You have recently been hired as the lead health educator for a state-wide project to discourage the use of e-cigarettes among teens. You have been tasked with developing a communica
Scenario1 : You have recently been hired as the lead health educator for a state-wide project to discourage the use of e-cigarettes among teens. You have been tasked with developing a communication intervention to address the health issue. Your intervention should be theory-driven.
Select a theory or model from the list below and apply two (2) of its constructs to the development of your health communication intervention. (Recommend: 3–4 paragraphs)
· Transtheoretical Model (Stages of Change)
· Theory of Planned Behavior
· Social Cognitive Theory
· Health Belief Model
· Diffusion of Innovation
Item 2: Write a brief overview of the research/study (in your own words) and then explain how the specific theory or model was applied to the health communication in the study. Provide a detailed explanation, be specific, and provide examples if needed. It should be clear in your response what health behavior theory or model and specific constructs were used to develop the health intervention. (Recommend: 2–3 paragraphs) (Research study to review attached)
More information will be given after acceptance.
Received: 27 March 2021 | Revised: 6 August 2021 | Accepted: 10 August 2021
DOI: 10.1111/hex.13357
S P E C I A L I S S U E PA P E R
Examining community mental health providers' delivery of structured weight loss intervention to youth with serious emotional disturbance: An application of the theory of planned behaviour
Thomas L. Wykes PhD, Staff Psychologist | Andrea S. Worth MS, Graduate Student |
Kathryn A. Richardson MS, Graduate Student |
Tonja Woods PharmD, Clinical Associate Professor |
Morgan Longstreth MS, Graduate Student | Christine L. McKibbin PhD, Professor
Department of Psychology, University of
Wyoming, Laramie, Wyoming, USA
Correspondence
Christine L. McKibbin, Department of
Psychology, University of Wyoming, 3415,
1000 E. University Ave, Laramie, WY 82071,
USA.
Email: [email protected]
Present address
Thomas L. Wykes, Veterans Affairs Cheyenne
Healthcare System, 2360 E. Pershing
BlvdCheyenne, WY 82001, USA.
Funding information
No funding was received to undertake this
study.
Abstract
Background: Rates of overweight and obesity are disproportionately high among youth
with serious emotional disturbance (SED). Little is known about community mental health
providers' delivery of weight loss interventions to this vulnerable population.
Objective: This study examined attitudinal predictors of their providers' intentions to
deliver weight loss interventions to youth with SED using the theory of planned
behaviour.
Design: This study used a cross‐sectional, single‐time‐point design to examine the re-
lationship of the theory of planned behaviour constructs with behavioural intention.
Setting and Participants: Community mental health providers (n = 101) serving youth
with SED in the United States completed online clinical practice and theory of
planned behaviour surveys.
Main Variables Studied: We examined the relationship of direct attitude constructs
(i.e., attitude towards the behaviour, social norms and perceived behavioural con-
trol), role beliefs and moral norms with behavioural intention. Analyses included a
confirmatory factor analysis and two‐step linear regression.
Results: The structure of the model and the reliability of the questionnaire were
supported. Direct attitude constructs, role beliefs and moral norms predicted
behavioural intention to deliver weight loss interventions.
Discussion: While there is debate about the usefulness of the theory of planned
behaviour, our results showed that traditional and newer attitudinal constructs ap-
pear to influence provider intentions to deliver weight loss interventions to youth
with SED. Findings suggest preliminary strategies to increase provider intentions.
Health Expectations. 2022;25:2056–2064.2056 | wileyonlinelibrary.com/journal/hex
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd
Public Contribution: This study was designed and the results were interpreted as
part of a larger, community‐based participatory research effort that included input
from youth, families, providers, administrators and researchers. Collaborative dis-
cussions with community mental health providers and administrators particularly
contributed to the study question asked as well as interpretation of results.
K E YWORD S
overweight and obesity, serious emotional disturbance, theory of planned behaviour, weight loss interventions, youth
1 | INTRODUCTION
Overweight and obesity (OW/OB) among youth are major global public
health problems.1,2 In the United States, the National Survey of Children's
Health in 2016–2017 calculated the prevalence of OW/OB among ran-
domly sampled children aged 10–17 years in the United States and found
that 9.5 million of these youth were either overweight (15.2%) or obese
(15.8%).3 A recent evidence report and systematic review of obesity
screening for the U.S. Preventive Services Task Force also indicated that
the prevalence of obesity among youth has increased over the past three
decades. While the authors suggest that the rate of obesity may be sta-
bilizing overall, they emphasized the importance of addressing OW/OB in
youth as a public health priority.4
Work over the last two decades suggests that OW/OB may dis-
proportionately affect youth with psychiatric disorders,5–8 referred to by
the Substance Abuse and Mental Health Services Administration
(SAMHSA) as serious emotional disturbance (SED). For example, a recent
large study utilizing the 2016 National Survey of Children's Health was
conducted to examine the prevalence of overweight among youth aged
10–17 years across 19 chronic conditions (n=10,997) compared to those
without chronic conditions (n=13,408). They found a significantly greater
prevalence of overweight among youth with depression (40.7%), beha-
viour problems (39.3%) and anxiety (36.6%) relative to youth without
these chronic conditions (27.8%).9 The authors of a smaller cross‐sectional
chart review study of adolescents (n =114) admitted to a
behavioural health partial hospitalisation programme found rates of
overweight (25.4%) and obesity (30.0%) that were significantly higher than
those of samples of youth in the general population of both the sur-
rounding county and across the nation.10 In another study of youth aged
8–11 years, Lumeng et al.11,12 found that clinically meaningful
behaviour problems were independently associated with an increased risk
of concurrent overweight and increased risk of becoming overweight
among previously normal‐weight children.
1.1 | Addressing OW/OB among youth with SED
Interventions are needed to address OW/OB among youth with both
SED and OW/OB. Despite risk for long‐term deleterious outcomes as-
sociated with SED, and the need for specialized interventions for this
vulnerable population, few programmes have been developed. A small
body of research to address healthy lifestyle has shown promising health
outcomes among emerging adult and adult populations with first‐
episode psychosis and across both community and mental health centre
settings.13,14 Mental health providers have either led or collaborated in
the delivery of these interventions. However, information about the in-
volvement of key stakeholders (e.g., youth and families, mental health
providers and administrators) in the development of these interventions
is less clear. Mental health providers may also be uniquely positioned to
contribute, along with researchers and both youth and families, to the
development of an intervention designed to be implemented within
existing mental health service systems. It is well known that mental
health providers have knowledge and expertize in working with youth
with SED and their family members, knowledge of the important system‐
level influences and barriers to service delivery, knowledge of social
determinants of health‐influencing outcomes in these populations and
expertize in the self‐management and behaviour change strategies that
are commonly used in mental health interventions.15–19 In general,
however, the degree to which these professional stakeholders are ready
and willing to engage vulnerable populations such as youth with SED and
OW/OB and family members is less well known.
Ashby et al.20 examined provider readiness to address healthy
lifestyles among 259 nonphysician, Australian, healthcare profes-
sionals. A total of 21 of these providers were psychologists and were
serving adult mental health clients with OW/OB. The psychologists in
the sample observed substantial deficits in perceived abilities to
provide healthy lifestyle advice to clients, as well as low knowledge
about weight loss, low confidence for setting weight loss goals and
low confidence in making dietary and physical activity recommenda-
tions. Despite these doubts, 42% (n = 8) of the psychologists in the
sample reported providing dietary advice and 60% (n = 12) believed
that doing so was within their professional role. Ashby et al.20 at-
tributed providers' decisions to convey weight‐related healthy life-
style advice to patients with OW/OB to the influence of several
factors, including providers’ beliefs regarding the scope of their
practice, their confidence in providing weight‐related healthy lifestyle
advice and access to supportive resources. Although the study carried
out by Ashby et al.20 is one of the first to examine engagement in and
attitudes towards providing weight‐related lifestyle advice among
mental health providers, their report of only descriptive data and
unclear operationalization of the theory of planned behaviour con-
structs limited the inferential power of their results. In addition, the
WYKES ET AL. | 2057
degree to which providers and the community of individuals with
mental health disorders was involved in developing the survey
questions was less clear.
1.2 | The theory of planned behaviour: Understanding provider intentions
The theory of planned behaviour21 may be a valuable framework for
understanding provider intentions to engage youth with SED and OW/OB
and their families in weight loss interventions. While the theory of planned
behaviour has received some criticism (e.g., limited validity, lack of ability
to empirically disprove the theory, lacking sufficient belief
altering guidelines)22 and other motivational theories have been put for-
ward as alternatives (e.g., Health Action Process Approach),23 this parti-
cular theory has been widely used in previous research to efficiently
characterize the decision‐making process regarding specific behaviours
and to predict future decisions to perform those behaviours. Unlike other
motivational theories, the Theory of Planned Behaviour has also been
extended to studies of provider behaviour. A systematic review of 78
studies seeking to predict healthcare professionals' intentions to perform
specific behaviours found that the theory of planned behaviour (or its
parent theory, the theory of reasoned action) was the most commonly
used model in investigations of healthcare professionals' intentions. The
theory of planned behaviour also demonstrated the strongest association
between theoretical components and the actual behaviours of provi-
ders.24 The theory of planned behaviour is founded on the assumption
that individuals develop intentions to perform a target behaviour (i.e.,
behavioural intentions) that lead to engagement in the behaviour.21 Sev-
eral psychological constructs contribute to the development of beha-
vioural intentions. The theory states that salient beliefs drive the cognitive
constructs that contribute to behavioural intentions. Salient beliefs include
specific beliefs about (1) the target behaviour (i.e., behavioural beliefs), (2)
others who would approve or disapprove of engaging in the behaviour
(i.e., normative beliefs) and (3) the ability to control aspects of the beha-
viour (i.e., control beliefs). These salient beliefs correspond directly to the
following cognitive constructs (i.e., direct attitude variables): (1) attitude
towards the behaviour, (2) subjective norm and (3) perceived behavioural
control. Attitude towards the behaviour refers to favourable or un-
favourable appraisals held by an individual about the specific behaviour.
Subjective norm refers to social pressure regarding whether or not to
engage in the behaviour. This social pressure is influenced by the opinions
of others whom the individual deems important. Finally, perceived beha-
vioural control refers to an individual's appraisal of and corresponding
beliefs about his or her own ability to carry out the behaviour in
question.21,25
The theory of planned behaviour also allows for the inclusion of
additional constructs when there is sufficient evidence to support doing
so. For example, the additional influence of role beliefs and moral norms
on the behavioural intentions of healthcare providers has received some
empirical support.24 These additional constructs stem from Triandis'26
theory of interpersonal behaviour. Role beliefs are defined as ‘… beha-
viors appropriate for persons holding a particular position in a group,
society, or social system’,26 (p. 208) and moral norms are defined as ‘…
feelings of personal responsibility regarding the performance… of a given
action’26 (p. 94). In their review of healthcare provider behaviour, Godin
et al.24 reported that role beliefs were a significant predictor of intention
in 8 of 14 studies that used the construct. Moral norms were a significant
predictor of intention in 10 of 14 studies that used the construct. The
authors identified role beliefs and moral norms as among ‘the most
consistently significant cognitive factors’ (p. 5) related to intention in the
context of healthcare provider behaviour. More recent studies have also
shown the value of moral norms in predicting intention to receive an
human papillomavirus vaccine,27 to comply with hand hygiene28 and
participate in regular leisure‐time physical activity among individuals with
diabetes,29 among other behaviours.30
1.3 | Aim of the present study
The present study was conducted by researchers in collaboration with a
group of key stakeholders including youth and families, mental health
providers, community mental health administrators and academic re-
searchers. This study is one of several steps towards the development of
a specialized intervention to promote healthy lifestyles among youth
with SED and OW/OB. For this study, the group sought to characterize
community mental health providers' engagement of youth with both
SED and OW/OB and their family members in weight loss programmes
as well as identify the key attitudinal predictors of providers' intentions
to engage this vulnerable population in structured weight loss inter-
ventions. Understanding the attitudinal factors that may influence the
availability of much‐needed and specialized health promotion services
for youth with OW/OB and their family members is expected to provide
additional avenues for provider education and programme development.
We first hypothesized that each direct attitude construct (i.e., attitude
towards the behaviour, subjective norm, perceived behavioural control)
as well as added constructs (i.e., role beliefs and moral norms) would be
positively associated with the intention to provide structured weight loss
interventions to youth with SED and OW/OB. We then hypothesized
that the intention to provide structured weight loss interventions to
youth with SED and OW/OB would be positively associated with self‐
reported history of providing such interventions. Given these specific
aims and existing gaps in the literature, a measure was developed for use
in the present study. As a result, additional aims of the present study
included assessing and reporting the fit of the observed provider data to
the expected factor structure.
2 | METHODS
2.1 | Sample
Community mental health providers who serve vulnerable youth with
SED were recruited from eligible mental health centres in the United
States. SED is defined by the United States SAMHSA as any youth from
birth to age 18 who has a diagnosable mental, behavioural or emotional
disorder that substantially interferes with or limits the youth's role or
functioning in family, school or community activities.31 Eligible mental
2058 | WYKES ET AL.
health centres were those that (1) provide mental health treatment
services to children, adolescents, young adults or adults; (2) provide
crisis or emergency treatment options; (3) operate in an outpatient
setting; (4) provide specialty services for SED; and (5) provide internet‐
based contact options for administration of study materials. Individuals
who were 18 years of age or older, who worked as a mental health
provider, who worked in an eligible mental health centre and who
expressed informed consent were eligible to participate.
2.2 | Measures
2.2.1 | Sociodemographics
A sociodemographic form was used to collect the personal and
professional characteristics of all participants (e.g., age, occupation
and years in practice).
2.2.2 | Theory of planned behaviour questionnaire
A 41‐item theory of planned behaviour questionnaire was developed
for the study, based on published theory of planned behaviour
guidelines,25,32 and was revised by three experts in the field. The
questionnaire addresses salient beliefs (i.e., behavioural beliefs, nor-
mative beliefs and control beliefs), direct attitude variables (i.e., atti-
tude towards the behaviour, subjective norm and perceived
behavioural control), role beliefs, moral norms and behavioural in-
tention. Role beliefs and moral norms were added to the measure
based on feedback from researchers with expertize in the theory. The
salient belief items were identified in a previous elicitation study from
this study group33 and were added to questions addressing the direct
attitude and behavioural intention constructs of the theory of plan-
ned behaviour. A single item (i.e., “I provide structured weight loss
intervention to my youth clients with SED and OW/OB”) measured
engagement in the target behaviour. All items were structured as
5‐point, Likert‐type items, and were coded such that higher scores
reflect more favourable beliefs and engagement in the target beha-
viour. For each scale, a summary score was calculated as the simple
mean of the items.
2.2.3 | Clinical practice survey
A 26‐item survey, based partly on the measure used by Ashby
et al.,20 collected information about engagement in weight‐related
treatment activities (e.g., providers' assessment of weight and life-
style behaviours, types of dietary and physical activity services pro-
vided). The survey included Likert‐type items (e.g., ‘For your youth
clients with SED and OW/OB, how often do you directly address
your client's weight in your sessions?’) and open‐ended questions
(e.g., ‘What percentage of your youth clients with SED have OW/
OB?’). The survey allowed for the calculation of frequency counts of
reported weight‐related treatment activities and qualitative descrip-
tion of additional needs and preferences in relation to these
behaviours.
2.3 | Procedure
This study was conducted as part of a larger community‐based parti-
cipatory research effort to develop a healthy lifestyle intervention for
youth with SED and OW/OB and their family members. The tool that
was used, intervention mapping (IM),34 is a community‐based, parti-
cipatory model, including patient and public involvement, which serves
as a blueprint for designing, implementing and evaluating an inter-
vention based on theoretical, empirical and practical information. A key
component of the IM protocol is the engagement of stakeholders in all
phases of intervention development from identification of the pro-
blem, to planning for research and needs assessments, to identification
of essential programme elements, to evaluation of the intervention. In
this case, a stakeholder board comprising parents and youth (n = 4),
community mental health providers (n = 4), administrators (n = 2) and
researchers (n = 6) met on a monthly basis. Feedback on design and
results from community mental health providers and administrators
was sought and incorporated into this study.
Participants in this study were recruited from community mental
health agencies listed in the United States SAMHSA national direc-
tory of mental health treatment facilities. The inclusion criteria were
applied to all 50 states and yielded a list of 1989 entries. Sites were
manually evaluated to verify eligibility for participation. Potential
participants were contacted via email and/or website‐based contact
forms.
All measures were administered through an internet‐based
survey platform (i.e., Qualtrics).35 Prospective participants first
navigated to a screening page to assess their inclusion criteria. All
participants had the opportunity to indicate informed consent and to
participate in the survey, which allowed administrators to review the
survey even if they were not direct service providers. However, those
who did not consent to participate were not included. The survey
took an average of 20min to complete. Responses for all survey
questions other than identity and survey completion status were
deidentified. Participants who completed the survey were entered in
a raffle for one of 15 Amazon gift cards, each worth $20. The Uni-
versity of Wyoming Institutional Review Board approved this study.
The study conforms to recognized standards of the US Federal Policy
for the Protection of Human Subjects.
2.4 | Data analysis
Descriptive statistics were calculated for all questionnaire items.
Responses to the Clinical Practice Survey were dichotomized as
‘Never or Almost Never’ and ‘Rarely’ versus ‘Sometimes’, ‘Frequently’
and ‘Always or Almost Always’. All relevant variables were checked
for normality (Kolmogorov–Smirnov test); transformations of
WYKES ET AL. | 2059
nonnormal variables did not result in improvements in normality, so
all analyses were performed with untransformed variables. Analyses
were performed using SPSS version 23 and Mplus version 7.2.
2.4.1 | Theory of planned behaviour questionnaire psychometrics
The internal consistency reliability of the direct attitude, role beliefs,
moral norms and behavioural intention scales was evaluated using
Cronbach's α. Item–total correlations were also calculated. Pearson
correlations were calculated between each item on each salient belief
scale and the total score on its corresponding direct attitude scale to
determine which beliefs have the strongest relationships with atti-
tudinal constructs.32 Finally, construct validity for the direct attitude
scales was tested with a confirmatory factor analysis and a maximum
likelihood estimation approach. Model fit was evaluated with three
tests:36 (1) standardized root mean square residual (SRMSR), (2) root
mean square error of approximation (RMSEA) and (3) the compara-
tive fit index (CFI).
2.4.2 | Direct attitude constructs as predictors of behavioural intention
A two‐step linear regression was conducted to evaluate the predic-
tion of behavioural intention by direct attitude constructs. The three
direct attitude scales (i.e., attitude towards the behaviour, subjective
norm and perceived behavioural control) were entered in Block 1,
and the role beliefs and moral norms scales were entered in Block 2.
The R2 change statistic was calculated to evaluate the incremental
change in the overall model caused by adding these constructs.
A Pearson correlation was also computed between behavioural in-
tention and engagement in the behaviour. For all analyses, alpha was
set to p < .05, and all results were two‐tailed.
3 | RESULTS
3.1 | Sample
A total of 578 (59.3%) sites fulfilled the inclusion criteria. Participants
were distributed across at least 49 unique sites (missing n = 3). Par-
ticipants (n = 101) were located across 25 states, with the largest
representation in New Hampshire (n = 10) and Washington (n = 10)
states. The majority were female, had obtained a master's degree and
were employed as a licensed professional counsellor (see Table 1).
3.2 | Clinical practice and needs
Nearly one‐half of the providers (n = 47, 47%) reported directly ad-
dressing weight with clients in some capacity; 44% (n = 44) reported
dispensing specific dietary advice; and 70%
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