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doi:10.1111/jpc.12164

ORIGINAL ARTICLE

Child obesity prevention in primary health care: Investigating

practice nurse roles, attitudes and current practices
Alison Robinson, Elizabeth Denney-Wilson, Rachel Laws* and Mark Harris
Research Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia

Aim: Overweight and obesity affects approximately 20% of Australian pre-schoolers. The general practice nurse (PN) workforce has increased
in recent years; however, little is known of PN capacity and potential to provide routine advice for the prevention of child obesity. This mixed
methods pilot study aims to explore the current practices, attitudes, condence and training needs of Australian PNs surrounding child obesity
prevention in the general practice setting.
Methods: PNs from three Divisions of General Practice in New South Wales were invited to complete a questionnaire investigating PN roles,
attitudes and practices in preventive care with a focus on child obesity. A total of 59 questionnaires were returned (response rate 22%).
Semi-structured qualitative interviews were also conducted with a subsample of PNs (n = 10).
Results: Questionnaire respondent demographics were similar to that of national PN data. PNs described preventive work as enjoyable
despite some perceived barriers including lack of condence. Number of years working in general practice did not appear to strongly inuence
nurses perceived barriers. Seventy per cent of PNs were interested in being more involved in conducting child health checks in practice, and 85%
expressed an interest in taking part in child obesity prevention training.
Conclusions: Findings from this pilot study suggest that PNs are interested in prevention of child obesity despite barriers to practice and low
condence levels. More research is needed to determine the effect of training on PN condence and behaviours in providing routine healthy
life-style messages for the prevention of child obesity.
Key words:

child; obesity; prevention; primary health care.

What is already known on this topic

What this paper adds

1 The primary health care setting plays an important role in providing care to families and children.
2 The general practice nurse (PN) workforce has more than
doubled over the past decade, enhancing the capacity of the
primary health-care team to offer preventive care.
3 The Medicare-supported Healthy Kids Check provides PNs with
the opportunity to assess pre-schoolers health and development and discuss life-style habits with parents.

1 PNs are interested in providing preventive care services in

general practice, with many nding this role rewarding due to
interaction with patients and improvement of patients health
status.
2 Barriers among PNs to provide preventive care for child obesity
included lack of condence, limited role autonomy and perceived
parental lack of interest in discussing healthy lifestyle behaviours.
3 Despite these barriers, PNs indicated great interest in being more
involved in providing child obesity prevention services in general
practice and in participating in child obesity prevention training.

Overweight and obesity affects approximately 20% of Australian pre-school children1 and is a condition with serious health,
social and psychological consequences. Overweight children are
at increased risk of carrying excess weight into adulthood2 and
of developing some chronic diseases early in life.3 Hence, the
prevention of overweight and obesity is critical, especially in the

Correspondence: Dr Elizabeth Denney-Wilson, Research Centre for

Primary Health Care and Equity, University of New South Wales, Sydney,
NSW 2052, Australia. Fax: +61(2) 9385 1513; email: e.denney-wilson@
unsw.edu.au
*Present address: Prevention Research Collaboration, The University of
Sydney, Sydney, NSW 2006, Australia.
Conict of interest: None declared.
Accepted for publication 28 May 2012.

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early years. Primary health care (PHC), and in the context of

this paper, general practice in particular, is an important setting
for addressing obesity prevention given the frequent contact
between professionals and families with young children.
Building skills and providing support for PHC professionals
are important strategies in the prevention and management of
obesity across the life-span.4 PHC providers have shown interest
in delivering care for child obesity and engaging in further
training to improve skills in assessing and monitoring weight as
well as behavioural counselling techniques such as motivational
interviewing.5
Despite this, PHC providers, especially general practitioners
(GPs), have limited time with patients and the routine incorporation of weight assessment is considered by some GPs as impractical.6,7 Even with recent growth in the Australian dietetic
workforce,8 mirrored increases in nutrition-related diseases such

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A Robinson et al.

Child obesity prevention

as obesity and diabetes9 render dietetic services unlikely to have

the capacity to provide universal preventive care for child obesity.
The Australian general practice nurse (PN) workforce has
more than doubled over the past decade, with most general
practices in Australia now employing one or more PN.10,11 This
strong nurse presence in general practice may increase the
capacity for routine healthy life-style advice for the prevention
of child obesity to be provided in this setting. PNs have the
opportunity to assess a childs health through a Medicare Benefits Schedule-rebated health check the Healthy Kids Check
(HKC), introduced by the Federal Government in 2008. Mandatory assessments in the HKC include assessment of eyesight,
hearing and oral health, measurement of height, weight
and calculation of body mass index (BMI).12 Discussion of
eating habits, physical activity and sedentary activities are
non-mandatory components of the HKC. As an established,
Medicare-supported health check, the HKC presents an opportunistic avenue from which PNs may be able to provide routine
healthy eating and activity advice to parents.
Understanding current PN roles, confidence, interest and barriers to providing preventive care for child obesity is needed to
determine the scope for child obesity prevention. This mixed
methods pilot study therefore aims to explore the current practices, attitudes, confidence and training needs of Australian PNs
surrounding child obesity prevention and management in the
general practice setting.

Materials and Methods

Semi-structured interviews
A purposeful subsample of the questionnaire respondents was
invited to participate in a semi-structured interview. Interviews were conducted either by telephone or face-to-face
depending on nurse preference, and lasted approximately
20 min. Informed consent was gained by participating nurses
for the recording, transcribing and qualitative analysis of interview data. Interview questions were designed to expand upon
questionnaire topics to gain a richer understanding of PN
experiences.

Analysis
Quantitative analysis was conducted using SPSS version 17.0
(IBM Corporation, Armonk, NY, USA) by two members of the
research team to investigate associations between PN demographics, workload and barriers and confidence levels relating to
child health checks. Qualitative data analysis was performed by
two members of the research team reading each transcript independently and then meeting to agree upon codes and themes.

Ethics

Participants
PNs from three Divisions of General Practice (DGP) (two metropolitan and one rural division with whom the authors have
previously conducted research) in New South Wales were
invited to take part in the study by responding to a questionnaire. Completion and return of the questionnaire was assumed
as consent for PNs undertaking this part of the study.

Questionnaire
The questionnaire was constructed by the research team and
included questions on nurse demographics, responsibilities,
confidence in and barriers to preventive care practices and interest in further education and training on child obesity prevention. The questionnaire was administered via nurses local DGP,
either electronically or in paper form. The sampling frame was
based on the list of PNs kept by the local DGP. A reply paid

Table 1

envelope was supplied to all PNs when sent a paper survey.

Approximately 292 surveys were distributed (exact number not
available because exact number of PNs in one DGP was
unknown at time of questionnaire administration) from May to
June 2010, with one survey reminder distributed approximately
1 month after the initial invitation.

The study was approved by the University of New South Wales

(UNSW) Human Research Ethics committee.

Results
Demographic data
A total of 59 questionnaires were returned (response rate
~22%), and most surveyed nurses (n = 34, 58%) expressed
interest in participating in an interview. Semi-structured interviews were conducted until data saturation was considered to be
reached (n = 10 interviews). Table 1 shows questionnaire
response rate by division characteristics.
Seven of the nurses interviewed were from a metro-classified
DGP, seven were aged over 40 years and seven had worked in
general practice for less than 5 years.

Questionnaire response rates by Division of General Practice

Division

Rurality

Distribution and return method

Number of nurses

Response rate

1
2
3

Metro
Metro
Rural

Paper based or online

Paper based or online
Online only

107
65
~120

21.5%
32.3%
~12.5

Classication of rurality determined using Rural Remote Metropolitan Area classication guide13.
Response rate approximate for Division as exact number of PNs unknown at time of questionnaire administration.

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A Robinson et al.

PN involvement in preventive care across the

life-span
Questionnaire data including respondent demographics is
detailed in Table 2. Adult health checks consumed up to half
of most (78%) PNs work time; however, the time spent on
child health checks was considerably lower, with 47% of PNs
indicating they spend less than 10% of their time on this
activity.
Qualitative data revealed that the amount of time PNs spent
in preventive care activities was largely determined by practice
employers, GPs and the needs of acute care patients. Most
nurses described enjoyment of preventive care activities, as they
perceived rewarding outcomes in working with and empowering patients to improve their health status.
Why do I enjoy it? I think because you are giving people
information for their own health and youre trying to get it so
that they understand what is wrong with them . . . so that
they can help look after themselves . . . and I think thats
giving people pride or independence back to them (Nurse 4,
rural).
Enjoyment of preventive care activities was also reflected in
the quantitative data with three-quarters of PNs reporting to be
moderately or very interested in being more involved in adult
health checks and/or providing child obesity prevention services
in their general practice (use of the term being more involved
was used in the survey; therefore, results are based on respondents own perception of more rather than a specific quantification of how much more involved PNs would like to be). Over
80% of nurses were moderately or very interested in participating in further training in chronic disease prevention in general
practice.

Barriers to providing preventive care for children

The most frequently cited barrier regarding prevention and
management of child obesity was the nurses perception that
socio-economic factors prevent families making healthy lifestyle changes, with over 70% of respondents rating this barrier
as moderately or very important. Perceived lack of patient interest (either parent or child) was also considered a concern, with
69% of respondents rating the barrier as moderately or very
important. No significant differences in perceived barriers such
as PN lack of confidence, insufficient knowledge, lack of interest
or lack of time were found between PNs with up to 5 or >5
years experience in general practice. However, PNs with <5
years experience in general practice rated a lack of educational
materials as more of a barrier (P = 0.05) and their own life-style
habits less of a barrier (P = 0.05) than PNs with more than 5
years experience in general practice. Questionnaire data
revealed respondents did not rate time as a highly important
barrier to providing care for child obesity; however, some PNs
interviewed described competing workload demands and staff
constraints as contributing to their lack of time.
I think time is a bit of a barrier . . . sometimes it would be nice
to have a little bit more time particularly with some patients
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that have more issues . . . youre constricted with time and

the busyness of the practice . . . (Nurse 7, metro).
Irrespective of time restraints, PNs who reported having a
high level of autonomy and a supportive general practice team
were able to overcome barriers of time and parent lack of
interest in HKCs by scheduling appointments in a way that best
suited parents.

Condence
Nurses reported greater confidence in providing healthy lifestyle advice to overweight adult patients compared with providing advice to parents of overweight children (Table 2). Less
than half of PNs (43.1%) surveyed reported moderate or high
confidence in conducting child health checks, assessing BMI
and providing suggestions to parents about healthy eating,
physical activity and limiting screen time. PNs spending more
than 10% of their time on child health checks reported greater
confidence providing healthy eating (P = 0.01) and physical
activity (P = 0.05) suggestions to parents than PNs spending
<10% of their time on child health checks. PNs with <5 years
experience in general practice indicated lesser confidence than
those with >5 years experience in assessing dietary intake as
part of child health checks (P = 0.003), providing advice to
parents of overweight children (P = 0.001) and providing
suggestions to parents regarding setting limits on screenbased activities for children (P = 0.01). Education, training,
resources, life experiences and employment history were
also key factors influencing confidence levels in providing
advice for child obesity prevention of the ten PNs who were
interviewed.
The [DGP] came through and gave us support to set it [HKC]
up. We have a template from them. . .and also training at the
Division so Im fairly confident in what Im doing (Nurse 3,
metro).

Experiences conducting the HKC

Despite PNs indicating greater confidence when providing
healthy eating and activity advice to overweight adult patients
than parents of overweight children, interviewed nurses
reported few problems with parents during consults, with only
some difficulties arising when raising issues of weight and
screen time.
Were finding almost 95% of the time its received quite well
. . . about 5% though is not received that well and perhaps
that has something to do with if . . . the child is overweight or
obese, we need to make some changes and if that parent that
is with them is obese . . . and resists in making changes in
their family so they dont really like to communicate too
much about it . . . (Nurse 8, rural).
Some PNs perceived hesitation from parents when attempting
to make appointments for the HKC and found they had to
explain the purpose and benefits of the check to parents before
parents would agree to make an appointment.

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A Robinson et al.

Table 2

Child obesity prevention

Questionnaire data

Gender
Female
Age
2039 years
4049 years
50+ years
Years in general practice nursing
05 years
610 years
11+ years
Responsibilities in practice nursing
030%
3150%
Time spent conducting adult health checks
32 (58.2%)
11 (20.0%)
Time spent conducting child health checks
47 (88.7%)
4 (7.5%)
Time spent in other preventive activities
30 (58.8%)
9 (17.6%)
Condence in practice
Conducting adult health checks
Providing advice to overweight adult patients about healthy eating and activity
Assessing body mass index as part of child health checks
Providing suggestions to parents regarding healthy eating for children
Assessing growth as part of child health checks
Providing suggestions to parents regarding physical activity recommendations for children
Providing suggestions to parents regarding setting limits on TV and other screen-based activities for children
Conducting child health checks
Assessing physical activity levels as part of child health checks
Providing advice to parents of overweight children regarding healthy eating and activity
Assessing dietary intake as part of child health checks
Potential barriers
Socio-economic factors affecting the ability of families to make a change (e.g. cost of health food/referral to
exercise programs)
Patients lack of interest in making life-style changes
A lack of referral pathways to provide additional/ongoing care for patients if required
A lack of support for me to undertake this work in my role
My own lack of time
Lack of appropriate education materials for patients available at my general practice
A lack of relevance to the patients presenting issue
My lack of condence in counselling skills regarding child obesity prevention
My concerns patients/parents will not be receptive to healthy eating and physical activity advice
My insufcient knowledge about preventive care for child obesity (including healthy eating and physical activity
recommendations)
Advice regarding healthy eating and physical activity is not effective in preventing child obesity
Communication difculties with patients
Lack of relevance to my job role
Cultural differences between nurses and patients
My lack of interest in addressing child obesity preventive measures
My own life-style habits
Interest in further education and training
Participating in further training in chronic disease prevention in general practice
Being more involved in conducting adult health checks in my practice
Being more involved in providing child obesity prevention services in general practice
Being more involved in conducting child health checks (e.g. 4-year-old health check) in my practice
Participating in further training in child obesity prevention in general practice
Training preference for those interested in participating in further training in child obesity prevention
Half-day workshop
Full-day workshop
Self-directed online tutorial
Online module with tutor
Unit of study within graduate diploma

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57 (96.6%)
15 (25.4%)
28 (47.5%)
16 (27.1%)
33 (55.9%)
11 (18.6%)
15 (25.4%)
>50%
12 (21.8%)
2 (3.8%)
12 (23.5%)
Moderately or very condent
51 (87.9%)
44 (75.9%)
28 (49.1%)
28 (48.3%)
27 (46.6%)
26 (44.8%)
26 (44.8%)
25 (43.1%)
24 (41.4%)
22 (37.9%)
21 (36.2%)
Moderately or very important
41 (73.2%)
38 (69.1%)
37 (66.1%)
35 (64.8%)
36 (62.1%)
34 (61.8%)
33 (60.0%)
33 (58.9%)
32 (57.1%)
29 (51.8%)
28 (50.9%)
28 (49.1%)
24 (46.2%)
21 (38.9%)
20 (37.0%)
19 (33.3%)
Moderately or very interested
48 (84.2%)
44 (78.6%)
44 (77.2%)
39 (70.9%)
Interested
50 (87.7%)
Indicated some interest (more
than one response allowed)
38 (65.5%)
37 (63.8%)
26 (44.8%)
23 (39.7%)
12 (20.7%)

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A Robinson et al.

When we make the appointment, I also remind them what

its about. They usually make inquiries. Some are hesitant
because they dont know why its being done . . . we go
through the need to have it done (Nurse 3, metro).
Qualitative data revealed PNs who described having a low
level of autonomy in their general practice perceived less positive experiences with patients and greater barriers to conducting
child health checks.

Future possibilities to improve services

Quantitative data showed over 85% of PNs expressed an interest in further child obesity prevention training, with workshops the most favourable formats for training. PNs stated they
would like broad information on healthy life-style assessment
and advice, as well as additional resources to improve their
services.
I think assessing childrens diets and the childrens BMI . . .
would actually be quite good (to have) a bit more background and knowledge about that as well . . . healthy
eating recommendations for children . . . physical activity
recommendations . . . and then perhaps some strategies to
encourage families to adopt healthy lifestyles as well (Nurse 7,
metro).

Discussion
This mixed methods pilot study investigated roles, attitudes and
preventive care practices for child obesity among a small sample
of PNs in New South Wales, Australia.
The HKC provides an ideal opportunity to assess a childs
weight and provide healthy life-style advice to promote healthy
weight gain as part of routine care. However, the overall percentage of time respondents spent conducting child health
checks was low, compared to that for adult health checks.
Although the number of HKCs performed by PNs increased by
15% between the periods July 2008 to June 2009 and July 2009
to June 2010,14 low awareness and reluctance of parents to
attend the child health check suggests the need for greater
promotion of the value of the checks to parents, perhaps as part
of the school enrolment process.
Qualitative findings in this pilot study indicated that GPs and
employers largely determined PN roles, with priority given to
the provision of acute care. This suggests organisational and
structural barriers to PNs providing preventive care that are
likely to require solutions at the system level such as greater
reimbursement and funding models to support PNs role in providing preventive care. The theory of planned behaviour,15,16
which has been previously applied to preventive care delivery in
general practice in a predominantly GP cohort,17 would suggest
that in this context, social pressure is focused away from PNs
performing preventive activities and directed rather at tasks
such as wound care and immunisations. Combined with a low
level of autonomy in determining workload, PNs may feel
expected to comply with this pressure and therefore less likely
to perform preventive care tasks.
Common problems to addressing child obesity prevention as
described by PNs surrounded parental barriers, including
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PN-perceived low receptiveness to healthy life-style messages,

particularly among low socio-economic groups; perceived lack
of confidence and lack of support, all of which are consistent
with previous research findings.6 Previous studies among
adults have observed no influence of socioeconomic status on
ability to make life-style changes18 and that life-style interventions can be equally effective for disadvantaged individuals;19
however, much less is known about the capacity and motivation for disadvantaged families to engage in obesity prevention
and there needs to be more research in this area. A study into
parent attitudes towards receiving healthy life-style advice for
prevention of child obesity by primary care GPs revealed that
parents were interested in improving their childrens dietary
intake and were receptive towards life-style counselling from
professionals trained in motivational interviewing.20 Recent
studies have shown that patient resistance to discussing
life-style issues is primarily a product of the practitioner
behaviour, in particular the use of confrontation, warning and
raising concerns and giving advice without permission.21,22
In contrast, the use of motivational interviewing approaches,
including affirming client autonomy, providing advice with
permission, using open questions, reflection and support, have
been shown to enhance patient receptiveness, reduce resistance and promote readiness to change.21,23,24 This suggests
the importance of PNs acquiring skills in motivational
interviewing.
PN lack of confidence in assessing BMI, dietary and activity
behaviours and providing health life-style advice for children is
a major issue in providing obesity prevention interventions. This
suggests the need for further training, which the nurses themselves were overwhelmingly in favour of. Previous research on
life-style risk factor management practices of PHC providers in
the community health setting suggests that professional development activities should focus largely on building positive clinician attitudes (or shifting negative perceptions) and building
self-efficacy and skills rather than just improving content
knowledge of life-style-related areas.25
Limitations to this pilot study include the small sample size
(n = 59) and PNs responding to the survey and those interviewed may have greater interest in child obesity prevention
and preventive care in general and may not reflect the broader
views of the PN workforce. However, demographic data of age
and years of PN experience of respondents was comparable
with nationwide estimates from the 2009 Australian General
Practice Network National Practice Nurse workforce survey
report.10 Another limitation of the study was the lack of piloting of the questionnaire used. However, the survey was
adapted from a previous validated tool, the Preventive Medicine Attitudes and Activities Questionnaire.26 Given the lack of
previous research on PN practices and attitudes in child obesity
prevention in Australia, this study provides important new
insights. Further research is however needed to explore PN
roles in obesity prevention interventions and the effectiveness
of such approaches.

Acknowledgements
This study was funded by a UNSW Faculty of Medicine, Early
Career Research Grant to E Denney-Wilson and a PHCRED

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Journal of Paediatrics and Child Health 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

A Robinson et al.

Child obesity prevention

Researcher Development Program placement to A Robinson.

We would like to thank participating DGP and PNs for their time
and valuable input into the study.

14

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