Participants’ Perceptions of “C.H.A.M.P. Families”: A Parent-Focused Intervention Targeting Paediatric Overweight and Obesity

Background: Recently, our team implemented a 13-week group-based intervention for parents of children with obesity (“C.H.A.M.P. Families”). The primary objective of this study was to explore, qualitatively, parents’ perspectives of their experiences in and influence of C.H.A.M.P. Families, as well as their recommendations for future paediatric obesity treatment interventions. Methods: Twelve parents (seven mothers, five fathers/step-fathers) representing seven children (four girls, three boys) with obesity participated in one of two focus groups following the intervention. Focus groups were audio recorded and transcribed verbatim and data were analyzed using inductive thematic analysis. Results: Findings showed that parents perceived their participation in C.H.A.M.P. Families to be a positive experience. Participants highlighted several positive health-related outcomes for children, families, and parents. Parents also underscored the importance and positive impact of the group environment, specific educational content, and additional program components such as free child-minding. Recommendations for future interventions were also provided, including greater child involvement and more practical strategies. Finally, parents identified several barriers including socioenvironmental issues, time constraints, and parenting challenges. Conclusions: Researchers developing family-based childhood obesity interventions should consider the balance of parent and child involvement, as well as emphasize group dynamics strategies and positive family communication.


Introduction
Obesity is widely recognized as one of the most significant health problems affecting children in the 21st century [1][2][3]. The prevalence of both overweight and obesity among children has increased dramatically over the last 30 years, with recent estimates showing that nearly 340 million children are affected worldwide [1]. The consequences of childhood overweight and obesity are severe and concerning. Children with obesity are at an increased risk of experiencing co-morbidities including type 2 diabetes [4], insulin resistance [5], metabolic syndrome [6], high blood pressure [4,7,8], non-alcoholic fatty liver disease [9], and asthma [10]. Childhood obesity has also been associated with negative and serious psychosocial outcomes such as depression [11] and reduced quality of life [10,12]. Furthermore, children with overweight and obesity tend to carry excess weight into later life [13], which can lead to the development of additional health consequences during adulthood, including stroke [14], osteoarthritis [15], and some cancers [15]. and participation from their parents in helping them to adopt and maintain healthy behaviour changes [51]. In addition, C.H.A.M.P. parents noted that they would have liked additional education and program engagement opportunities (e.g., professional consultation, take-home materials, hands-on learning activities) and that they wanted program staff to hold them more accountable for lifestyle changes and participation in the program [52]. However, despite expressing a need for more involvement in the program, parental adherence to the C.H.A.M.P. intervention was low in comparison to that of children (i.e., 69% vs. 91% over 4 weeks). Indeed, such findings are in line with the literature as participant adherence and attrition issues have been cited as important barriers to and limitations of other childhood obesity interventions, particularly those that target parents [35,37,55].
On the basis of evidence from the original C.H.A.M.P. program (including parents' perceptions of the program and recommendations for future interventions [52]), as well as the growing literature and documented effectiveness of childhood obesity interventions targeting parents, our team recently developed and implemented a 13-week group-based intervention entitled "C.H.A.M.P. Families". Whereas the original C.H.A.M.P. program was offered primarily to children (with a relatively small family-based/parental component), C.H.A.M.P. Families was offered to parents (with minimal direct child involvement) who had a child with overweight or obesity. The overall purpose of the C.H.A.M.P. Families program of research was to implement and assess the feasibility of the pilot intervention using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, a tool applied to facilitate the design and evaluation of health behaviour interventions [56][57][58][59]. Gathering information about participants' perceptions of and experiences in such programs is a critical component of assessing intervention acceptability and feasibility [60]. Thus, the primary objective of the current study was to explore the perspectives of parents who participated in the C.H.A.M.P. Families intervention with regard to their experiences in the program, as well as the program's influence on various aspects of child and parental wellbeing (i.e., health behaviours, parental confidence for supporting health behaviour change, and family communication). A secondary purpose was to explore parents' perceptions of the program's strengths and weaknesses, and to identify practical issues that could help to inform the design of future childhood obesity treatment programs. While previous studies have highlighted parents' perspectives of their experiences related to primary care [61,62] and family-based childhood obesity interventions [63][64][65], to our knowledge, this is the first study to explore the perceptions of parents in the context of a community-based, parent-only lifestyle intervention targeting childhood obesity.

Intervention Description
C.H.A.M.P. Families was designed as a single-centre, single group, non-randomized prospective study. Grounded in a theoretical model integrating Social Cognitive Theory [66,67], group dynamics [50,68,69], and motivational interviewing techniques [70,71], C.H.A.M.P. Families was a 13-week intervention consisting of eight 90-min education sessions delivered to parents/guardians only (purposefully scheduled weekly and then bi-weekly to avoid an overreliance on the group [72,73]), as well as two post-program 'booster sessions' offered to guardians and children (see Reilly et al., 2018, for a detailed description of the study protocol and theoretical foundation [74]). All educational sessions were offered on Monday evenings at a local YMCA and covered a range of relevant child and family health topics including, but not limited to: child growth and development, nutrition, physical activity, sleep, sedentary behaviours, parenting and family dynamics, and mental health. Several experts (i.e., health professionals, researchers) and individuals from community organizations were invited to deliver intervention content to parents in interactive, group-based sessions. At the end of each session, parents received take-home materials, and were assigned "homework" activities to reinforce concepts and to assist parents in implementing lifestyle modifications with children in the home environment. Participation in C.H.A.M.P. Families was free and YMCA drop-in programming/child-minding was also available for all children, free of charge, while parents attended the educational sessions. All components of the study were approved by the host University's Research Ethics Board and registered retrospectively with International Standard Randomised Controlled Trials Number (ISRCTN; ID# 10752416).

Participant Recruitment and Eligibility
Participants were recruited using a variety of strategies including newspaper and radio advertisements, social media, posters displayed in various community settings (e.g., libraries, local businesses, family health clinics), and study pamphlets and posters delivered to community paediatricians and family physicians. Parents/guardians were eligible to participate if: (a) they had a child between the ages of 6 and 14 years with a BMI ≥85th percentile for their age and sex; and (b) both the parent and child were fluent in English. Al parents and guardians, including those living in separate homes, were invited to attend the program and participate in the study if interested and eligible.

Focus Groups
Two focus groups for parents/guardians and one for children were held concurrently during the last session of the formal intervention (i.e., in December 2017). Following a short end-of-program celebration during which the Program Coordinator (K.C.R.) and Principal Investigator (S.M.B.) presented families with participation certificates and awards, as well as a light dinner and refreshments, parents/guardians were asked to relocate to one of two focus group rooms within the YMCA facility (children remained in the main program location for their focus group; results from this focus group will be reported elsewhere). Parents were assigned by the Project Coordinator (K.C.R.) to one of two focus groups to ensure similar numbers in both groups. All focus group participants provided consent to participate, and in cases where more than one parent and/or guardian participated in the intervention, both were invited to participate in the same focus group to facilitate conversation and comfort.
Focus groups for parents were approximately 75 min in duration, audio-recorded, and transcribed verbatim. The Principal Investigator (S.M.B.) and a Masters-level graduate student (D.B.) moderated focus groups using a semi-structured interview guide developed based on relevant RE-AIM dimensions [56][57][58][59] and criteria for evaluating feasibility studies [60]. Once in their designated rooms, participants were reminded of the focus group's purpose and procedures, and that participation was voluntary. To reduce the potential for socially desirable responses, parents were also told that there were no correct or incorrect answers, that their honest views and experiences were being sought, and were asked to keep the discussion confidential [75]. To begin the discussion, participants were asked to comment on their overall experience in C.H.A.M.P. Families (e.g., "How did you feel about C.H.A.M.P. Families and your family's participation in the program?"). Next, participants were asked about their perceptions and the potential influence of C.H.A.M.P. Families with regard to: (1) child and parent physical activity and dietary behaviours (e.g., "What is different, if anything, for you about your own eating behaviours [or your thoughts about food and nutrition] since you started the C.H.A.M.P. Families program?"); (2) parenting confidence (e.g., "Do you find that you have higher levels of confidence in your ability to facilitate and support healthy choices in your family? If so, in what way(s)?"); (3) family communication and cohesion (e.g., "In what ways, if any, has your family's communication changed since starting this program?"); and (4) barriers and facilitators to health behaviour changes (e.g., "Can you identify any barriers that might have impacted your child's physical activity levels throughout this program?"). Finally, participants were asked to identify logistical issues (e.g., "How did you feel about the time commitment for this study?") as well as considerations and recommendations for future programming (e.g., "How could the program be improved?").

Data Analysis
Two researchers (K.C.R. and D.B.) reviewed the transcripts for accuracy and anonymized excerpts. The researchers subsequently analyzed the data in NVivo (Version 11.4, 2016; QSR International Pty Ltd, Doncaster, Australia) using an inductive approach in accordance with the six phases of thematic analysis described by Braun and Clarke [76,77]: (1) familiarising yourself with the data (i.e., multiple readings of the transcripts, noting preliminary ideas); (2) generating initial codes (i.e., systematically aggregating the data set into codes); (3) searching for themes (i.e., grouping codes and all relevant data into potential themes); (4) reviewing themes (i.e., creating thematic maps and confirming that themes accurately represent codes and data); (5) defining and naming themes (i.e., creating and refining names and definitions of themes); and (6) producing the report (i.e., choosing illustrative excerpts to exemplify data and connect it to the analysis, research question, and literature). The researchers conducted their initial analyses independently, and met subsequently with a third investigator (S.M.B.) to discuss and corroborate their findings. When discrepancies arose, the researchers discussed their interpretations of the data until agreement was achieved. Once a final consensus was reached for each theme, the researchers worked collaboratively to select a number of illustrative quotes. Several measures proposed by Lincoln and Guba [78] and adapted by Irwin and colleagues [79], including member checking, summarizing, and peer debriefing, were taken to ensure trustworthiness (i.e., credibility, dependability, confirmability, and transferability [78,80]) of the data and analysis.

Results
Twelve of the 16 parents (75%; 7 mothers, 5 fathers/step-fathers) who were enrolled in C.H.A.M.P. Families participated in one of the two focus groups (n = 6 participants per group). Participants (n = 12; M age = 41.5, SD = 5.2; mean researcher-assessed parent BMI at baseline = 34.3 kg/m 2 , SD = 11.7) were parents/guardians of 7 children (M age = 9, SD = 0.82; 4 girls, 3 boys; mean researcher-assessed child BMI-z at baseline = 2.20, SD = 0.28). Unfortunately, baseline BMI data were not available for one focus group participant, and age was not recorded for two participants. Parents who participated in a focus group attended an average of 85% of the educational sessions, a mean that was greater than that calculated for all parents in the program (n = 16; 73%). Additional demographic information for parents/families who took part in the focus groups is presented in Table 1. Level of Education (n = 10) University degree (or higher) 6 (60) College diploma 3 (30) Post-secondary qualification 1 (10) Annual Household Income (n = 10) $100,000 or more 6 (60) $50,000-$99,999 3 (30) $49,999 or less 1 (10) Note: Two parents/guardians did not complete the full demographic questionnaire.

Outcomes for Children
Parents noted that they had observed several positive changes in their children since beginning C.H.A.M.P Families. These outcomes were grouped into three overarching themes: improved dietary behaviours; increased physical activity; and enhanced empowerment and autonomy. Quotations exemplifying these three themes are displayed in Table 2.

Enhanced Empowerment and Autonomy
• "One thing she's [my daughter] taken upon herself is to make her own eggs for breakfast. She'll have eggs with cheese and a little piece of fruit and water. Not that she didn't eat eggs before, but she made them herself now." (Participant 1, female) • "I let [my daughter] make dinner, and giving up the control and saying OK you can do that. I didn't think she could be able to it, but . . . she gave me, you know, the idea that she really was old enough to help us do more in that way." (Participant 7, female) • "Our daughter tried out for volleyball, which I'm not so sure if she would've done that before . . . she didn't make the team but she was confident enough to go . . . . I think there is a healthier diet and she's healthier and stronger so she's willing to take on more and take those risks, and if you don't make it, that's OK." (Participant 1, female)

Improved Dietary Behaviours
Many parents expressed that their child(ren) displayed a greater awareness of their dietary behaviours and were making conscious efforts to choose healthier foods. Specifically, some parents described how their child(ren) showed more interest in the nutritional content of foods and were increasingly involved in meal planning and preparation throughout the duration of the program.

Increased Physical Activity
A number of parents also noted that some children displayed greater motivation for and participation in various (and sometimes new) physical activities. Some parents mentioned that their child(ren) independently sought out opportunities to be active, and in some cases, attempted a new sport.

Enhanced Empowerment and Autonomy
Parents discussed that their child(ren) seemed to feel more empowered and demonstrated greater autonomy over their health behaviours since starting the program. Many detailed how children appeared to be exhibiting greater control over their diet by preparing and/or choosing their own meals, as well as independently selecting and engaging in new physical activities.

Outcomes for Parents and Families
Parents were also asked about any personal, parenting, and/or family-related changes experienced as a result of their participation in C.H.A.M.P. Families. Three overarching themes and eight subthemes emerged within this category, including: healthy food choices for the family (i.e., healthier food purchases and food preparation at home); enhanced family dynamics (i.e., greater confidence to have conversations with children about weight, increased family communication, and full family engagement in health behaviour changes); and greater parental confidence to promote health behaviours in children (i.e., confidence to serve as the primary "agent-of-change", enhancing children's responsibility for their health ["letting go"], and perseverance towards change). Illustrative quotes for these themes and subthemes are presented in Table 3. Table 3. Selected quotes related to parents' perceptions of outcomes for parents and families.

i. Healthier Food Purchases
• "We go one night a week for our treat night, but before it was any day of the week." • "I would say the [biggest change is] packaged food. We're not buying near as many chips anymore." ii. Preparing Healthier Meals at Home • "Instead of just whipping up a batch of chocolate chip cookies, because the kids love chocolate chip cookies, I'm looking for healthier choices in a cookie that I can hide. Now I make a quinoa chocolate chip cookie that the kids think is just a regular chocolate chip cookie, but it's fortified with a whole bunch of stuff that they can't see." (Participant 9, female) • "Something we took away from this was preparing meals ahead of time, like the day before for the next day so it would be a healthy meal and not a rushed out of the box meal sort of thing.

Healthy Food Choices for the Family
This theme captured improvements experienced by several parents with regard to food purchasing and food preparation behaviours. For example, many parents reported that they were selecting healthier options at the grocery store or avoiding packaged foods or treats while shopping. A number of parents also described how at-home food preparation had changed for them as a result of the program, with many opting to prepare meals from scratch and/or substituting more nutritious ingredients for the less healthy products used previously.

Enhanced Family Dynamics
This theme focused on parents' perceptions of increasingly positive interactions and activities occurring within the family since beginning C.H.A.M.P. Families. Several parents noted that family communication had improved. More specifically, many parents noted that that they felt more comfortable in broaching the topic of weight with their children, and that these discussions had become easier to have as a family unit. Rather than focusing solely on the child, parents discussed the involvement of the entire family in working toward positive and sustained health behaviour changes.

Greater Parental Confidence to Promote Health Behaviours in Children
Several parents expressed that they had experienced an increased level of confidence in relation to their knowledge and role as the primary 'agent of change' within the family unit and in the home environment. In addition to this enhanced confidence for supporting behaviour change, parents also reported that they were more confident in their ability to empower and provide their children with additional responsibility and control over their own health. Specifically, parents commented on the benefits of 'letting go' from a health perspective; described by many as acknowledging children's abilities and preferences by allowing them to choose their own foods and assist with meal preparation. Finally, parents voiced that the despite the challenges and barriers experienced in promoting and changing health behaviours, they had the confidence to persist with the efforts required to achieve their family health goals.

Impactful Components of C.H.A.M.P. Families
The following three themes and seven subthemes were identified on the basis of parents' responses regarding their perceptions of the effective components of C.H.A.M.P. Families: group environment (i.e., sense of community/belonging and group interaction and support); program experts and information (i.e., inspiring and motivational expert speakers, relevant and applicable information and resources, reminders and reinforcements); and additional program benefits (i.e., complimentary programming for children and at-home data collection visits, tools, and personnel). Quotes exemplifying these themes and subthemes are displayed in Table 4.

Group Environment
The positive aspects and significance of the group environment were emphasized often by parents, particularly in reference to the sense of community and belonging that were generated. Parents expressed the importance and benefits associated with feeling as though they were part of a group, and that they were not alone in their struggles to improve their child's health. Many parents also noted that the group-based focus of the program, as well as the social support provided by program personnel and other participants, were very impactful. Parents spoke pointedly to the power of hearing other families' experiences and struggles, and the significant impact of group problem solving.

Program Experts and Information
Many parents stated that the information delivered throughout the program was both relevant and applicable to their child and family, and they highlighted specific ways they were able to use the resources received (e.g., C.H.A.M.P. Families binder, children's kitchen utensils, posters and readings). In addition to the usefulness of program information and resources, parents noted that the intervention agents (i.e., the "experts") delivering the content were also highly impactful. Several participants noted that they found the guest speakers to be inspiring and motivational, highlighting the positive impact of the sessions delivered by the professional chef, the dietitian, and the public health nurse who specialized in mental health specifically. Finally, parents expressed that the program content and materials bolstered parents' existing knowledge about health and that the program itself served as a nudge or a reminder to prompt behaviour change.

Additional Program Benefits
Parents commented on a number of additional program components that were not part of the formal intervention delivered to parents (i.e., components that took place outside of the group-based sessions). For example, several parents stated that the complimentary YMCA programming offered to children through the C.H.A.M.P. Families program was perceived very positively by both themselves and their children. Having a structured, easily accessible, and safe activity program available for children to engage in-with other children whose parents were enrolled in the program-was identified as being very important to and an unexpected benefit of the program for most parents. Furthermore, parents commented positively on the research-related components of the program, namely the home data collection visits and the positive relationships developed with program personnel. Specifically, parents described how home visits with the Project Coordinator were important for establishing trust, ensuring comfort, and facilitating dialogue within the family unit and among parents, children, and C.H.A.M.P. staff. Parents also expressed that the research tools used and administered/distributed during home visits (i.e., questionnaires and accelerometers) were a source of motivation for children.

Barriers to Health Behaviour Change
Insofar as barriers and challenges related to changing health behaviours are concerned, the following three overarching themes and eight subthemes were identified based on parents' responses: socioenvironmental issues (i.e., school-related issues, stigma and bullying, social pressures and the food environment, lack of flexible and cost-effective programming for children, and geographic and seasonal issues); time constraints; and parenting issues (i.e., protecting children's feelings, setting appropriate boundaries, and difficulties associated with relaying program content to children). Illustrative quotes for these themes and subthemes are found in Table 5. "He's had such a struggle always and we've been trying to reach out to get help, but it's so hard. We live in a small community, about an hour away from here, but this was the closest that we could really get help." (Participant 6, male)

Socioenvironmental Barriers
Parents identified a broad range of socioenvironmental barriers that affect both themselves and their families. First, some parents reported that they experienced feelings of shame and perceived disapproval from others for having a child with overweight or obesity. Furthermore, they spoke of the bullying and discrimination some of their children experienced as a result of their weight. Second, parents noted specific issues related to the school system, including children's perceptions that school lunch and snack breaks were too short. Many parents felt that the lack of time available for children to eat during school hours had a negative impact on their diet in that children would either have to rush to eat at an unhealthy pace or leave food uneaten. Parents also voiced concern about the perceived lack of health, nutrition, and physical activity-related education their children were receiving at school. The third subtheme, social pressures and the food environment, captured parents' perceptions of the social forces (i.e., family, peers, cultural, and societal norms) as well as the physical presence of and proximity to food that promote the consumption of unhealthy foods. Several parents spoke about the challenges of maintaining a healthy diet during holidays, at family functions, and during parties when treats and other unhealthy foods are readily available. One parent spoke to the pervasiveness of food marketing and how it affects children's food preferences and attitudes. The fourth theme pertained to parental perceptions of the lack of flexible and cost-effective programs available for children in the community, referring most often to a lack of informal, inexpensive, physical activity programming for children. Many parents felt that current programs were overly structured and competition-focused which was discouraging for some children and required families to commit for several weeks/months (often without a trial period). The fifth and final subtheme, geographic and seasonal issues, referred specifically to the barriers to health behaviour change that parents identified (e.g., cold winter months, living in a small community with few resources) in relation to weather and location.

Time Constraints
The perceived lack of time, and/or inability to manage time effectively, to prepare healthy meals and engage in physical activity was identified by parents as a significant barrier to sustained health behaviour change. Many parents suggested that between work, school, and extra-curricular activities and responsibilities, it was challenging for both parents and children to schedule time for grocery shopping, meal preparation, and physical activity.

Parenting Issues
The following three subthemes related broadly to parenting were identified as barriers to healthy behaviour change: protecting children's feelings, setting appropriate boundaries, and difficulties relaying program content to children. A number of parents voiced concerns about hurting their children's feelings, damaging their self-esteem, or unintentionally creating other issues by discussing weight-and health-related topics with them. Parents also expressed that they found setting appropriate limits related to food and screen time challenging, as many felt they were being overly withholding or restrictive to children. Finally, several participants noted that because their children did not view them as an 'expert' or authority on health, parents' ability to relay and share the knowledge and information gained during the intervention with children at home was difficult and not always well-received. Some parents suggested that children would be more open to receiving this information, and therefore more likely to change their behaviours, if the intervention were delivered to the children themselves by experts.

Recommendations for Future Paediatric Overweight/Obesity Interventions
Two overarching themes and five subthemes resulting from parents' recommendations for future interventions were generated, including: greater child involvement (i.e., increased accountability of children, hands-on activities for children, and peer supports and interactions among children) and practical information and strategies (i.e., missing the 'how' to follow through on lessons learned and other topics of interest). Quotes reflecting the abovementioned themes and subthemes are presented in Table 6. iii. Peer Support and Interactions Among Children • "I like the idea of exchanging numbers, not just for the parents, but for the children, like you guys make friends within the program." (Participant 3, male) • "If a peer group similar to this could be made for kids. The parents can get together and find useful solutions, while the kids play and make friends. They'd probably all go to different schools, but they'd have the exact same issues and they won't judge." (Participant 12, female) • "Bring them together. We're doing our thing, but they're doing something on a different level . . . . That brings the kids together at their own language and pace, and builds some friendships too." (Participant 9, female)

Greater Child Involvement
Most parents voiced a preference for children to be more directly involved in the intervention. Specifically, parents expressed that by adding a structured, child-focused program component, children would be more empowered, as well as more conscientious of, committed to, and accountable for their health behaviours. Parents provided a number of suggestions for future programs, including the inclusion of opportunities for children to participate in practical learning (i.e., 'hands-on') learning experiences such as cooking classes. Parents also spoke to the importance of and benefits associated with fostering additional peer support and interactions among children. Many noted that engaging children in group activities would have helped to develop additional friendships and supportive relationships among children who experience the same issues and challenges. Parents felt that the group-based format had been a very impactful component of the program for themselves, and that creating a similar environment for children would have had a powerful and positive effect on their children as well.

Practical Information and Strategies
The final theme is divided into two subthemes that focus on information (i.e., other topics of interest) and strategies (i.e., how to implement the information learned during C.H.A.M.P. Families). Parents expressed an interest in different topics related broadly to child health such as weight-related communication and emotional intelligence. Parents also stated that time management strategies would have been helpful, as time constraints were identified as a hindrance to healthy eating and physical activity in their family. Many parents voiced that while they had sufficient information on certain topics, they still felt they lacked concrete strategies pertaining to how to implement this knowledge with their children and families in the home environment.

Discussion
The purpose of this study was to explore parents' perspectives related to their role(s) as the 'primary agent-of-change' in a parent-focused childhood overweight/obesity program, as well as the perceived impact of the program on child and parental health and wellbeing. Program strengths and weaknesses, as well as practical issues and recommendations that could contribute to the design of future family-based treatment programs for paediatric obesity were also elicited. Several studies have highlighted parents' perspectives of their experiences related to primary care [61,62] and family-based interventions [63][64][65], but to our knowledge, this is the first study to explore the perceptions of parents in the context of a community-based, parent-only lifestyle intervention targeting childhood obesity.
The parents who participated in focus groups described several perceived benefits for children (i.e., improved dietary behaviours, increased physical activity, and enhanced empowerment and autonomy), families (i.e., enhanced family dynamics and healthy food choices), and themselves (i.e., greater parental confidence to support and promote health behaviours in children), all of which were attributed to their involvement in the program. One additional and unanticipated benefit of the program that was highlighted by many parents related to the free, active programming that was offered to children at the YMCA during the parent-only sessions. Though this programming was not part of the formal intervention and was originally intended to reduce barriers to participation, it was noted by participants to have very positive outcomes for both children and parents. Interestingly, while parents noted improvements in their confidence to serve as agents of change for their families and to have conversations with children about health-and weight-related issues, they also emphasized that these areas could be addressed more explicitly in future paediatric obesity treatment programs. For example, several parents articulated challenges associated with relaying program content to children, suggesting that while they felt they had sufficient knowledge about the health topics discussed during the sessions, they lacked the necessary tools and strategies to effectively implement changes in the home environment. Some parents also noted that their children would likely be more receptive to the information if it came from an "expert" rather than from a parent or guardian. With regard to communication, many parents expressed a desire to protect their children's feelings and self-esteem, which they believed could be damaged if they did not broach certain health-and weight-related topics sensitively.
Indeed, poor family communication has been found to be associated with an increased risk of child overweight/obesity [81], and certain types of parent-child weight-related talk has also been identified as potentially detrimental to a child's health and wellbeing [82]. For instance, in a 2016 meta-analysis consisting of 4 intervention studies and 38 associative (cross-sectional and prospective) studies, Gillison and colleagues found that communication consisting of weight criticism (i.e., teasing) and encouraging weight loss increases the likelihood of poor physical self-perceptions, dysfunctional eating, and dieting behaviours in children [82]. Conversely, Gillison et al. reported that encouraging healthy exercise and diet without discussing weight directly was associated with less unhealthy weight control and dieting behaviours among children [82]. Unfortunately, evidence-based resources and strategies to help parents navigate conversations with children about food and weight management are lacking in the literature [81,82]. Furthermore, it important that as researchers, we acknowledge the possibility that we may inadvertently draw parents', and subsequently children's, attention to weight given that weight-related measures such as BMI-z are often the primary outcome in childhood obesity studies [35]. Thus, shifting the focus towards healthy lifestyles and facilitating positive and supportive family communication are important considerations for future paediatric overweight/obesity interventions [82]. Additional barriers to health behaviour change identified by C.H.A.M.P. Families participants, including time constraints, parenting issues, and lack of social support, were consistent with those that have been previously cited by parents in the childhood obesity treatment literature [62][63][64].
As noted previously, C.H.A.M.P. Families was informed by feedback from parents who took part in the original C.H.A.M.P. program [50], many of whom advocated for greater parental involvement and accountability in future paediatric obesity interventions [52]. Despite evidence indicating that parent-only interventions for childhood overweight/obesity may be as effective, or even more effective, than parent-child interventions [37], many of the parents in the current study noted that their children would have benefited from increased participation in the program. Taken together, it is reasonable to suggest that parents seem to desire a childhood obesity treatment program that is relevant for, and balances the involvement and accountability of, both parents and children.
While nearly all of the feedback about C.H.A.M.P. Families was positive, one parent did note that the delivery of content provided by one of the invited guest speakers was not relatable or relevant to their family. Although this comment was not deemed to be sufficient to warrant its own theme per se, such feedback will certainly be used by our team in the development of future programs.
One of the most impactful components of C.H.A.M.P. Families identified by participants was the sense of community and belonging that developed among the parents in the program. Connecting with other parents in a group-based setting was perceived by parents, especially those who had experienced stigma associated with having a child with overweight/obesity, as very powerful; many noted that they valued feeling as though they were "not alone". This finding stresses the importance of cultivating a positive and inclusive group-based environment to support health behaviour change [83]. Groups can be powerful facilitators of change for and adherence to a variety of health behaviours [83][84][85][86], and in the context of childhood obesity, group-based programs have been shown to be more effective in reducing child BMI-z scores than treatments administered individually [87,88]. As stated previously, C.H.A.M.P. Families was intentionally designed using several evidence-based group dynamics strategies [74] that have been used successfully in previous family-based childhood obesity interventions [50] in an attempt to enhance adherence, group cohesion, and other health-related outcomes.
In addition to the importance of the group environment, participants emphasized that their experience in the program was enhanced by the rapport developed between themselves (including their children) and the Project Coordinator whom they described as likeable, engaging, and non-judgmental. Weight bias among primary care providers [89,90], as well as exercise and nutrition professionals [91], has been well-documented in the literature and has been shown to compromise patient outcomes and quality of care [92]. Furthermore, perceptions of judgment from health professionals can have a negative effect on weight loss [93]. While this intervention was administered by researchers in a community setting, it remained important for program staff to foster supportive relationships with participants to ensure that they felt accepted and did not experience stigma or judgment.
The present study is not without its limitations. First, given that the focus groups were moderated by members of the research team, it is possible that the positive feedback received from participants was influenced by social desirability [94], despite the use of honesty demands [75]. Second, the focus groups were conducted immediately following the intervention which might have increased positive perceptions related to the program and also limits the researchers' ability to capture participants' long-term perspectives of the program. Third, while the majority of C.H.A.M.P. Families participants (75%) attended a focus group session, there were four participants who did not participate in the focus groups (one who withdrew from study and three who had scheduling conflicts) and thus, whose perspectives and experiences were not captured. Three of the four participants who did not partake in the focus groups reported lower than average household income and/or education levels, and the same number of participants (although not necessarily the same individuals) attended ≤ 50% of the C.H.A.M.P. Families sessions. Given our small sample, it is unclear whether these factors impacted program participation or effectiveness, or whether the current findings might have differed had these individuals shared their experiences in a focus group. Fourth, it should be noted that despite efforts to recruit a diverse sample of participants, the individuals who participated in these focus groups, and in C.H.A.M.P. Families overall, were fairly homogenous in terms of their ethnicity and socioeconomic factors (i.e., household income and education). This is in line with a previously noted limitation in the childhood obesity intervention literature in which individuals of ethnic minorities and low socioeconomic status tend to be under-represented [55]. Further research examining strategies to improve recruitment, engagement, and adherence of these individuals is warranted. Lastly, as a result of the limited sample size, it was difficult to assert with confidence that true data saturation was reached.

Conclusions
Given the current prevalence of childhood obesity, there is an urgent need for treatment programs that are feasible, effective, and accessible to parents and families [27]. Based onparticipants' perceptions, C.H.A.M.P. Families appears to have been well-received, and to have had an overall positive influence on the health and wellbeing of both parents and children. Further research exploring the development and dissemination of effective communication strategies related to weight and other sensitive health-related topics for families is necessary. Finally, group dynamics strategies should be used to enhance perceptions of belonging among families, and positive family communication should also be emphasized in future childhood overweight/obesity treatment interventions.