Our research will use a multiple qualitative case study methodology . Data will be collected from four distinct research sites with each of the following sites representing a case: (i) Pediatric Centre for Weight and Health in Edmonton, Alberta; (ii) Centre for Healthy Weights in Vancouver, British Columbia; (iii) Metabolism, Obesity and Health Program at McMaster Children’s Hospital, Hamilton, Ontario; and (iv) Healthy Weight Clinic in Montreal, Quebec. A case study approach is appropriate for this research since the topic of interest is represented within each selected case, and each case represents a population within the topic of interest . Within each case, the unit of analysis will be the family members who were referred or received weight management care (e.g., a child/youth and a parent). By collecting perspectives from multiple families, we will be able to create an account that represents each of the four cases. Commonalities and differences between and within cases will then be identified. Ultimately, this will enable us to provide detailed information about experiences and decisions regarding families’ initiation, continuation, and termination of care that are relevant to centres across the country. The multiple qualitative case study methodology is appropriate for this study for several reasons. First, the research questions require detailed information about participants’ perceptions and experiences; such data could not be obtained through quantitative measures (e.g., questionnaires). Second, it is important to study multiple cases across Canada in order to establish local level variations in addition to common factors that influence families’ decisions to initiate, continue, and terminate care. Finally, case study methodology is appropriate for studying ‘bounded’ social systems. In the proposed study, each site is a bounded system with specific rules and norms of social interaction. Using this approach, researchers can obtain data to identify key issues relevant to each case (and shared between cases), triangulate key findings for interpretation, consider alterative explanations, and develop assertions about the cases [34, 35]. The four multidisciplinary pediatric weight management centres represented in this study were selected based on their existing administrative and research infrastructure, national leadership roles of their program directors, diverse demographic characteristics of the communities they serve, and similar philosophical approaches to providing family-centred care.
A total of 100 families (n = 25/site) will be recruited for this study. The number of families per site has been estimated based on a previous study  in which an adequate level of saturation was reached after interviewing families at one weight management centre. The inclusion of a broader sample usually requires additional data to achieve saturation than would be required with a more tightly defined sample . A purposeful sampling approach will be used, a strategy that is designed to identify the most information-rich cases from which to learn about issues that are fundamental to the purpose of the research . Given the aims of the study, families will be recruited based on whether they satisfy the following eligibility criteria:
Non-Initiators (n = 5 families/site; 20 families total): Families in this group will include a child with obesity who was referred for weight management within the past six months, but did not follow-up the referral by attending a clinical appointment. We anticipate this group of families will be more difficult to recruit and enroll, which is reflected in the smaller sample size. This group of families will allow us to explore issues related to decisions regarding initiation of care.
Initiators (n = 10 families/site; 40 families total): Families in this group will include a child with obesity who was referred for weight management within the past six months, who did follow-up the referral by attending at least one clinical appointment, and discontinued care following a brief period of time. This group of families will allow us to explore issues related to both the initiation and premature termination of care.
Continuers (n = 10 families/site; 40 families total): Families in this group will have a child with obesity who was referred for weight management and completed a formal weight management intervention within the past 12 months and will have continued with follow-up care for at least six months. This group of families will allow us to explore issues related to both the initiation and continuation of care.
Families will be eligible for this study if children with obesity were (i) referred for weight management to one of the four multidisciplinary pediatric weight management centers, (ii) 10–17 years old at the time of referral, and (iii) possessed an age- and sex-specific body mass index (BMI) ≥97th percentile at the time of referral. Parents (mothers, fathers, and legal guardians) will be eligible for this study if they self-identify as the primary caregiver of a child with obesity. Families will determine the adult who can, in their view, best represent their family’s experiences and perceptions regarding pediatric weight management.
To enhance our ability to successfully recruit families into all three categories from all four sites, we will apply three main strategies. First, we will offer families the option of holding interviews at times (e.g., evenings, weekends) and locations (e.g., weight management center, family residence) that are most convenient for them. Second, we will offer each family a $100 gift card at a local business or shopping mall as an incentive to participate and acknowledgement of the time, effort, and (potential) time away from work. Finally, we will work collaboratively across our four sites to enhance recruitment. At study initiation, we will develop a site-specific recruitment timeline, which will include milestones and a clear plan to document all successful and unsuccessful recruitment approaches. We will collectively discuss and develop study promotional materials and family recruitment letters, so similar information (both in English and French) will be used across study sites. Families in the Non-Initiator and Initiator groups will be contacted by regular mail with additional correspondence by telephone or e-mail, when appropriate, because they will not be attending regular clinic appointments. Following institutional ethics approvals, mailing addresses for potential participants will be retrieved from patient registries that are maintained by all four study centres. Families in the Continuers group will be contacted in-person by a member of each centre’s administrative staff during a scheduled clinical appointment. Study promotional materials will be shared with families at this time. If families express interest in the study, follow-up (either in-person, by telephone or email) for study recruitment will be initiated by research coordinators (RCs) at each site. Once inclusion criteria are confirmed, RCs will complete the informed consent and assent procedures with parents and children, respectively.
Participants (children and parents) will engage in one individual semi-structured interview each. Assuming that we interview one child and one parent per family, there will be a total of 200 interviews. Interviews will be conducted at each site by trained Graduate Research Assistants (GRAs) and/or RCs. Interviews will be 30 (child) to 60 (parent) minutes in length and will be digitally recorded using Olympus Digital Voice Recorders (WS-400S). Interviews will include open-ended questions about factors related to the initiation, continuation, and/or termination of care, reasons for making those decisions, who was involved in making those decisions, and how they feel about those decisions. Information about the micro (e.g., child, parent, family), meso (e.g., clinicians, clinical setting), and macro (e.g., health care system, environment) factors will be gathered; probes regarding perceptions, experiences, examples, and preferences related to decision-making will be used. Preferences, perceived strengths and limitations, and areas for improvement regarding health services for managing pediatric obesity will be explored. Participants will be asked to provide specific examples of challenges and opportunities they faced. A closing discussion will probe perceptions of need for long-term support, how support should be delivered, and expectations for maintaining changes initiated during and following treatment. Demographic and anthropometric/clinical information will also be obtained for contextual purposes. Demographic variables will include mailing address (to calculate geographic distance between weight management centers and families’ residences), dates of birth, sex, relationship between child and parent, ethnicity, and socioeconomic status. Anthropometric/clinical variables will include weight, height, waist circumference, BMI, BMI percentile (child only), BMI z-score (child only), presence/absence of obesity-related co-morbidities, and family history of chronic disease. Portable medical scales, stadiometers, and tape measures will be used to collect up-to-date weight, height, and waist circumference data, respectively, from all participants, which will be particularly important when interviews are conducted away from clinical settings. Demographic and clinical data will be collected by site-specific GRAs and RCs from several sources including weight management referral forms and research or medical charts for boys and girls who attended one of our centres. The accuracy and completeness of data gleaned from referral forms and charts will be confirmed with families upon study enrolment. Methodological rigour will be enhanced by adhering to evidence-based protocols for medical record review research [39, 40].
Digitally-recorded interview data from all centres will be submitted electronically to the Comma Police (http://www.commapolice.com) for transcription. Subsequently, transcribed data will be entered verbatim into N-VIVO 8 (QSR, Melbourne, Australia) for data management and analysis. Interviews held in Vancouver, Edmonton, and Hamilton will be conducted in English whereas interviews in Montreal will be conducted in either English or French. Data will be transcribed to text in the original language of the interview (English or French). At the final stage of analysis, results from both languages will be compared and contrasted. Data analysis will commence as soon as the first transcripts are received. Initial coding will be performed by GRAs and RCs at each of the four sites under the guidance of the principal and co-investigators. Although all data will be subjected to the same coding procedures (described below), analysis will be conducted on a case-by-case basis to identify specific issues based on participants’ experiences from each of the four research sites. Stake’s  categorical aggregation method for case study methodology will be used. First, transcripts will be read using line-by-line coding to identify specific themes. This process requires examining, questioning, and corroborating themes throughout the analysis. As themes are identified, similar instances or occurrences will be aggregated to create a basic coding schema. A written description will then be constructed to explain each category. During the final stages of coding, data from each center will be aggregated to establish common themes and specific local variations.
Consistent with case study methodology , several techniques have been built into the research design to enhance the methodological rigor of the analysis. First, obtaining data from multiple sources (children and parents) across four sites will allow us to triangulate the findings [34, 38]. Second, data analysis will be corroborated by the research team who will compile a quarterly report of the findings to date, which will be discussed with all team members during quarterly team meetings. This process will also be repeated with the final results, which will allow us to corroborate the analysis and remain sensitive to local, contextual issues. Third, a member checking protocol  will be used. Participants in each of the four research sites will receive a summary of the findings and be asked to evaluate whether the analysis reflects their personal experiences in pediatric weight management care. Finally, the sample size is substantial and will enhance our ability to attain data saturation, which will allow us to draw meaningful conclusions from the data.
Information retrieved from referral forms and medical charts will include contextual data from children and parents. Data will be retrieved from these sources (and supplemented by information collected from families during individual interviews) using standardized case report forms that will be developed with input from all team members. Quantitative data will be analyzed using SPSS 17.0 (SPSS Inc.; Chicago, IL). Continuous variables will be described by univariable summaries (e.g., means, medians, ranges, SDs) and frequency distributions will be determined for categorical variables. For key outcome variables, 95% confidence intervals will be reported for means and proportions. To display continuous variables, box plots and histograms will be used; bar charts will be used for categorical variables.