Management of overweight and obesity in children and adolescents by nurses: a mixed-method study

Abstract Objective: to analyze the management of overweight and obesity in children and adolescents by nurses of the Family Health Strategy. Method: this is a study of convergent parallel mixed methods, developed in Health Centers of a municipality in northeastern Brazil. In the quantitative stage, data were collected from a questionnaire applied to 98 nurses and analyzed by descriptive statistics. For the qualitative stage, semi-structured interviews were conducted with seven nurses, interpreted by inductive thematic analysis. The quantitative and qualitative results were integrated and presented by a joint display. Results: most nurses rarely checked waist circumference (77.6%), dyslipidemia (55.7%), blood glucose (42.3%), and neither evaluated blood pressure (75.3%). In the qualitative results, we identified that there are nurses who did not classify body mass index according to sex and age. As for medical tests, the requests were mainly related to the routine of childcare. Guidance on physical activity and diet were given in a basic way or attributed to other professionals, and referrals to other services or professionals were not followed up. Conclusion: it is imperative to train nurses for the management of overweight and obesity in primary care for children and adolescents, with a view to quality of care for the prevention of comorbidities.

age and 28.1% of children between five and nine years of age are overweight, and 7% and 13.2% of them, respectively, are obese according to the Body Mass Index (BMI) for age. As for adolescents assisted in PHC, 27.9% are overweight and 9.7% are obese (3) .
Although biological factors have a strong influence on obesity and overweight, the increase in their prevalence in recent decades is related to the adherence to unhealthy lifestyle habits (8) . Thus, obesity can be avoided or minimized if there is prevention and/or timely assistance focusing on recommendations aimed at children, young people, and their families to support a healthy diet to achieve good results, with consumption of more natural and less industrialized foods, physical activity, quality sleep, and reduction of the use of screens and sedentary lifestyle (9) .
Considering the complications caused by this morbidity, the high prevalence rates and the need to manage this chronic disease, managers and health professionals should be attentive and trained to minimize the incidence, prevalence, and consequences of obesity (10) .
The management of overweight and obesity in children and adolescents is one of the nurse's attributions, a function anchored on a legal basis that legitimizes it, including actions related to anthropometry, assessment of nutritional status, guidance on a healthy lifestyle, request for tests, identification of risk factors and more recurrent morbidities associated with overweight, and referrals to other professionals when necessary (3,(11)(12)(13)(14) .
Although studies on the role of PHC nurses in the management of overweight and obesity in children and adolescents are still considered scarce, recent publications show weaknesses in the professionals' conduct to implement the promotion, prevention, and treatment of this morbidity (14)(15)(16)(17)(18)(19) . Among them are studies conducted in Australia (17) , Sweden (19) , and the United States of America (20) . Identifying this management is the first step to support the development of specific protocols and training for this professional category, aiming at the search for improvements in the provided care as well as better quality of life for children and adolescents.
Taking this into consideration, we aim to analyze the management of overweight and obesity in children and adolescents by nurses of the Family Health Strategy.

Method Study design
This is a study of mixed methods, of the convergent parallel type, which is characterized by the collection and analysis of qualitative and quantitative data simultaneously and independently. At the end of the study, the results are integrated in search of convergences and/or divergences between them, considering the same weight allocation to the two approaches (QUAN + QUAL) (21) .
In this sense, a cross-sectional study was developed in the quantitative approach and an exploratorydescriptive research for the qualitative approach.

Data collection site
Data was collected at a UBS in the municipality of Campina Grande, state of Paraíba (PB), Brazil.
In the aforementioned city, the Primary Health and 11 FHT in HD X. Therefore, in total, there were 106 FHT, with one nurse in each team.

Study period
Data were collected between May 2019 and March 2020.

Study population
The study population consisted of 106 nurses from the FHT that worked in the urban, rural, and district UBS, under the responsibility of the Municipal Department of Health of the study municipality.

Selection criteria
The inclusion criteria were: to work in the FHT of UBS in the urban, rural areas, and administrative districts that were under the responsibility of the Municipal Department of Health of Campina Grande (PB); and perform their function for a period of more than three months. The exclusion criteria were: being on vacation, on medical leave, or leave of absence; being an intern or substitute nurse of the UBS. The authors deemed loss after the fourth unsuccessful attempt to meet the professional for data collection.

Data collection
Data from both approaches were concomitantly collected. The qualitative interview was conducted before the application of the quantitative instrument, in such a way that its structured items did not influence the participants' answers. Data were collected in the period prior to the new coronavirus pandemic; therefore, the interviews were conducted in person at the UBS and took place when the nurses finished their work shifts or when they had a free moment between appointments.

Participants
The quantitative approach was performed by a census (23) , that is, with the population of nurses from the FHT of the municipality under study, except for losses and exclusions. After applying the inclusion and exclusion criteria, of the 106 nurses registered in the Department of Health of the municipality, seven professionals were excluded, one for having less than three months of work at the institution, three for being on vacation, and three for being on bonus leave. There was also a loss after the fourth contact attempt. Therefore, 98 professionals participated in the quantitative approach.

Instruments used to collect information
A structured instrument was prepared, considering that no questionnaire was found in the literature to  (12) . It was also based on Law No. 7498/1986, concerning the professional practice (24) , Resolution No. 195/1997, which provides for the request for routine and complementary tests by nurses (25) , and the Nurse's Protocol in the FHS of the State of Paraíba (13) .
To evaluate the reliability and internal consistency of the data collection instrument, the Cronbach's alpha coefficient was applied, whose results vary between 0 and 1, with no negative limits. The closer the Cronbach's alpha coefficient is to 1, the greater the internal consistency of the scale items. Thus, the parameters for evaluation are as follows: α>0.9 -excellent; α>0.8 -good; α>0.7 -acceptable; α>0.6 -questionable; α>0.5 -bad; and α<0.5 -unacceptable (26) . In this sense, the domain "UBS Materials and Anthropometry," although it did not reach the reliability value of 0.7, was maintained in the analysis due to its importance for the evaluation and management of overweight and obesity. Moreover, the Cronbach's alpha value obtained in this dimension is not considered bad or unacceptable. Therefore, the items are homogeneous and the instrument adequately evaluates the construct to which it was applied (Table 1).

Data collection
The quantitative questionnaire was applied faceto-face with the participants, and the questions were impartially asked to the nurses.

Data processing and analysis
The Statistical Package for the Social Sciences (SPSS) software, version 18.0, was used for descriptive analysis of all variables by absolute and relative frequencies, measures of central tendency (mean) and dispersion (standard deviation). Missing data were processed as "missing."

Participants
Seven nurses from different HD were interviewed, selected by convenience sampling, considering the availability of time to participate in the interviews, which were conducted in the nurses' work environment.

Instruments used to collect information
An interview was conducted with a semi-structured script, based on the following guiding question: how is the management of overweight or obesity carried out with children and adolescents?

Data collection
The interviews were conducted in a private room available at the UBS and recorded in audio by digital media, with an average duration of 43 minutes each, after the interviewees' consent. The participants were led by the main researcher of the study, a doctorate student. Regarding the reliability of the qualitative approach, the precepts contemplated by Sandelowski (27) were followed. Field notes were made after the interviews.
The end of the collection occurred according to the criterion of sufficiency, when the authors certified that an internal logic of the data was achieved, enabling to establish a comprehensive framework of the object of study (28) .

Data processing and analysis
The interviews were fully transcribed and interpreted by inductive thematic analysis (ITA) (29) . The conceptual framework that delimited this analysis was the management of overweight and obesity in children and adolescents contained in the national guidelines (3,(11)(12)(13)(14) with regard to Laws, Resolutions, and the Nurse's Protocol (24)(25) .
ITA was developed in six steps. In the first, data were familiarized by transcription, reading, and rereading to survey initial ideas. In the second, the initial codes were produced from the systematized organization of the data set in significant semantic groups. In the third, the search for potential topics was performed by grouping the codes.
In the fourth step, the formulated topics were reviewed to confirm whether they were in accordance with the coded extracts and the data set. In the fifth, a new refinement analysis was carried out to name the topics. In the sixth and last step, the report that is presented in the results section of this study was prepared.
Although it is a sequential process, it is worth emphasizing that these steps are flexible and allowed a back-and-forth movement through the data set, coded extracts, and the analysis performed throughout the steps (29) . Based on the groupings, 65 codes were identified, which generated the topic: "Management of overweight or obesity in children and adolescents performed by nurses of the Family Health Strategy (FHS)." After quantitative and qualitative analyses of the data, independently and following all the specific methodological rigor for each of the elements, the data were integrated. In the integration, the quantitative and qualitative results were compared to identify convergences and divergences, as well as combinations for better understanding in the response to the general purpose of the study, interpreted in a single conclusion (21) .
The integrated data are presented in a joint display in the Results section.

Ethical aspects
This study was developed in accordance with  The results of the integration of quantitative and qualitative data are presented in a joint display, which simultaneously displays the quantitative and qualitative results and their integration, enabling to better visualize the information. There was convergence in all elements.
In the qualitative element, we could also identify singularities ( Figure 1). The nurses provided guidance on the performance of physical activity. However, in the qualitative approach, we identified that this guidance was mainly aimed at older children or adolescents.

Eating practices
Most professionals stated they provide guidance on healthy eating (n=83;85.6%), but 73.5% did not use the Sisvan form. Most nurses gave guidance on healthy eating, but did so in a basic way and referred patients to the nutritionist. Others referred patients without nutritional counseling, because they did not think it is the responsibility of nurses.

Laboratory tests
The majority of the sample (n=53; 54.6%) requested tests, but 55.7% rarely requested dyslipidemia assessment and 42.3% blood glucose test in children and adolescents diagnosed with overweight. The nurses requested tests. Nevertheless, they were not aimed to the evaluation of possible complications related to overweight such as dyslipidemias and blood glucose.
Nurses who did not request tests informed that it was due to knowing what the child had; fear of the request being prevented by the regulatory system because it was requested by the nursing professional; understanding that the overweight child had no comorbidities; and they did not consider that they were also the responsibility of the nurse. The nurses referred the child or adolescent with overweight or obesity to other professionals. Moreover, the qualitative study identified that, after this referral, the nurses no longer followed up the overweight child or adolescent, and there was no dialogue between the nurse and the nutritionist about the patient due to the demand of appointments.  The WHO recommends the use of growth curves to measure, monitor, and evaluate children and adolescents from zero to 19 years of age to detect juvenile overweight and obesity (3) .
Waist circumference (WC) is an important datum for the evaluation of overweight and obesity in children and adolescents (11)(12) . Nevertheless, we evidenced that nurses of the FHS participating in the study did not verify nor evaluate this measure. This is worrisome, because WC, in addition to being a fast and low-cost measure, is strongly associated with high blood pressure in children and adolescents, even more than BMI itself, which is routinely evaluated by nurses (32) .
A study conducted in Spain on 265 schoolchildren aged from 6 to 17 years identified that, in early ages, Overweight or obese children may develop morbidities associated with overweight (34)  In addition to anthropometric data, blood pressure measurement and request for tests, guidance, and referrals are part of the follow-up protocol of these children (12) . Only identifying obesity and registering it in the handbook of children and/or adolescents are not sufficient actions to reduce the prevalence of this health issue (10) .  (17) . Other studies have identified that nurses, when referring overweight children or adolescents to the nutritionist, do not have a dialogue with this professional (19,36) as well as no longer follow up these young people after referral (20,38) . These results corroborate the findings of our study.
To solve this problem of dialogue between parents and professionals, nurses in Canada who were referring obese children and adolescents to a reference center in the treatment of this morbidity requested that a counter-referral be sent with updates, informing about the situation of these young people and their families.
Thus, they contributed to a better communication between professionals and to the continuity of care to this group (36) .
In addition to the guidelines on healthy eating and referrals to the nutritionist, it is important to value the performance of physical activity. In this study, as in another research (17) , the guidance provided by nurses were basic and focused on older children. However, for a healthy life, physical activity must be stimulated and performed from the first years and continue throughout life (12,39) . A study identified that nurses do not guide parents about physical activity, due to the lack of confidence in their knowledge (17) and agree on the need for training on the subject (19)(20) . In the present study, in addition to the identification of nurses' limited knowledge of physical activity, we noticed that they do not provide these guidelines because they believe in a conception of division of tasks between professional categories, and that the guidance on this practice are the sole responsibility of the physical educator.
It is of fundamental importance for nurses to provide these guidance in their appointments, as these young people, when having a multiprofessional care, have better compliance with treatment recommendations and more effective results (19)(20) . It is also essential to resume that changes in behavior should be extended to the entire family, aiming to obtain greater treatment adherence and better outcomes of the patients (40) .
To improve the knowledge and practice of nurses, it is necessary to invest in continuing education on obesity and skills in its management as well as to reorganize the health system to follow up people with this morbidity (17,19) .
In addition, other initiatives may contribute to best practices in the management actions of juvenile overweight and obesity. Among them are the development of specific Due to the use of the quantitative and qualitative approach, it was possible to minimize the weaknesses of both methods, because the positive points of one strategy compensated for the weaknesses of the other.
As a limitation, we point out the nonuse of a quantitative research instrument validated for the evaluation of the management of overweight and obesity aimed to children and adolescents.

Conclusion
When analyzing the management of overweight and obesity of children and adolescents by nurses of the FHS, weaknesses in knowledge and practice were evidenced.
Specific protocols for FHS nurses and continuing health education are important strategies for better practices.
By performing adequate management of overweight and obesity of the juvenile population in PHC, it will be possible to provide opportunities for a better quality of life for these children and young people, as well as to stimulate the reduction of comorbidities in their lives as adults -such as cardiovascular and metabolic diseases, which have shown high mortality rates in increasingly young populations. Moreover, healthier adults reduce SUS costs, as chronic diseases require high investments for treatments and hospitalizations.