totravel to the place and then comingback with another small child, atthe time I think she was a baby,was really difficult for me… It wasjust that really, I really want to goas well (144, female, Pakistani)

Familiar venue I think if you go through theschool it’s better. Everybodyhas to take their children toschool. So if in the morningwhen they’ve gone to schoolto drop their child off or inthe afternoon if the teacherscome forward and talk to theparents then like ‘this is what’shappening and if you wouldlike to attend’ maybe theywould be, because everybodytakes their kids to school andthat would be a good way ofcatching them. (FG1, P3, female,Bangladeshi)

Programme timing I think that it’s about timingbecause some people have youngchildren and others are older sothey need to pick them up fromschool, others are in college sothey need to collect them, so Ithink it’s about timing. (FG3(conducted in Urdu), P1,female, Pakistani)

…the timing and, you know, it’snot – and town is like, you know,busy and…so…especially after 4.It’s really hard. They have, like, theirown activity. Mosque and everything.Tuition. This and that. So that’s whyI couldn’t (133, female, Pakistani)Weekends, because after school theygo to school and Mosque, all Muslims,even Indian or Bengali or Pakistani,every Asian, children attends Mosqueafter school (139, female, Pakistani)

Programme in schooltime

Well, you know this weekend,it would be better, the childrenwould be home and you couldtake them instead of missingthem and they’re taking timeoff from school. (FG1, P1,female, Pakistani)

I’m sure if it’s a school day, theschool would give him an houror so just to go into, it’s regardinghealth isn’t it, so I’m sure schoolwould allow him to go for an houror do the programme in the weekendlike Saturday/Sunday. (129, male,Bangladeshi)

I was upset because I couldn’t go. Icouldn’t have the time, I couldn’t takemy – especially with schools now wherethey’re strict on the children, you know,attending school and not missing days.So it was hard for me. (104, female,Pakistani)

Siblings I didn’t have younger childrenbut other families had youngchildren with them. And theysat too, it wasn’t that theyounger ones couldn’t sitand listen too. (FG2, P4,female, Pakistani)

When I started receiving letters andphone calls from yourselves then Irealised that there might be support.My daughter says to me that ‘mammaI want to go for exercise’... I told herthat I couldn’t go with her because Ihave other children. I have small children,my youngest is 2 years old. (109, female,Pakistani (interview conducted in Urdu))

Language barriers

Initial contact Someone rang on my home phonespeaking English & inviting me toattend the programme but I was


Table 3 Themes emerging from the interviews and focus groups with Pakistani and Bangladeshi parents, and quotes to illustratethe themes (Continued)


asking her if I needed to take mydaughter with me, because myEnglish is not very good; but shecould not understand what I wastrying to ask her. I was asking if Ineeded to take my daughter withme. She couldn’t understand me soshe said she will call me back butwe never heard from her again.(150, female, Bangladeshi (interviewconducted in Bengali))

Programme sessions I don’t know English, theywere English, but I understoodeverything because of the waythey explained it, with gesturesand all the information so thatwe could understand.(FG3(conducted in Urdu), P2, male,Pakistani)From FG3 (conducted in Urdu):Facilitator: So was there atranslator there?Participant 1: No. Because at firstI didn’t really mention it becausemy daughter was with me andso I didn’t have any problemsbecause my daughter wouldspeak for me and she’d translatewhat I was saying back to themabout what to do etc.(female, Pakistani)

Yes because I’ve seen someparents there that are likeit was hard for them tounderstand and I was doinga lot of explaining to them aswell (123, female, Pakistani)

My niece had taken her son to FirstSteps programme, but she herselfdidn’t understand English, right? …She told me what was there, butshe felt left out, as a parent—sayingthat, you know, ‘If there’s enoughinformation for me, because I can’tread,’ she said, ‘and I can’t understand,then it would have been easier if therewas somebody to explain to me(113, female, Pakistani)

Programme structure and delivery

Programme and sessionduration

It’s not reasonable for me goingand going back and comingback, so that is an issue, as well.So if the hours were extended,like an hour and a half or twohours, that would be reasonable.(113, female, Pakistani)I think 7 weeks is OK, to be honest,yeah. That’s not a problem. I thinkthat’s just about right to be honest,yeah. Because if you make it toolong, probably get a bit boringwouldn’t it. (143, female, Pakistani)

Children attending Because sometimes childrendon’t listen to their mum ordad but they listen to theteacher or outsider (FG4(conducted in Urdu), P1,male, Pakistani)So if like you know if like ifthese sessions are done butthen it’s explained to the kidsa little bit more about ‘this iswhat you need to do becauseit’s your life, you’re going to beaffected in the future’ and stufflike that then it might help them.(FG1, P3, female, Bangladeshi)

It would have been a bit moreideal if the kids were moreinvolved. That’s what I would -,because then yes we need tohave that understanding, but Ibelieve the kids need to understandwhat they should have and theintake and how it’s with their body.(107, female, Pakistani)I think children should go everysession because then, you know,well how I look at is if the childrendon’t go and then we’re telling ‘ohyou’ve got to do this, this’, theyprobably think we just sometimes,most kids, they will think oh justmy parents being horrible to me,my parents, but when they go intoclasses and they see these otherpeople they don’t know who are

...although my daughter does listento me. I think getting the informationfirst hand would make a big difference.So it’s important for both mother &child to attend. (150, female,Bangladeshi (interview conductedin Bengali))




actually telling them, then theywill listen more because they willthink: hang on if I don’t know thechap there was telling me, so Ithink my dad is right, so yeahOK I’ll try that. (129, male,Bangladeshi)

Programme interactivity The visual, it was the visualthings really that she allbrought the visual thingsand that really like makesit more better understandingthen like you know. (FG1, P1,female, Pakistani)[Participant talking about arelated workshop that wasnot delivered as part of themain programme] It wasn’treally cooking it was justreadymade wraps, and youwould just put salad in it,and we needed to cut it andput it in and whatever youneed to put in there like butterthey had brought along withthem. So we cut it up, and thechildren cut it up and madethem and then you have alook. In this way I think thechildren enjoy it too, so theyunderstand that this ishappening for them, so itsinks into their minds thatif they do this then it will beof benefit to them. (FG3(conducted in Urdu), P1,female, Pakistani)

I thought it was going to be likekind of activities where they actuallyshow you what kind of activities youcan do with your children, whatkind of sports and obviously getthem interested in them kind ofactivities. But obviously it was likejust basically information just sitthere and obviously giving usinformation about what kind ofnutrition and diet and exerciseand everything but I thought itwas going to be more physicalthan obviously classroom based(142, female, Pakistani)I think there was a bit too muchpaperwork and what it is, shewas giving out the information,yes she was trying her best, but Ithink the way she was deliveringit everyone was like going halfasleep... because some parentsdon’t take it in as that, and it’slike they need to get up and do(107, female, Pakistani)

Group sessions andshared experiences

There was different communityfamilies, and friendly. Indian,Bengali, English, Sikh, andchildren’s mix up, and sharetheir experiences. (FG2, P4,female, Pakistani)Because it was the same lady[facilitator] for all five sections,and she nicely laughs and youknow and mostly my son washappy you know and whendifferent communities peoplesit and talk and like it was likea challenge between everyoneand she used to push themto compete. (FG2, P4, female,Pakistani)

I think this is a really good idealike when you go to a talk thenyou get to hear the views ofothers and that has an effect onyou (109, female, Pakistani(interview conducted in Urdu))

Programme content

Focus on weight status I know it was weigh in and therewas less time but with the kids Ithink if they approach them a bitdifferently because nowadays kidsare very, very sensitive and everysort of thing just sticks in theirhead and I think, you know, ‘ohGod mum’ and then in schoolthey’ll have that -, because theyhad to come out of school and

I don’t see it as overweight,‘cause I know what they eat.I know they’re not eating thewrong food. Yes, they’re lessactive, but what do you do?(108, female, Pakistani)My daughter, she’s not reallyoverweight, it’s just that herweight has gone a bit over themark (104, female, Pakistani)




then it’s them like ‘oh we’re goingfor the weigh in’ and she wasembarrassed to even tell herbrother and sisters what shewas going for (107, female,Pakistani)

I mean, if you look at my son,he’s not overweight, I mean,he’s quite, for his age, he looksbigger than his age, I mean,he doesn’t look like really bigor anything but he is quiteheavy (144, female, Pakistani)

Nutritional knowledgeand skills

But the way they explainedeverything it was very interesting.I didn’t know just a bottle ofwater with lemon juice had likeso many rounds of sugar inthere and all that stuff and likethey said biscuits you think that’sthe healthy option, actually it isn’t.You know like so it was quite aneye opener. (FG1, P3, female,Bangladeshi)Because they brought a lot ofmaterial about foods with them,like sweet packets, crisps, sugaretc., all these things were thereand how much sugar was in them.How much salt is in things andhow to swap these things and itwill be effective. And I did this100% and it took effect. (FG3(conducted in Urdu), P1, female, Pakistani)

We went on the first session.The minute that plate came upand those sugary – you know,those little packets and everything,we thought, ‘Oh, we’ve been there,done that. Forget this’ (121, female,Pakistani)When you buy the shopping, morelabelling, more information, becauseI understand what they say sometimesthere’s energy and then the parents,some get confused because obviouslyand some English is not even there, soif they can like give a bit more which ismore better and which is morehealthy, like [drink brand], becauseI didn’t pick it up from there,[drink brand] does have a lotmore sugar than we thought(107, female, Pakistani)

I thought it would be just liketalking through healthy andunhealthy but myself, I alwayslook on the internet for healthyoptions, healthy meals and youknow what’s good for me, what’snot good for me. So I’m constantlyon the internet, right? So I thoughtI probably know it anyway’(104, female, Pakistani)

South Asian andWestern foods

From FG1:Interviewer: And what sort offoods would you like to learnabout in cooking, westernisedor traditional or a bit of both?Participant 4: A bit of both, yeah.Participant 1: A bit of – thechildren do have both.(female, Pakistani)Participant 4: They get to have,they get bored with this typeof food all the time, they wantto try something different. Sothat would be like a mixturereally. (female, Pakistani)

I think they should talk aboutboth [Asian and Western food].We do eat Asian food a lot butmy children like both so it wouldbe beneficial to get advice on both.(150, female, Bangladesh (interviewconducted in Bengali))We do eat fish and we do eat bakedbeans and stuff, but we do eat ourown food, as well, so we neededucation on our own food (113,female, Pakistani)We eat a range of foods and mydaughter likes eating food like this.They eat Pakistani food too but alsoEnglish foods that are vegetarian.(109, female, Pakistani (interviewconducted in Urdu))

Cooking of traditionalfoods

Yeah because if I change usingless oil, I can’t taste my currywithout oil, since I was 3 andhave grown up, I can’t changethat but I can swap other things,fat milk with semi skimmed andwhite with wholemeal breads butI can’t change my curries. (FG2,P1, female, Pakistani)

I want to know, if I’m making achapatti, how many calories arein there? You know. If I’m makinga curry – it’s really hard to – howmany calories – you know, hand-size or, you know, it’s hard – inreality, it’s really, really hard. Maybedo a cooking session; say, ‘This is aportion.’ You know. ‘It’s right.’Maybe do it that way…or even,like, give recipes on maybe evenhealthier Asian food, rather than –fair enough, do the English food,as well. OK, we have it once aweek or whatever. And that’sovenly – oven-made or it’s grilled.But help us with the type of foodthat we’re eating. Where are wegoing wrong? (108, female, Pakistani)




‘Junk’ foods andtakeaways

She eats a lot of chocolates,sweets and crisps, she eats a lotof takeaways, like burgers, drinksa lot of fizzy drinks, she eats a lotof this stuff. Stuff like chapatti andcurry, she eats less of. (154, female,Pakistani (interview conductedin Urdu))But, the temptation in this area isthat we have cheap takeaways,and they are very tempting. Youknow, you think, ‘Why cook?’ And,you know, we’re tempted to, youknow, just, ‘Oh, it’s an easier option.We’ll get chicken and chips. It’s only£1.50.’ So, you know, that’s why theweight is creeping up with children(113, female, Pakistani)

Physical activity content If they could like have ameeting for half an hourand then integrate likeanother half an hour todo the sports, I think thatwould be good as well.(FG1, P3, female, Bangladeshi)I think that if you are doingthis programme then youneed to put some exercisesessions in it too, whateveris best for children... if youhave the space then youshould have exerciseprogrammes in it too(FG3 (conducted in Urdu),P1, female, Pakistani)

They should do more activitieslike, you know, physical activitiesto help them and not justconcentrate on the food side(123, female, Pakistani)

Barriers and facilitators tophysical activity

And you can do somethingat home as well, childrensitting down, it’s better totell them to walk like tentimes on the stairs, up anddown. That’s a good exercisefor them. (FG2, P1, female,Pakistani)

There’s just nowhere for us tosend them where they can getexercise. Whether they can playfootball or cricket or anything,they should do something. AndI would enrol them there.(155, female, Pakistani)My sister gets into the car anddrops them off to the secondaryschool, you see. But they needthat exercise. They need to learnhow to walk, as well. You know,the car is very convenient, but it’sreally bad for the kids (121, female,Pakistani)

We rarely get to go to the parkunless it’s a hot summer’s day.It’s just busy. (108, female,Pakistani)I want to ride a bike ... and myhusband goes ‘can you seehow dangerous it is, the carsout there (112, female, Pakistani)And you can’t let them go tothe parks alone. And it’s justround the corner but you justcan’t... You just can’t let themout, ‘cause a lot has been, youknow, happening around here.(108, female, Pakistani)

Parental behaviours andinfluence over child

I’ve tried to cut down. Youknow they showed us acertain plate of vegetables,that’s how much and allthat stuff and I’ve trieddoing that, I’ve really triedgetting into it but I findthat he sneaks behind me,he goes in the kitchen andhelps himself. (FG1, P3,female, Bangladeshi)

When he goes to my mum’s house,he helps himself a lot and thenwhen we go to family, like, hedoesn’t listen, he helps himself alot (103, female, Pakistani)But the drink wise, he does drinksometimes fizzy drink and I’mgoing to deny that I do bringsometimes, I feel bad, they like it,right, so just drink a bottle andgive it to them, I say ‘look hide it(129, male, Bangladeshi)


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Template for Intervention Description and Replication(TIDieR) checklist [37] (see Additional file 2).

Programme promotion and recruitmentThe initial written and verbal contact with families whowere referred to the service was modified so that non-English speaking parents were contacted by telephone intheir preferred language.

Key changes to programme structure and deliverySession length was increased from 60 to 90 min, andprovision of weekend programmes was increased.Children were included in all programme sessions. Flexi-bility was built into all programme sessions to enable adegree of tailoring to the individual families attending.This was achieved through the development of inter-active activities that helped families identify their specificchallenges and have the opportunity to discuss thesewith the facilitator.

Session contentThe emphasis of the programme was changed so thatthere was more focus on changing eating and physicalactivity behaviours to improve health, and less focus onweight. Sessions were adapted to include much moreinteractivity, and physically active elements were intro-duced into every session. Content was also designed toencourage interaction and peer support between thefamilies. Behaviour change techniques were incorporatedacross the programme, and a specific parenting sessionwas developed to help parents think about how they canbest support their child to change their behaviours.

Developed resourcesColourful visual display boards and resources for theinteractive activities were developed for use within thesessions, as this was recognised as an important factorin engaging children and families. All materials were de-signed to have pictorial representations and minimalwritten information. To further encourage interactivity,a website was developed as a supporting resource forfamilies (both parents and children). This was mainly inEnglish, but Urdu and Bengali translations were availablefor the front page introduction and the FrequentlyAsked Questions section. A facilitator guide and twofacilitator training sessions were developed.

DiscussionThe aim of this study was to adapt a selected childweight management programme to make it morerelevant and acceptable to Pakistani and Bangladeshifamilies so that once they commenced the programme,they would be more likely to complete it. The interven-tion adaptation process was multistage and iterative, and

was informed by the experiences and views ofprogramme participants and providers, as well as in-corporating the available research evidence relating tochildren’s weight management intervention.The BCW [33] and Typology of cultural adaptation

[15] frameworks enabled us to use the qualitative data todevelop a theoretical understanding of the behaviour offamilies and how adaptations to the programme couldsupport behaviour change whilst also being acceptableto all families. This resulted in explicit articulation ofhow the different elements of the programme were de-signed to positively influence the identified target behav-iours. The cultural adaptation typology enabled a focuson cultural needs throughout the process, but it becameclear that many of the adaptations required were notspecific to the cultural groups that we were focusing on,and related more to addressing the daily challenges facedby families that impaired their ability to undertakehealthy behaviours. It was also clear from the qualitativestudy and local programme information that there is aneed to deliver the programme in a flexible and respon-sive way so that the needs of individual families are met,as family contexts differ greatly, regardless of their ethni-city. Therefore, the adapted intervention was designed toincorporate flexibility so that facilitators delivering theprogramme could respond to the needs of all partici-pants. This approach is coherent with the recognisedneed for a conceptual shift from a traditional focus on‘ethnic groups’ to a greater understanding of populationdiversification in terms of a range of related anddynamic factors linked to migration (so-called super-diversity) [38].The adaptation process also provided opportunity to

ensure that the design of the programme was informed bythe current children’s weight management research evi-dence. We searched for all relevant literature but therewas little further information to add that was not alreadycaptured in the NICE guidelines [5], which were publishedin November 2013 and were underpinned by two compre-hensive systematic literature reviews [30, 31]. Therefore,the adaptation process incorporated an explicit step ofconsidering any relevant NICE recommendations.Cultural adaptation can occur at two levels: surface and

deep structure adaptations. The former are adaptationswhich address the visible characteristics of a minority eth-nic group, for example, adaptations to address languageneeds or including culturally matched images and foods inmaterials. The latter address less visible aspects such ascore values and beliefs that contribute to a person’s worldview [39, 40]. The adaptations made in this studyaddressed both levels. The responsiveness of theprogramme to individual family contexts, the focus onhealth rather than weight loss, and the fostering of peersupport are all adaptations at the deep structural level.


There is still relatively little research into the culturaladaptation of health promotion programmes. In 2012 alandmark review on health promotion programme adap-tation for minority ethnic groups was published. Thissynthesised literature on health promotion programmestargeting diet, physical activity and smoking [15], andhighlighted that most research in this field is US basedand focused on African-American communities, whichlimits the applicability of the findings to the UK context.This is reflected in childhood obesity intervention re-search, where the focus has been on US minority ethniccommunities. Systematic reviews of culturally targetedinterventions have highlighted that adaptations are oftenconfined to the surface level, although there are someexamples of deep structural adaptations [14, 41]. A lackof reporting of the adaptation strategies used has alsobeen highlighted [41], which limits understanding of thetheory which underpins the adapted programmes. Aparticular strength of this study is that we have used for-mative research and applied theoretical frameworks inour cultural adaptation approach, which has resulted inexplicit articulation of the theory underpinning theadaptations made to the programme.The study had some limitations. Recruitment to the

qualitative study was challenging, with limited success inrecruiting participants in the completing group to theFGs, despite efforts to make them as convenient andaccessible as possible. There may be cultural reasonscontributing to this non-attendance, which we have yetto identify. These may in part also contribute to highattrition from weight management programmes seen infamilies from these communities. The low number ofparticipants in the FGs potentially limited the richnessof the data, as group sizes of 6–8 are needed to maxi-mise group interaction and discussion [28]. However,even with the limitations of the FG data, we were stillable to identify differences between the completing andnon-completing/non-attending families (e.g. perceptionsof their child’s weight as a problem, expectations aroundgaining new knowledge from programme attendanceetc.). Another potential limitation is that despite explain-ing the nature of the research, and that it was beingundertaken by an independent organisation, some par-ticipants still believed the research team to be part ofthe children’s weight management service, which mayhave influenced the data obtained in the study. Forexample, they may have been less willing to be critical ofthe programme. Even taking into account these limita-tions, we were able to collect rich data that yielded valu-able information that fed into the adaptation process.It is possible that adapting the programme to suit the

specific needs of Pakistani and Bangladeshi familiescould be discordant with families from other culturalcommunities. However, many of the issues raised by

parents within this study are coherent with the wider lit-erature on barriers and facilitators to families attendingweight management programmes [42]. In addition, flexi-bility to respond to different family contexts was incor-porated into the adapted intervention, which enables adegree of tailoring to all families. The subsequent feasi-bility trial of this culturally adapted intervention that wehave undertaken and reported in a separate paper [20]gives further information on the acceptability of theprogramme to Pakistani and Bangladeshi families, andfamilies who are not from these communities.

ConclusionsIn this paper we have presented a process of cultural adap-tation of a children’s weight management programme,which has resulted in a programme that is culturallyadapted at both the surface and deep structural levels. Theprocess undertaken has enabled us to explicitly articulatethe theory which underpins the adaptations that have beenmade. The theoretical approach that we used could poten-tially be replicated by others who are planning to culturallyadapt health promotion programmes.

Additional files

Additional file 1: CHANGE study: an example of the interventionadaptation process. (DOCX 14 kb)

Additional file 2: The CHANGE study adapted children’s weightmanagement intervention: Template for Intervention Description andReplication (TIDieR) checklist. (DOCX 18 kb)

AbbreviationsBCW: Behaviour Change Wheel; BMI: Body Mass Index; CHANGE: ChildweigHt mANaGement for Ethnically diverse communities; COM-B: Capability,Opportunity, Motivation and Behaviour; FG: Focus Group; MRC: MedicalResearch Council; NHS: National Health Service; NICE: National Institute forHealth and Care Excellence; RCT: Randomised Controlled Trial;TIDieR: Template for Intervention Description and Replication; UK: UnitedKingdom; USA: United States of America

AcknowledgementsWe thank the parents and the NHS delivery staff who participated in thestudy. We acknowledge the support and collaboration of the BirminghamCommunity Healthcare NHS Trust children’s weight management providerteam, and the Birmingham City Council Public Health team. We thank all theadministrative and research staff who contributed to the study: AndreaAnastassiou, Laura Ocansey, Aisha Ahmad, Minara Bibi and Salma Khan; andthank James Martin for his statistical advice. We would like to thankmembers of the Parent Advisory Panel for their advice throughout the study:Mrs. Zahida Arif, Mrs. Shazia Begum and Mrs. Masuma Chaudry. We wouldlike acknowledge members of the external Study Steering Committee foroverseeing the study: Dr. Wendy Robertson, University of Warwick (Chair),Professor Mark Johnson, De Montfort University, Leicester, Dr. Ruth Kipping,University of Bristol, and Mrs. Shahin Ashraf (public representative).

Authors’ contributionsMP (Principal Investigator) led the design and conduct of the studythroughout, and drafted the manuscript. TG coordinated the study,undertook the qualitative study and intervention development process, andcontributed to drafting the manuscript. LG contributed to the design andanalysis of the qualitative study. KH, JB and EM contributed to theintervention adaptation process and final intervention design, and the


https://doi.org/10.1186/s12889-019-7159-5

https://doi.org/10.1186/s12889-019-7159-5

overall design and conduct of the study. EL, EF, KJ, JLT, PG and JPcontributed to the overall design and conduct of the study, andinterpretation of the findings. PA mentored the Principal Investigator andcontributed to the overall design and conduct of the study, andinterpretation of the findings. All authors read and approved the final versionof the manuscript.

FundingThe study was funded by the National Institute for Health Research HealthTechnology Assessment Programme (project number 12/137/05). Thefunding body had no role in the design of the study and collection, analysis,and interpretation of data and in writing the manuscript. The viewsexpressed are those of the authors and not necessarily those of the NHS, theNIHR or the Department of Health and Social Care. Kate Jolly is part-fundedby the Collaboration for Leadership in Applied Health Research and CareWest Midlands.

Availability of data and materialsAll data are available on request from the corresponding author.

Ethics approval and consent to participateEthical approval for the study was received from the Edgbaston LocalResearch Ethics Committee in July 2014 (14/WM/1036). Written consent wasobtained from all participants.

Consent for publicationNot applicable.

Competing interestsEM was the manager of the First Steps children’s weight managementprogramme (the programme on which this study is based). PA is a memberof the National Institute for Health Research Public Health Research FundingBoard. The authors have no other competing interests to declare.

Author details1Institute of Applied Health Research, University of Birmingham, Edgbaston,Birmingham B15 2TT, UK. 2Department for Health, University of Bath,University of Bath, Bath BA2 7AY, UK. 3School of Life and Health Sciences,Aston University, Aston Triangle, Birmingham B4 7ET, UK. 4Warwick MedicalSchool, University of Warwick, Coventry CV4 7AL, UK. 5School of Social Policy,University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. 6BirminghamCommunity Healthcare NHS Trust, 1 Priestley Wharf, Holt Street, BirminghamB7 4BN, UK. 7School of Sport, Exercise and Rehabilitation Sciences, Universityof Birmingham, Edgbaston, Birmingham B15 2TT, UK.

Received: 16 April 2018 Accepted: 12 June 2019

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https://www.nice.org.uk/guidance/ph47/evidence/review-of-effectiveness-and-cost-effectiveness-pdf-430360093






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