What help do young women want in their efforts to control their weight? Implications for program development.

Abstract

The aim of this study was to examine women's views on the usefulness of various types of information and practical sessions on weight control, their preferences for program delivery, and likelihood of participation. Cross-sectional survey of 462 women aged 18-33 years randomly selected from the community was conducted. We examined the perceived usefulness of various types of information and practical classes on weight control; preferred mode of delivery; willingness to participate. Among the women 82% were interested in trying to lose or control weight. Information on weight control was considered to be more useful than practical sessions. Information about meal planning, cooking and low-fat recipes and how to manage stress was considered most useful. Fifty-eight per cent of women reported they would prefer to participate in an individual face-to-face program delivered by a health professional. Thirty-one per cent of women reported it was very likely that they would participate in a program if it included the sort of things they considered useful and was offered in the way they preferred; a further 35% felt it 'likely'. It appears that health professional-delivered, individual, information-based programs appear most popular among this target group. Tailoring the content and delivery mode of weight management programs to young women's preferences may enhance program participation.

Key words: individual counselling, preference, tailored intervention.

INTRODUCTION

Throughout the developed world, overweight and obesity are conditions that affect a large and increasing proportion of children and adults across the socioeconomic spectrum. In countries like the USA, Britain, Canada and Australia, as many as one in four children and adolescents and more than half of the adult population carry excess fat that puts them at increased risk for a range of chronic conditions. (1) The costs to the health care system are staggering and are likely to increase significantly given current trends. (2) Although overweight and obesity are recognised as serious health issues that require urgent action, public health authorities currently lack effective strategies to tackle these problems. One of the major public health challenges of the twenty-first century is to develop and implement affordable and sustainable weight control strategies that can impact large segments of the population.

Expert groups have suggested a range of potential approaches to prevent and manage the obesity epidemic. (3-5) These range from individual, family and settings-based strategies to inform and encourage the population to make healthier dietary and physical activity choices, through to strategies aimed at modifying the physical and policy level influences on diet and activity in order to create more supportive environments. Given the extent of the obesity epidemic, the diverse population groups that are affected and the need to both prevent unhealthy weight gain in currently healthy-weight individuals and assist those with an existing weight problem, it seems likely that a combination of different approaches will be required. Regardless of the approaches that are finally adopted to tackle the epidemic, it will be important for public health authorities to have an understanding of the kinds of help the community is seeking in their efforts to control their weight in order to tailor programs to meet community needs and thus maximise participation and retention.

A review of the literature reveals that there has been surprisingly little research that has examined community views on the desirable attributes of weight control programs. There have been only two studies that we could identify from the published literature. In their study of consumer preferences, Sherwood et al. surveyed just over 600 participants aged 20-45 years in their community-based Pound of Prevention Study. (6) They found that among their community volunteers, interest was stronger for mail-based programs than for face-to-face programs. In terms of program content, exercise, stress and eating, recipe cookbooks and dietary assessment were the topics most preferred by the study participants. Similar research with urban dwelling American-Indian women showed that among those interested in losing weight, the features considered the most important were the inclusion of exercise as part of the program, advice on how to fit healthful eating and exercise into daily routines and low-fat cooking demonstrations. (7)

Apart from the two studies described above, we are not aware of any other research that has examined community preferences for weight control programs. This paper examines young women's views on the usefulness of various types of information and practical sessions on weight control, their preferences for mode of program delivery and their likelihood of participating in a weight control program that meets their preferences. We focus on young adult women, as this is a group known to be concerned about their weight (8) and to be at particular risk of weight gain. (9,10) We have previously shown that young women's ability to engage in weight gain prevention strategies such as healthy low-fat eating and physical activity is influenced by women's current weight, as well as by socio-demographic factors such as their household composition. (11,12) The present study also examined how weight control program preferences varied by weight status, socioeconomic status and household composition/domestic situation.

METHODS

Participants

A sample of 1200 women was selected from the Australian Electoral Roll using a stratified random sampling procedure, with strata based on the number of eligible cases in the eight States/Territories of Australia. The electoral roll provides a complete record of population data on Australian residents aged 18 years and over, as voting is compulsory for Australian adults. A total of 462 women participated; a response rate of 41% after excluding those who had moved and left no forwarding address. Although this represents a modest response rate, it is consistent with those achieved in population health surveys (13) and with international trends of declining survey participation. (14) It is also noteworthy that a recent review of the survey research literature suggests that a modest response rate does not necessarily impact on the validity of the findings. (14)

Procedures

A questionnaire, invitation to participate, consent form and paid reply envelope were mailed to the women in October 2001. The questionnaire was pilot tested with a group of 10 women in the same age group as the participants. A reminder postcard was sent to non-responders two weeks after the initial mailing and a second reminder (with replacement questionnaire) was mailed a further three weeks later to maximise the response. The research procedures were approved by the Deakin University Human Ethics Committee.

Measures

Socio-demographic information

The women were asked to report their current age in years. Educational attainment was assessed by asking 'What is your highest level of schooling' with response options; still at school; primary school; some high school; completed high school; technical or trade school certificate/apprenticeship and university or tertiary qualified. For the purposes of analysis, the women were categorised as tertiary educated or not tertiary educated. Domestic situation was assessed by asking 'Who lives with you' with response options: no-one, I live alone; partner/spouse; own children; someone else's children; parents; brothers/sisters; other adult relatives; and other adults who are not family members. This was subsequently re-categorised as living with parental family; living alone/share 'flatting'; living with partner (no children) or living with children (including those living with partner and children and single mothers).

Height and weight

Women were asked to self-report their height and weight, which was used to calculate Body Mass Index (BMI = weight (kg)/heigh[t.sup.2] ([m.sup.2])). Self-reported height and weight have been shown to provide a reasonably valid measure of actual height and weight for the purpose of investigating relationships in epidemiological studies. (15) Based on international cut points, (2) women with a BMI > 25 were classified as overweight.

Preferences for program content

Women were asked if they were interested in or were trying to lose weight, prevent weight gain or control their body shape. Those women who answered yes were asked how useful ('Not at all useful to me'; 'Somewhat useful to me'; 'Very useful to me') they would find information about and practical classes on: a structured exercise program; how to increase physical activity levels; diet/how to eat healthy foods; meal planning, cooking and low-fat recipes and how to eat healthy foods when out (see Table 1 for a complete list of the items).

Preferences for mode of program delivery

To assess preferences for different modes of program delivery, women were asked 'If you were given the opportunity to participate in a weight control program, which one of the following types of program would you most prefer'. Response options were: an individual face-to-face program delivered by a health professional; a group face-to-face program delivered by a health professional; a self-help program offered through the mail; a self-help program offered by mail with telephone back-up; a self-help program offered over the Internet and some other kind of program.

Likelihood of participation in a weight control program

Participants were asked 'If there were a weight control program that included the sort of things you considered useful and it was offered in the way you prefer, how likely is it you would participate' ('very unlikely'; 'unlikely'; 'not sure'; 'likely'; 'very likely').

Statistical analyses

Analyses were conducted using SPSS version 11.0.0 statistical software. (16) Initially descriptive analyses (frequencies) were conducted to examine: the proportion of women who were interested in trying to lose weight, prevent weight gain or control body shape; these women's views of the usefulness of the various types of information and practical sessions; preferences for program delivery and the likeliness of participation in a weight control program. Cross-tabulations were then conducted on each item to examine differences by the women's domestic situation, educational status and weight status.

RESULTS

Profile of participants

The 462 women surveyed within the present study ranged in age from 18 to 33 years (median age 26 years). Demographic characteristics of the women are described in detail elsewhere. (12) Briefly, just under half of the women in the sample were tertiary educated (42%), 36% of the women were married and almost one-third (30%) had one or more children. Almost one-third of the women (31%) were overweight. A total of 372/462 women (82%) reported that they were interested in or were trying to lose weight, prevent weight gain or control their body shape. The demographic characteristics of these women were similar to those of the whole sample.

Preferences for program content

The women's views of the usefulness of the various types of information and practical sessions are presented in Table 1. The items that were rated as most useful included 'information about meal planning, cooking and low-fat recipes' and 'information about how to manage stress'. The items that were considered by the women to be the least useful were 'practical sessions on how to eat healthy when you are out' and 'practical sessions on how to increase your physical activity levels'. In general, women were more likely to describe information as more useful to them than practical sessions (classes).

There were no significant differences in the women's views of the usefulness of the various types of information and practical sessions by their domestic situation. However, there were differences between women who were tertiary educated and those who were not, and between women who were overweight and those who were not. Women without a tertiary education were more likely than those with tertiary qualifications to describe information about how to increase physical activity levels, information about diet/how to eat healthy foods, information about meal planning, cooking and low-fat recipes and information about eating healthy foods when out as somewhat or very useful to them (Table 2). Overweight women were more likely than women who were not overweight to describe the information and practical sessions listed in Table 3 as very useful to them in helping them to control their weight.

Preferences for mode of program delivery

Fifty-eight per cent of women reported they would most prefer to participate in an individual face-to-face weight control program delivered by a health professional. Other modes of program delivery were far less popular. Only 15% nominated a group face-to-face program delivered by a health professional; 13% nominated a self-help program offered through the mail; 6% nominated a self-help program offered by mail with telephone backup; 4% nominated a self-help program offered over the Internet (4%) and 3% nominated another kind of program. There were no significant differences in preferences for mode of program delivery according to educational, domestic or weight status.

Likelihood of participation in a weight control program

The women were asked how likely they would be to participate in a weight control program that included the sort of things they considered useful and was offered in the way they preferred. Almost a third of the women (31%) reported it was 'very likely' that they would participate, 35% felt it 'likely', 21% were uncertain; 6% were 'unlikely to participate' and a further 8% were 'very unlikely'. Reported likelihood of participating in a weight control program did not differ according to women's domestic situation. Women without a tertiary education were more likely than those with a tertiary education to report they were 'likely' or 'very likely' to participate in a weight control program (71% vs 58%, respectively). Overweight women were more likely than women not overweight to report that they were 'likely' or 'very likely' to participate (75% and 60%, respectively).

DISCUSSION

The present study is significant in that it is one of only a few to have examined community preferences regarding the content and format of weight control programs. It shows that a majority of young adult women are interested in trying to lose weight, prevent weight gain or control their body shape, that they have specific views about the kinds of help they would like in their efforts to control their weight and that a significant proportion, perhaps as many as one-third, would be very likely to participate in a program that catered to their preferences. However, as Sherwood et al. noted in their study, (6) there is likely to be a discrepancy between stated interest and actual participation in a weight control program. Nonetheless, the findings of the present study are important as they provide an insight into the kinds of help women want as they attempt to achieve or maintain a healthy weight.

Generally, the women surveyed reported they would prefer a weight control program to provide information rather than to include practical classes, although many of the overweight women did see classes as being very useful for them. The demand for information by the women is surprising given that there is already a great deal of information about nutrition, physical activity and weight control available to consumers. However, the fact that the women wanted information to be included in weight control programs suggests they do not currently have access to good quality information regarding eating and physical activity and weight control. Other research has shown that women do not trust nutrition and weight loss information from popular sources like magazines (17,18) and it may be that the plethora of information that is currently available simply serves to confuse women. Whatever their reasons, it appears that there is a demand for information about a range of weight control issues among women and the inclusion of information should therefore be an important consideration for those developing community weight control programs.

Unlike participants in the Pound of Prevention study, who preferred mail-based rather than face-to-face programs, (6) the women in the present study were more interested in face-to-face weight control programs that those delivered in other ways (i.e. via mail, telephone or the Internet). It is noteworthy that the preferred mode of program delivery did not vary according to the women's domestic situation. Given that our previous research has shown that women with children more often cite lack of time as a barrier to weight maintenance, (11) we might have expected them to be more interested in self-help programs; however, this was not the case. Almost 60% of all women interested in weight control in the present study wanted an individual face-to-face program delivered by a health professional, with relatively few interested in a group-based program. The low level of stated interest in self-help and group-based programs has important implications for public health efforts to promote healthy weight. Although such programs are appealing because of their low cost and their potential to reach large numbers of people, the present findings suggest that population approaches that rely on group-based or self-help formats are likely to meet with limited success among young women because of a lack of uptake.

If health professionals are to play a role in promoting healthy weight as young women would like, it will be necessary to upgrade their existing knowledge and skill levels. There is a substantial body of evidence which indicates that the majority of family physicians are ill-equipped to address issues relating to overweight and weight control, (19-21) and even qualified dietitians do not employ all the elements of known best practice in the management of their overweight clients, with many describing their training in the area as poor. (22) Given the costs associated with health professionals delivering one-to-one weight control programs, it may be necessary to consider other models of delivery. One such example is the 'Green Prescription', whereby health professionals provide only brief intervention and 'prescribe' lifestyle change to their clients. (23) Other approaches that could potentially reduce the time health professionals spend with clients (and thus the cost of program delivery), while still meeting women's stated needs, might include the use of computer-based expert systems (24) or the Internet. (25,26)

CONCLUSION

It appears that health professional-delivered, individual, information-based weight control programs are the most popular among young adult women. Tailoring the content and delivery mode of weight management programs to match consumer preferences may enhance program participation and adherence. The challenge for public health will be to implement tailored weight control programs that meet young women's needs in a cost-efficient manner.

ACKNOWLEDGEMENTS

We would like to thank Ms Anna Sztendur for her expert assistance with the analysis of the data. Kylie Ball and David Crawford are supported by Career Development Awards from the National Health and Medical Research Council/National Heart Foundation.

REFERENCES

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4 US Department of Health and Human Services. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: US Department of Health and Human Services, 2001.

5 National Audit Office. Tackling Obesity in England. London: Stationery Office, 2001.

6 Sherwood NE, Morton N, Jeffery RW, French SA, Neumark-Sztainer D, Falkner NH. Consumer preferences in format and type of community-based weight control programs. Am J Health Promot 1998; 13: 12-18.

7 Sherwood NE, Harnack L, Story M. Weight-loss practices, nutrition beliefs, and weight-loss program preferences of urban American Indian women. J Am Diet Assoc 2000; 100: 442-6.

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9 Williamson DF, Kahn HS, Remington PL, Anda RF. The 10-year incidence of overweight and major weight gain in US adults. Arch Intern Med 1990; 150: 665-72.

10 Ball K, Brown W, Crawford D. Who does not gain weight? Prevalence and predictors of weight maintenance in young women. Int J Obes Relat Metab Disord 2002; 26: 1570-78.

11 Andajani-Sutjahjo S, Ball K, Warren N, Inglis V, Crawford D. Perceived personal, social and environmental barriers to weight maintenance among young women. Int J Behav Nutr Phys Act 2004; 1: 15.

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16 SPSS. SPSS for Windows, Release 11.0.0. Chicago, IL: SPSS, 2001.

17 Worsley A. Perceived reliability of sources of health information. Health Educ Res 1989; 4: 367-76.

18 Crawford D, Baghurst KI. Nutrition information in Australia--the public's view. Aust J Nutr Diet 1991; 48: 40-44.

19 Cade J, O'Connell S. Management of weight problems and obesity: knowledge, attitudes and current practice of general practitioners. Br J Gen Pract 1991; 41: 147-50

20 Campbell K, Engel H, Timperio A, Cooper C, Crawford D. Australian general practitioners' attitudes and practices regarding the management of obesity. Obes Res 2000; 8: 459-66.

21 Kristeller JL, Hoerr RA. Physician attitudes toward managing obesity: differences among six specialty groups. Prev Med 1997; 26: 542-9.

22 Campbell K, Crawford D. Management of obesity: attitudes and practices of Australian dietitians. Int J Obes Relat Metab Disord 2000; 24: 701-10.

23 Ellery R, Kerse N, Arroll B, Swinburn B, Ashton T, Robinson E. Cost-effectiveness of physical activity counselling in general practice. N Z Med J 2004; 117: U1216.

24 Brug J, Campbell M, van Assema P. The application and impact of computer-generated personalized nutrition education: a review of the literature. Patient Educ Couns 1999; 36: 145-56.

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David CRAWFORD and Kylie BALL

School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia

D. Crawford, PhD, Associate Head of School (Research)

K. Ball, PhD, Senior Research Fellow

Correspondence: D. Crawford, 221 Burwood Highway, Burwood, Vic. 3125, Australia. Email: [e-mail]

Table 1 Perceived usefulness of various types of information and
practical sessions in helping women to control weight (n = 372)

                                      Perceived usefulness
                                      Not at all  Somewhat    Very
                                      useful (%)  useful (%)  useful (%)

Information about a structured        19          38          44
  exercise program
Practical sessions (classes) on       25          41          34
  structured exercise
Information about how to increase     22          36          42
  your physical activity levels
Practical sessions (classes) on how   34          36          31
  to increase your physical activity
  levels
Information about diet/how to eat     23          33          44
  healthy foods
Practical sessions (classes) about    36          29          36
  diet/how to eat healthy foods
Information about meal planning,      19          27          54
  cooking and low-fat recipes
Practical sessions (classes) on meal  31          26          43
  planning, cooking and low-fat
  recipes
Information about how to eat healthy  22          39          40
  foods when you are out
Practical sessions (classes)          43          30          27
  about how to eat healthy foods
  when you are out
Information about how to manage       17          35          49
  stress
Practical sessions (classes) about    31          29          40
  how to manage stress

Table 2 Perceived usefulness of various types of information and
practical sessions in helping women to control weight--differences by
socioeconomic status (a) (n = 372)

                         Non-tertiary  Tertiary
                         educated (%)  educated (%)  P-value

Information about how to increase your physical activity levels
Not at all useful to me  15            33            <0.001
Somewhat useful to me    40            31
Very useful to me        45            37

Information about diet/how to eat healthy foods
Not at all useful to me  18            29             0.039
Somewhat useful to me    35            32
Very useful to me        47            39

Information about meal planning, cooking and low-fat recipes
Not at all useful to me  15            25             0.048
Somewhat useful to me    28            24
Very useful to me        57            51

Information about how to eat healthy foods when you are out
Not at all useful to me  17            28             0.026
Somewhat useful to me    43            33
Very useful to me        40            39

Practical sessions (classes) about how to eat healthy foods when you
  are out
Not at all useful to me  38            48             0.007
Somewhat useful to me    37            22
Very useful to me        25            30

(a) Only significant associations presented.

Table 3 Perceived usefulness of various types of information and
practical sessions in helping women to control weight--differences by
weight status (a) (n = 372)

                         Not overweight (%)  Overweight (%)  P-value

Information about how to increase your physical activity levels
Not at all useful to me  27                  16               0.026
Somewhat useful to me    37                  35
Very useful to me        36                  49

Practical sessions (classes) on how to increase your physical activity
  levels
Not at all useful to me  37                  28               0.026
Somewhat useful to me    38                  33
Very useful to me        25                  39

Information about diet/how to eat healthy foods
Not at all useful to me  28                  15               0.003
Somewhat useful to me    36                  31
Very useful to me        37                  55

Practical sessions (classes) about diet/how to eat healthy foods
Not at all useful to me  43                  23              <0.001
Somewhat useful to me    29                  27
Very useful to me        28                  50

Information about meal planning, cooking and low-fat recipes
Not at all useful to me  23                  12               0.003
Somewhat useful to me    29                  22
Very useful to me        47                  66

Practical sessions (classes) on meal planning, cooking and low-fat
  recipes
Not at all useful to me  36                  25               0.009
Somewhat useful to me    28                  22
Very useful to me        36                  53

Information about how to eat healthy foods when you are out
Not at all useful to me  28                  15               0.020
Somewhat useful to me    36                  41
Very useful to me        37                  42

(a) Only significant associations presented.