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Service quality and attrition: an examination of a pediatric obesity program

Max P. Cote, Terri Byczkowski, Uma Kotagal, Shelley Kirk, Meg Zeller, Stephen Daniels
DOI: http://dx.doi.org/10.1093/intqhc/mzh015 165-173 First published online: 29 March 2004


Objective. To examine the demographic, illness, and quality of care determinants of service attrition in a pediatric obesity program, and to elucidate factors that may promote families’ return to care.

Design. Cross-sectional survey with semi-structured interviews.

Setting. A regional children’s hospital in the United States.

Study participants. Caregivers of 163 patients, consecutively enrolled in a pediatric obesity treatment program between January 1998 and September 2000, were contacted by telephone and offered participation in a survey of clinical care experiences. A total of 120 (74%) families participated.

Main outcome measures. Service attrition as defined as premature discontinuation of treatment before completing phase I of a multi-phase treatment program.

Results. Multivariate results indicated that service attrition was associated with both insurance status and perceived quality of care. Patients with government-subsidized insurance were more likely to defect from services than those with commercial insurance. Perceived quality of care was highly associated with attrition after controlling for demographic and health parameters. Caregiver-reported reasons for service attrition included difficulty with adequate insurance coverage (53%), the child’s desire to leave the program (50%), and the program taking too much time (32%). The most frequent suggestions to facilitate families’ return to the program were: (i) assistance with insurance coverage; (ii) following up with families; and (iii) increasing engagement with the child.

Conclusions. This study found few demographic differences between patients completing the program and those defecting from services. Both families completing the program and those discontinuing prematurely rated the overall quality of the program as high. However, lower quality of care was related to increased service attrition even after controlling for the effects of demographic and health parameters. Although a considerable number of patients discontinued services, very few reported that they would not return to the program. The results provide further support for ongoing audit and examination of families’ care perceptions in preventing attrition and promoting service recovery.

  • attrition
  • children
  • health care utilization
  • service quality

Failure to attend and complete treatment programs is a common and worrying problem for professionals working in medical and behavioral health services. In fact, several authors have noted the importance of reducing ‘service attrition’ in improving access to care, improving the effectiveness of treatments, and reducing the social costs associated with illness and disability [1,2]. When customers leave a service prematurely, missed appointments contribute to delays in access to care for those already waiting for treatment. More importantly, retention is essential to the success of most interventions and is recognized as one of the biggest hurdles of treatment programs [4]. However, interventions to increase patient attendance at treatment have focused on compliance of the patient [5] and not on the care environment or delivery. Considering non-compliance solely as a function of the defective patient ignores the patient perspective and evidence suggesting that their evaluation of services may be the most important determinant of appointment keeping [6]. Thus, the importance of understanding the patient perspective is critical to developing effective strategies to promote patient completion of empirically supported programs.

Retention in pediatric weight management programs

Retention of patients is particularly important for developing weight management programs attempting to address the growing problem of pediatric obesity in the United States. Overweight is the most common health problem for children in the United States and continues to increase rapidly, particularly among African Americans and Hispanics [7]. The significance of the growing problem of pediatric obesity is evident in the relationship between body fatness in children and adolescents, and increased cardiovascular risk factors including elevated blood pressure, total cholesterol, and serum lipoproteins [8,9]. Furthermore, evidence suggests that obesity in adolescence carries risks for early death and morbidity into adulthood [10] and that costs of obesity in adults in the United States approximate $100 billion annually [11]. Consequently, several authors have suggested the importance of concerted efforts to prevent or treat pediatric obesity in achieving substantial benefits in social costs and outcomes across the developmental span [1214].

Clinicians working directly with patients, however, have suggested that most pediatric obesity interventions are marked by small changes in relative weight and large losses to follow-up [15]. In fact, a multi-center study using nutrition intervention with >1300 children was deemed a failure after the attrition rate exceeded 90% [16]. Although some pediatric weight management programs have been successful in the retention of patients and consistently improving health outcomes [17], they have usually included highly selected patients in a routine clinical weight management setting. Consequently, little is known about pediatric patients who discontinue treatment or their perspectives.

Research with adult populations has reported attrition rates of 66% for behavioral weight control programs [18]. The determinants of retention in adult weight management programs appear to vary across demographic, behavioral, illness severity, and psychological variables [19]. For example, Clark et al. [20] found that increased age and exercise were associated with decreased attrition in a weight management program, while higher levels of depression and current cigarette smoking were associated with increased attrition. Similarly, Mitchell and Stuart [21] reported that increased age, perceived success and efficacy were associated with decreased attrition, and increased frequency of weight loss attempts were associated with increased program attrition. Despite several studies examining the determinants of attrition from adult weight management programs [19], no studies could be found with pediatric populations.

Understanding and addressing the determinants of attrition and treatment failure in pediatric weight management programs are important to ensuring the ongoing support of health care organizations who are initially reluctant to fund these empirically based treatments [12,22]. In addition, by understanding the reasons why patients discontinue services, providers and administrators can develop interventions to improve retention and ultimate outcomes [2].

The purpose of the current investigation was three-fold: (i) to examine sociodemographic, health, and quality of care parameters associated with attrition in a pediatric obesity program; (ii)to determine parental reasons for attrition; and (iii) to elucidate factors that may promote retention and customer recovery. Previous studies of non-attendance have concentrated on measuring the magnitude of service attrition or on solely comparing characteristics of those who attend and those who do not [23]. However, we hypothesize that a lower perceived quality of care is associated with attrition, even when physical health status and other potential confounding demographic variables are controlled analytically.


Program requirements and definition of service attrition

The study took place in a newly developed multidisciplinary pediatric obesity program of an urban tertiary care children’s hospital. The pediatric obesity program is structured to provide an intensive initial phase (see Table 1), followed by varying intensities of intervention individualized to meet families’ needs and goals [24]. HealthWorks! phase I includes a 12-week comprehensive weight-management treatment program for children (5–10 years old) and adolescents (11–17 years old) emphasizing: diet modifications, promotion of an active lifestyle, behavior therapy, supportive parental involvement, comprehensive clinical evaluation, individual nutrition counseling, group exercise sessions, and group parental education. The goals of the program include positive changes in body composition, adherence to a healthier lifestyle, improved child self-esteem, and communication with family members and peers. After participants complete the 12-week program and reassessment, 6-month (phase II) and 12-month (phase III) integrated after-care programs are available. Each successive phase remains individualized to the patient’s after-care needs and involves treatment support from the entire care team. With each new phase, contacts between the care team and families occur with decreasing frequency, and weight management strategies become progressively less clinic-based and more home-based.

View this table:
Table 1

Phase I: pediatric obesity program components

1. Initial assessmentThe initial clinical assessment includes evaluation by a physician, a psychologist, a registered dietitian, a nurse, and an exercise physiologist.
2. Orientation to behavior managementPrior to establishing a plan for treatment, all families are required to attend a group orientation session providing information about the components of effective behavioral management including the use of goals, contracts, incentives, and daily monitoring.
3. Treatment planFollowing the initial assessment, care providers meet to review results and to determine an appropriate intervention strategy, which is subsequently tailored to the needs of the family.
4. Follow-up visits and group activityOnce every 2 weeks participants and their families meet with a registered dietitian/case manager. The case manager reviews adherence and provides reinforcement for the contracted goals. In phase I there are a total of five follow-up visits. Between follow-up visits, each participant is required to attend group physical activity at least once a week.
5. Parent education classesEducation sessions are offered to parents while their child is attending group physical activity. These sessions are designed to equip caregivers with the skills to support the participating child.
6. ReassessmentThe reassessment involves repeating the measures obtained at the initial assessment and reviewing subsequent changes with the family to promote long-term motivation and commitment to health maintenance.

Multiple outcome indicators are used to evaluate progress, including the adoption of healthier eating behaviors, increases in the level of physical activity and fitness, improvements in body composition rather than strictly weight loss, and other clinical measures (e.g. blood pressure, blood lipids, and insulin levels). The program is demanding and participants are closely followed using a case management model, with registered dieticians providing regular follow-up and support; additional support and consultation are provided by an interdisciplinary treatment team comprised of a physician, psychologist, nurse, and exercise physiologist.

In the current study, service attrition was defined as any premature discontinuation of treatment before completing phase I of the program (see Table 1) and the associated treatment goals; ‘completers’ included all those who completed phase I.

Setting and participants

Participants who were eligible for inclusion were 163 consecutive families receiving treatment between January 1998 and September 2000. This program had three admission criteria unrelated to the purpose of the present study: (i) children (aged 5–10 years) with a body mass index (BMI, kg/m2) greater than the 95th percentile; and (ii) adolescents (aged 11–17 years) with either 100% over their ideal body weight (defined as expected weight at the 50th percentile for BMI) or (iii) with a BMI greater than the 95th percentile and a medical complication associated with being overweight.

Procedure and measures

The data were collected by telephone using interviewers trained and experienced in conducting patient satisfaction interviews. Two weeks prior to telephone interviews, all eligible participants were sent a letter describing the purpose of the planned interviews and requesting their participation. Verbal consent for participation was obtained at the time of the interview. Each participant was informed verbally that the interview was voluntary, and that even after the interview had begun, participants were free to refuse to answer any question and/or to terminate the interview at any point. Participants were also informed that only aggregated responses would be supplied to program coordinators, and that no report of this study would ever identify them in any way. Clinic records were also used to acquire additional information such as percentage over ideal body weight (IBW), child race, and medical insurance status. Data were collected from September 2000 through August 2000. Attempts were made to conduct telephone interviews with parents of all consecutively enrolled patients during the study period. All procedures were in keeping with the standards established by the Institutional Review Board. The following measures were completed by parents at the time of the phone interview.


Parents were asked to provide general demographic information about the family, including child age, gender, race, primary caregiver income, education, and insurance status.

Health parameters

Health status was assessed using the Children’s Health Questionnaire global health assessment question [25]. Primary parents, or guardians, were asked to rate their child’s overall health on a five-point scale (excellent = 1, very good = 2, good = 3, fair = 4, poor = 5). This estimate of general health status has been used extensively in studies of child health [26,27]. In addition, height, weight, BMI, and percentage over IBW at intake was collected from chart review. Percentage overweight was calculated in reference to the 50th percentile BMI based on age and gender [28]. The BMI is considered the most appropriate measure to evaluate obesity in the clinical setting [29] and has been used extensively in studies of adult and pediatric weight management [7,30,31].

Quality of care

Quality of care was assessed using the overall quality of care single item rating from the Consumer Assessment of Health Plan Study (CAHPS 2.0) surveys. Parents were asked to rate the overall quality of care their child received on an 11-point scale (0 = the worst care possible, 10 = the best care possible). The CAHPS surveys were developed jointly between the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality), Harvard Medical School, RAND Corporation (Santa Monica, CA), and the Research Triangle Institute (Research Triangle Park, NC). The purpose of the collaborative effort was to develop a comprehensive set of surveys for assessing the experience of care for persons in health care plans. The CAHPS activities included the development and evaluation of a survey about children’s experiences with care and health plans. The CAHPS surveys have been extensively studied and demonstrate adequate validity and reliability estimates [32,33].

Reasons for drop-out

Families in the early drop-out group were asked to rate a list of possible reasons for leaving the program including: (i) difficulty with medical insurance coverage; (ii) program participation took too much time; (iii) issues with adequate transportation; (iv) program’s failure to meet family expectations; (v) child’s desire to leave the program; and (vi) inconvenience of appointment times. Ratings on the ‘reasons for drop-out’ items were obtained on a 3-point scale (a lot, a little, not at all). The final list of reasons was based on clinician consensus regarding common reasons families report discontinuing services. As a supplement, families were asked to report any additional reasons for leaving the program. Lastly, families in the drop-out group were asked what the program could do to facilitate their return.

Statistical analysis

The statistical methods used in this study include bivariate and multivariate techniques analyzed using the SAS Statistical Software, Version 8.1 (SAS Institute, Inc.). Descriptive statistics were used to describe demographic and health characteristics of the patient population. To examine the sociodemographic, health, and quality of care parameters associated with retention, preliminary analyses were performed to determine which potential predictor variables had significant bivariate relationships with the primary outcome variable, retention. The independent variable of primary interest for these analyses is parent-reported quality of care. To confirm that any associations between perceived quality of care and retention are not caused by a third or background factor, we controlled for the child’s health status and family sociodemographic characteristics. Health-related control variables included percentage over IBW and parental report of general health status. Sociodemographic control variables included income, parent education, medical insurance status, child age, race, and gender.

Child race, gender, parental education, income, and method of payment were treated as classification variables; dummy variables were used to include these variables in the regression analysis. Patient race was categorized as white and non-white (black, biracial, and other). Medical insurance coverage was categorized as commercial (i.e. commercially available health insurance), Medicaid (i.e. government-provided health insurance), or self-pay. Income was classified as <$20 000, $20 000–39 000, $40 000–59 000, and >$60 000. Parental education was classified as less than high school equivalency, high school equivalency, some college, or college graduate. Child age, overall health status, percentage over IBW, and overall quality of care were treated as continuous variables.

Multivariate analysis included logistic regression to examine whether perceived quality of care was associated with attrition before completing the first phase of the pediatric obesity program. We performed the analyses in the following manner: (i) the dichotomous dependent variable was whether or not the child dropped out prematurely from the program (1 = drop-out, 0 = completed); and (ii) the main effect (perceived quality of care) was included in the regression model, after including and controlling for sociodemographic variables (child age, race, gender, family income, and medical insurance type) and health parameters (health status and percentage over IBW).

Parent reasons for premature termination and suggestions for facilitating participants’ return to the program were summarized using frequency tables.


Patient enrollment and demographics

Of the 163 eligible participants (completers, n = 59; early drop-outs, n = 104), 37 patients could not be reached by telephone and six refused to participate. A significant difference in survey participation was observed between completers and early drop-out patients (P < 0.05). Thus, a total of 120 patients (completers, n = 54; early drop-outs, n = 66) remained for analysis. Of those interviewed, 55% described their ethnic group as white, 40% black, 3.3% bi-racial, and 1.7% other. Forty-seven percent reported Medicaid as their primary form of medical insurance. Thirty-nine percent reported annual incomes of >$40 000 and 89.2% reported receiving at least a high school education. With respect to health parameters, 17.5% of the sample population reported poor to fair health status and the mean [± standard deviation (SD)] percentage over IBW was 105.5 ± 45.0.


Early drop-out patients (n = 66) were compared with completing patients on each of the primary demographic measures (i.e. patient age, race, education, income, medical insurance type), health measures (i.e. overall health status and percentage over IBW) and quality of care measure (i.e. overall quality of care) (see Table 2). Chi-square analyses revealed no significant differences between drop-out and completing participants with respect to education, income, race, gender, or medical insurance type (P > 0.05). Independent t-tests revealed significant differences between drop-out and completing patients on overall health status and overall quality of care (P < 0.005). Drop-out patients had a mean overall health status score of 2.9 (SD = 1.0) and completing patients a mean of 2.4 (SD = 1.0). The mean overall quality of care rating for drop-out patients was 8.4 (SD = 1.6), while for completing patients the mean was 9.3 (SD = 1.0). Parental ratings on the ‘reasons for drop-out’ indicated that >30% of parents defecting from the program had difficulty with medical insurance coverage (see Table 3). Similarly, >30% of parents reported that the ‘child’s desire to leave the program’ was a factor in their decision to discontinue treatment.

View this table:
Table 2

Patient and health characteristics (n = 120)

Completing group (n = 54)Drop-out group (n = 66)
Mean age (years)11.4 (2.54)12.21 (3.33)
Insurance status
    Self pay16.7%12.1%
    Less than high school equivalency13.0%9.1%
    High graduates27.8%28.8%
    Some college29.6%45.5%
    College graduate29.6%16.7%
Household income <$40 00055.8%42.4%
Mean overall health status [standard deviation (SD)]2.35 (0.99)2.89 (1.02)1
Mean percentage over ideal body weight (SD)100.2 (37.23)109.85 (50.36)
Mean overall quality of care (SD)9.3 (.95)8.4 (1.56)2
  • 1 P < 0.01.

  • 2 P < 0.001.

View this table:
Table 3

Parent-reported reasons for drop-out from a pediatric obesity program (n = 66)

Percentage reporting
A lot (%)A little (%)Not at all (%)
Difficulty with insurance coverage33.319.747.0
Program participation took too much time6.125.868.2
Issues with adequate transportation18.29.172.7
Programs failure to meet family expectations12.115.271.2
Child’s desire to leave the program33.316.750.0
Inconvenience of appointment times6.125.866.7

Multivariate analysis

Multivariate logistic regression models were constructed to test the effect of perceived quality of care on attrition, controlling for socioeconomic and health parameters. In the regression model, attrition was higher among those with Medicaid insurance type. Unlike the results from the bivariate analyses, overall health status was not significantly associated with attrition once perceived quality of care was added to the final model. Even when the effects of sociodemographic and health parameters are accounted for, perceived quality of care continues to be associated with withdrawal from the program. Table 4 indicates that caregivers who rated their child’s quality of care as lower were significantly more likely to have left the program before completing the first phase of treatment.

View this table:
Table 4

Logistic model predicting service attrition in the pediatric obesity program by quality of care, controlling for demographic and health parameters

VariableLost to follow-up
P-valueBeta coefficientOdds ratio
Child age0.90−0.010.99
    Less than high school equivalency0.70−0.310.73
    Some college0.74−0.190.83
    College graduate0.13−1.160.31
    Household income <$40 0000.91−0.070.93
    Overall health status0.12−0.370.69
    Percentage over ideal body weight0.330.011.01
    Quality of care0.01−0.5620.57
  • 1 P < 0.05

  • 2 P < 0.01.

Controlling for sociodemographic and health parameters in the logistic regression model analysis is another way to ensure that immutable factors (e.g. race), poor health, or both, which may be associated with attrition, do not confound the association between lower perceived quality of care and premature withdrawal from the program. In fact, even when these sociodemographic and health parameters were accounted for, the association between lower perceived quality of care and attrition remained. The multivariate analyses provide support for an independent effect of lower perceived quality in increasing the frequency of attrition from the pediatric obesity program.

Facilitating families return to the program

Table 5 presents details of families’ suggestions to facilitate return to the program. Firstly, families frequently suggested that the clinic assist caregivers with understanding and facilitating insurance coverage of program. In fact, several of the families in the drop-out group reported that their medical insurance company failed to cover the costs of the program. Secondly, many caregivers suggested that follow-up phone calls would be sufficient in promoting their family to return. Although initial attempts to re-engage the family at the time of drop-out were unsuccessful, the results suggest that several families may reconsider their participation over time. Thirdly, respondents suggested improving the availability/flexibility of appointment times, with families requesting later evening as well as weekend appointments. Fourthly, caregivers also suggested that their children were resisting attendance and requested that the program increasingly work directly with the child to provide encouragement and facilitate engagement.

View this table:
Table 5

Parental suggestions for facilitating return to the program (number of suggestions = 701)

SuggestionFrequency (%)
Help with insurance problems24%
Just call12%
Child doesn’t want to—help engaging the child12%
Nothing, the child doesn’t want to11%
Better appointment times9%
Reduce the cost9%
Increase the range of services6%
Help with transportation problems5%
Other suggestions to facilitate patient return included:
    Reduce time commitment required
    Improve the billing system
    Nothing, the child has a more serious medical condition at this time
    Nothing, we finished the program
    Address child’s self-esteem needs
  • 1 Four drop-out respondents provided two recommendations each.


The current study examined the relations of demographic, illness, and quality of care variables to retention in a pediatric weight management program in the United States. Three major conclusions can be drawn from the study. Firstly, these findings confirm that service attrition is a significant problem in pediatric weight management, with rates of attrition similar to programs for adult populations [18]. The case for finding ways to increase retention or to provide alternative means of health service provision is therefore strong.

Secondly, similar to adult studies, the reasons for attrition are multifactorial and do not appear to be captured sufficiently using demographic or health-related parameters in isolation. Although previous studies of pediatric populations have suggested the importance of demographic variables in predicting appointment attendance, with the exception of Medicaid versus commercial medical insurance, the current study failed to find any significant differences. However, it is conceivable that factors associated with attendance at routine appointments are different from those actively seeking involvement in a structured treatment program. In fact, research with adult weight management programs suggests that demographic predictors are less often associated with attrition than are behavioral or psychological factors [34,35]. With respect to health parameters in the bivariate analyses, patients with poorer overall health, as perceived by their caregivers, were more likely to have left the program. It is conceivable that those individuals with poorer overall health also suffer from higher comorbidities that require more health care services and that may be of greater concern to parents than their child’s weight. In fact, research has shown that parents of obese children often do not view their child’s condition as a significant health threat [36]; thus, they may be more inclined to pursue other health services for more acute health concerns. In addition, patients with poorer health status may have been perceived by their parents or guardians as less able to actively participate and as such removed their children from the program. For example, Hammersley and colleagues [37] showed an increased morbidity in the defaulters from an adult diabetes clinic. However, the relationship between health status and attrition was not observed in the multivariate regression model for the current study. Thus, the findings suggest that the relationship between health status and attrition may be mediated by other variables included in the model. However, the variable most significantly associated with retention was overall quality of care as perceived by parents. As hypothesized, parents who rated the overall quality of the program as lower were more likely to have discontinued prematurely.

Closer examination of parent responses to factors influencing their decision to leave the program provides further support for the notion that these decisions were complex and multi-faceted. One of the major reasons for attrition mentioned by caregivers was difficulty with insurance coverage. However, our decision to create categories on the basis of insurance type may not sufficiently represent the actual variation in coverage or the difficulty in securing coverage for the various program components. In the current sample, a higher proportion of patients with Medicaid left the program despite having complete coverage for the program; an examination of parental responses suggests that those with commercial medical insurance defected because it wasn’t covered.

In addition, the role of the child in the decision to participate in the program appears to exert significant influence on whether families remain engaged in the program; a potential determinant of attendance that may often be underestimated by clinicians. In fact, a paucity of literature exists to capture the voice of the actual patient in the context of pediatric care [38]. As the current study sought parental feedback alone, it can not be said with certainty that the patients themselves were the driving factor in the decision to discontinue services. However, parents reporting that the child influenced the decision to discontinue services raises a few important questions: (i) to what degree do parents themselves consider obesity to be a medical threat to their children; thus, would parents exhibit the same exit response if their child had a more acute condition?; (ii) are parents potentially using their children as a reason for their own decision to discontinue the program?; (iii) are parents inappropriately empowering their children’s health decisions?; and (iv) are the program components sufficiently tailored to ‘meet families’ where they are in the behavior change process. Considerable research has examined the process of behavior change and has demonstrated the difficulty in changing and maintaining change in complex behaviors [39]. The current program was considerably time intensive and structured. Depending upon the perceived need for change on the part of the parent (and child), this would be expected to result in different outcomes. Regardless, the findings suggest the need to understand the issues families face, and to develop further programs that seek and meet the expressed needs of patients and their families.

Thirdly, the need exists to re-examine means of promoting retention or return to programs. Although previous studies of attendance at routine office visits suggests that family reminders, patient contracting, and clinic orientation programs are successful at promoting attendance with scheduled appointments [40], the current findings suggest that greater attention to process level variables (e.g. quality of care, medical insurance issues, and engagement of the child) and associated interventions are needed. Respondents in the current study suggested a variety of recommendations to facilitate their return to the program. Most obvious, assisting families to navigate the difficulties associated with insurance coverage and billing were considered extremely important in facilitating their return. It is also important to note that while previous authors have highlighted the importance of parental decision-making regarding participation/attendance with health programs [41], the current findings suggest that parental perception of the willingness of their children appears to play a significant role in their continued involvement in the program. However, it is important to note that although parents frequently reported that assistance with insurance issues or follow-up phone calls would be sufficient to facilitate their return, participants and non-completers were contacted frequently throughout the program and after. Similarly, families were provided with individualized financial counseling and assistance with their medical insurance providers.

Although there have been numerous studies of pediatric appointment-keeping behaviors, there is scant literature examining attrition in structured health improvement programs for children. Similarly, very few studies have examined treatment process variables (e.g. perceived quality of care) in behavioral medicine treatments. In contrast, studies of psychotherapy attrition rates underscore the importance of process variables (e.g. the nature and quality of the therapeutic relationship). Based on the current findings, it is conceivable that process factors operating in individual and group psychotherapy attrition may also be occurring in behavioral medicine interventions. By largely ignoring treatment process variables, attempts to identify the determinants of attrition may unknowingly omit factors that are clearly associated with premature discontinuation of treatment. More detrimental, however, is that without adequate consideration of process-related variables professionals may continue to view attrition solely as non-compliant patient behavior. In our current study, we looked at service attrition from a different angle, namely examining both demographic and health parameters as well as a key process indicator, perceived quality of care.

This study has its limitations. Firstly, attrition was conceptualized as a single category; thus, no attempt was made to examine potential differences between early and late drop-outs. Early drop-outs may have difficulty with the treatment rationale or adequate medical insurance coverage, whereas late drop-outs may have an insufficient therapeutic alliance or difficulty with implementation or observing the desired results. Also, an examination of the qualitative responses for facilitating return to the program suggested that at least one family felt that they had completed the program even though they had not reached the objective goals set at the onset of phase I. If additional families felt similarly, it is conceiveable that categorizing all of these families as one homogeneous group could obscure possible mechanisms or predictors distinguishing these two potentially distinct populations [19]. Secondly, the retrospective nature of this research relied heavily on post-hoc interpretation of parent-reported predictors.

Our findings suggest that process level measures are the predominant factors that influence families’ retention in a program to reduce pediatric obesity. The actual disease morbidity and caregiver’s perception of their child’s overall health status appears to be of lesser importance. A number of potential implications for reducing attrition and improving customer recovery can be taken from the findings of this study. Firstly, clinicians and program administrators should give greater consideration to process-related predictors of attrition in behavioral medicine interventions. By not routinely examining the impact of treatment process variables, clinicians remain uninformed regarding treatment-specific factors that could directly influence attrition. Regular audits of patients and their families regarding their perception of care delivery as well as causes of attrition will provide increased opportunity for the improvement of services [42]. Secondly, our study indicates that specific attention should be paid to child participant perceptions and the role their perceptions play in influencing their parents’ decisions to remain engaged in the program. Parents may benefit from increased provider support in addressing the appropriate involvement of children in health care decisions based on the child’s developmental status. Furthermore, greater engagement of child participants as well as soliciting their health service perceptions appear to be important, as children potentially play a greater than anticipated role in remaining with the program. Ultimately, by improving our understanding of the child’s health service perceptions, we will be better equipped to support patients and their parents with respect to the difficulties associated with lifestyle and health behavior change.

Lastly, many families’ suggestions to facilitate return to the program were as simple as a follow-up phone call. In fact, very few of the families contacted indicated that they were not interested in returning to the program. However, it is conceivable that respondents’ suggestions for follow-up were merely a response to demand characteristics associated with survey methodology. More specifically, the act of inquiring about families returning to the program could stimulate the response of a ‘just a phone call’. Further research is needed on these and other techniques for re-engaging those who defect from service since the structure of the program itself would suggest that families as a whole would have received regular telephone follow-up and other interventions to facilitate their maintenance and return to the program. Without such work, the available technological improvements in the care of obesity will not influence the medical status and long-term outcomes of the many patients who defect and disengage from treatment. Collectively, the findings of the current study suggest ample opportunity to prevent service attrition and to promote service recovery in the treatment of pediatric obesity.


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