A total of 16 individuals were interviewed in this study, nine trial intervention participants and seven HCPs. Thirteen of the fourteen participants randomised to the trial intervention initially agreed to be contacted to participate in this interview study. Two were subsequently unavailable; one could not be contacted within the study timeframe; and one reported that they were too busy to participate, therefore nine participants were interviewed. At least one participant from five of the seven participating practices was interviewed. All nine participant interviews were conducted face-to-face in participants’ homes. The median age of participants in this report was 32 years (range 23–42 years). Eight participants lost weight during the intervention and one maintained their baseline weight (see Additional File 2). Further details of participant characteristics are reported in the trial paper previously published . All nurses approached were interviewed. Four nurse interviews were conducted by telephone (three in their practice and one at home) and three were face-to-face in practices. One nurse (or GP) from each of the seven intervention practices was interviewed: six practice nurses and one general practitioner.
Three main themes emerged from all the interview data; evaluation of the intervention, feelings around self-weighing and weight loss, barriers and facilitators to weight loss; (Additional File 3), 18 sub-themes from intervention participants and 17 sub-themes from practice nurses. This report focuses on the sub-themes where different perspectives around the same issue demonstrate disjuncture between intervention participants and nurses; or where sub-themes unique to either party contribute to contemporary discussion and debate regarding raising the topic of weight during health care consultations and routine weighing of participants by HCPs.
How, where and when is the right time to intervene?
No participants thought that child immunisation appointments were an inappropriate time for delivering a brief weight loss intervention, or to discuss weight with them. Some women appreciated the convenience that they did not have to make an ‘extra trip out of the house’ with their baby to be weighed, and that it was easy to integrate the intervention into their lives. Most nurses felt that the ‘ideal time’ for raising the topic of weight loss with mothers was 6–8 weeks postnatally, with some nurses suggesting an alternative or additional time could be to deliver the intervention at the six week postnatal check as this is an appointment specifically to assess the health of women, rather than the baby. There was also a feeling amongst nurses that any HCP that had contact with the mother could discuss weight loss with new mothers.
“That would be… quite inconvenient. Just to go there to be weighed. Because I’d have to take the baby, and. In the early days… you know… It’s more difficult to get out and about, so… I was happy to do it, because I was there anyway.” Participant 9, (lost weight)
“I just think. as a healthcare provider I’d be more erm, open to having that discussion [about weight loss] at the postnatal check with the mum.” Nurse 5.
Whilst most participants talked about the difficulties of caring for a new-born baby, only one would have preferred to start the intervention a few weeks later than the first immunisation; they perceived that this would place less pressure on mothers, who could be going through a “hard” time.
Feelings about self-weighing and including weighing at child immunisation appointments
No participants voiced objections to being prompted/reminded to self-weigh and record their weight on their record card. Likewise, most nurses reported that participants seemed comfortable with being weighed by them; with one nurse reporting that one participant “jumped on the scales” and appeared to enjoy finding out how much weight they had lost. However, two nurses reported that some of their participants were uncomfortable with being weighed, appearing embarrassed about their weight. Only one nurse reported that any of their participants had declined to be weighed by them (on these occasions participants had not lost weight). Some nurses commented that they were concerned that pressuring mothers to lose weight too soon after birth might contribute to postnatal depression (PND).
I didn’t get the impression there were any concerns at all [about being weighed] Nurse 3.
“Your weight’s not going to come off straightaway. So I don’t think we should be pressurising mothers too much. And especially with things like postnatal depression” Nurse 5.
When self-weighing, participants reported how their expectations of their weight affected their emotions; typically they felt “good” when expecting to see that their weight had decreased, while being worried, fearful or “bad” if they expected an increase in weight, due to a “bad week”. For some, self-weighing gave them a sense of being in control of their weight.
“Yeah. some weeks I felt a bit anxious if I hadn’t done well,” Participant 6, (lost weight)
“I guess just like on days when I weigh myself and my weight has gone down, I feel great… and like, I’m in control of things. Do you know what I mean? Like I’m directing the ship and it’s going in the right direction.” Participant 1, (lost weight)
Whilst participants were comfortable with talking about weight with their nurse at immunisations, nurses were more reticent about doing so. Most nurses were concerned about not having enough time at the appointment to discuss a sensitive, and potentially upsetting topic, and then to provide adequate support. With a new mother generally, some nurses were concerned about damaging their relationship by raising the topic. However, because participants were expecting to be weighed at the appointment as part of the intervention, nurses felt this legitimised them raising the topic.
“In an appointment which is already quite full with the baby, you can’t offer the mum the support that you want to offer her because I’d just feel awful if somebody walked out and I was thinking ‘Oh God, I hope they’re alright’.” Nurse 4.
Almost all participants indicated that they were able to weigh themselves most weeks and found the process easy to remember; typically doing so on a specific day. Participants found the weight displayed on the scales as an important way to see that their weight loss efforts were having an effect, and that they were making progress.
“By just setting… the day and the time to do it meant that I could just… yeah, just every Wednesday morning.” Participant 9, (lost weight)
Barriers to weighing women at child immunisations appointments
Regardless of the time allocated for immunisations at their practice, all nurses reported that there was not enough time in current appointment schedule to add more tasks such as this intervention, and a longer appointment time was required if the intervention was rolled out as part of usual care for all women in the UK. Most nurses commented that the purpose of the appointment was to vaccinate babies, therefore weighing women was not a priority.
“I mean, it would be great… if I had time to, you know, give them the encouragement and spend more time on that, but the focus of the consultation was the child.” Nurse 5.
External accountability as a strategy for weight loss
Most participants described that the intervention and the regular contact with their nurse offered a sense of accountability, of being monitored regularly and not wanting to ‘let down’ the nurse; this provided them with a source of motivation to continue to adhere to a healthy lifestyle and weight loss. In contrast, only two nurses referred to the concept of accountability when reflecting on their role in the intervention; both nurses viewed accountability as a positive feature, and that participants knowing that their past weight could be visually seen and compared to their current weight by the nurse, would result in increased motivation to lose weight. Related to this, when participants were asked how the intervention could be improved, about half thought it would be useful to have a phone number or email address to contact if they needed to ask something and did not want to wait until the next immunisation appointment. However, the nature of intervention participants’ responses suggested that this was more about a need for regular contact with a person to keep them motivated, than a need for advice per se, consistent with a desire for external accountability.
“I think it’s more of an incentive. Especially knowing that they [the participants] was being weighed.” Nurse 6.
“Yes because obviously to lose weight these days… is difficult to do on your own than when you’ve got somebody there nagging you in the back of your head. You know you’ve got this programme that you’re doing. It’s like just going to Weight Watchers. You know every week you have to be weighed. It’s similar to this as well. Every week you have to be weighed, so… you’re keeping track of your weight.” Participant 2, (no weight loss)
Signposting to technology for support to lose weight
Both participants and nurses commented that they felt it was acceptable to include referral to an online weight loss programme for support within child immunisation appointments. Most participants commented that the online programme was motivating. Participants expressed views that valued the online support that could be accessed frequently at any time of the day which allowed them to fit around the baby’s unpredictable schedule and they did not need to leave home to receive support. Some participants valued the fact that the information on the POWeR website came from a “trusted source” due to its links with the NHS. Some nurses also highlighted the problem of participants being able to access reliable advice about weight loss after pregnancy from the internet and were pleased the study website contained accurate information for women.
“[It’s] easier because you haven’t got to go out of the house to them. You know, go out of the house with a baby in tow. Um, and you can sort of do it at home. At your own pace sort of thing” Participant 4, (lost weight)
Views about HCPs providing support for weight loss to women at child immunisations
When asked who should be providing postnatal women with advice and information on how to lose weight, nurses felt that any HCP in contact with mothers would be appropriate. One nurse described their role as a nurse as ideal, since midwives or healthcare visitors were focused on the baby, not the mother. Most nurses expressed views that, at least partly, inferred weight loss was the responsibility of the mother, not them.
“Like… people know that they need to lose weight if they are overweight.” Nurse 5.
Several nurses felt the postnatal period was a vulnerable time and that raising the topic of weight loss was an additional “pressure” for women that should be avoided.
“Just relax for a bit. You’ve been through a really traumatic experience. You might already have two toddlers running you. ragged I just think sort of give them a break really, you know?” Nurse 4.
Facilitators and barriers to weight loss after giving birth
All participants were motivated to join the study because they were keen to lose weight. Several participants commented that simply being part of the trial was useful to them, a regular reminder that they had to focus on losing weight. All participants found the intervention, or some aspect of it, increased their motivation or commitment to losing weight. Most intervention participants commented on the perceived effectiveness of the intervention for them. Several participants reported that in some ways, being a new mother was a facilitator, a window of opportunity to re-start healthy habits for themselves and their family. All participants except one would recommend the study to other mothers.
“I want to lose weight. As soon as I had a baby I wanted to lose weight because I’m planning on, a big holiday! So I want, I want to be able to go on the beach.” Participant 2, (no weight loss)
“We want [them] to eat healthy, you know, and it’s all vegetables and fruits that we have [them] on, so that’s nice too- We eat [their] leftovers too. They’re good for us too. We’ll show [them] like “Look, pear is good!” Participant 1, (lost weight)
Breastfeeding was viewed both as a facilitator and a barrier. Some participants felt that it could lead to more calories being burned but others commented that it hindered their efforts to be physically active, for example when gyms did not have breastfeeding facilities and increased hunger from breastfeeding led them to eating more food.
“[They don’]t like bottles and so swimming I can do because I can run up to [the local public swimming baths], swim for a half hour, come back and be back for [their] next feed.” Participant 1, (lost weight)
“The more I’m breastfeeding, I’m more hungry” Participant 2, (no weight loss)
Most participants had to negotiate around the all the needs and schedule of their baby if they wanted to be physically active and it was difficult to leave the house to exercise. Some participants mentioned tiredness from raising a new-born baby and that this impacted their eating behaviours. Similarly, having a new-born baby meant an unknown schedule, and a necessity to plan and work around the schedule of the baby, which led to choosing less healthy foods that were quicker to prepare.
“It’s tough… already. You have a new baby… that is depriving you of sleep. Erm, you have what, two hours sleep, interruptions overnight at times all you want is, you know, cake, wine, takeaway and a few indulgences.” Participant 3, (lost weight)
Participants commented that maintaining behavioural changes was difficult and most discussed the temptation to “fall off the wagon” and to stop their weight loss efforts in the face of alternative pressures, such as stress or tiredness, or allow themselves an “indulgence”. The design of the study intervention was viewed as a method to help them keep “on track”.
“[Being involved] been good because it helped me to, stay in track of my weight because I see, weigh myself every week.” Participant 2, (no weight loss)