In light of the child overweight and obesity problem in Australia, resistance training programs have been trialled as an innovative way of assisting children increase lean body mass and reduce body fat. The purpose of this study was to investigate the factors influencing overweight children's participation in a resistance training trial program.
Parent-child pairs who participated in the trial program were invited to take part in a follow-up individual interview to discuss their program experiences. In total, 22 semi-structured interviews were conducted with 11 parent-child pairs.
The factors found to be most relevant to program commencement among parents were a desire for their child to lose weight and gain confidence, the proximity of the venue, and no cost for participation. For children, the most relevant factors were the opportunity to build strength and improve fitness and having supportive parents who facilitated program initiation. The factors most relevant to continuation for parents were the quality of the program management, being able to stay for the sessions, the child's improved weight status, coordination, and confidence, and no cost for participation. Weight loss and improved confidence were also motivators for continuation among the children, along with pleasant social interaction with peers and trainers and ongoing parental support.
Different factors variably influence program commencement and program continuation in both parents and children. This has important implications for future interventions that aim to successfully recruit and retain intervention participants.
Overweight and obesity in Australia constitute a widespread health problem that has been named a national priority by the National Preventative Health Taskforce . Child overweight and obesity are particularly concerning because weight problems in childhood typically continue into adulthood [2,3]. One in four Australian children are currently overweight or obese , representing a substantial increase over the 1985 figures of 9% of boys and 10% of girls .
Overweight and obese children can experience numerous problems as a result of their weight status. These include neurological , gastroenterological [7,8], and orthopaedic complications . Emotional problems are also common because overweight and obese children are more likely to be victims of bullying  and to experience low self-esteem . They have been found to have higher anxiety and depression scores tracking from childhood into adulthood, and this is especially apparent in females . Given these problems, it is important to develop effective interventions to prevent and treat child overweight and obesity. Such interventions require low attrition rates to achieve their potential, and it is this aspect of program development, within the context of resistance training programs, that was the focus of this study.
Exercise training, which encompasses both resistance and aerobic exercise, has been found to be beneficial in promoting healthy body composition and weight control for children aged six to 18 years [13,14]. While there have been concerns about negative impacts, it has been demonstrated that resistance training carried out in the appropriate manner is safe for children . This form of training has been shown to be an especially appropriate form of exercise training for weight control in overweight and obese children because they are often stronger than their normal weight peers, making them more able to tolerate resistance work . This is in contrast to aerobic exercise, which can be stressful on overweight and obese children's musculoskeletal systems as well as being particularly effortful for them . Recent studies have demonstrated the efficacy of resistance training programs ranging from 6 to 12 weeks in duration for improving body composition in overweight and obese children [17-19]. Reflecting the success of these programs, the National Strength and Conditioning Association, the world authority in resistance training, has released a position statement noting the benefits of resistance training for young people . Similarly, the United States Physical Activity Guidelines for Youth have been updated to include the recommendation of resistance training .
Resistance training programs can also have positive psychological outcomes for children. In particular, they have been shown to have a positive effect on physical self-perception in young people [22,23]. An example is the New Moves program that was introduced in the United States. New Moves was a trial obesity prevention program for overweight and at risk for overweight adolescent girls that incorporated exercise, social support, and nutritional components . Four physical activity sessions were completed each week, with one of these sessions dedicated to strength training. Other activities included yoga, dance, and self-defence. Nutrition and social support sessions focused on healthy eating patterns and creating healthy body images. The program evaluation conducted with parents and children found high levels of satisfaction among both groups for all components. In particular, the girls felt that New Moves had led to an improvement in their activity levels and allowed them to become more accepting of their bodies.
Despite the benefits of physical activity, it can be difficult to encourage exercise initiation among overweight and obese children . While peer pressure, being in poor health, and being unfit have been identified as motivating factors for obese adolescents to commence exercising behaviours , the factors affecting program commencement and continuation among younger children are not known.
Given the relative recency of resistance training programs for children and our poor understanding of the factors that influence participation in such programs, the purpose of the present study was to explore the barriers, motivators, and facilitators to overweight and obese children commencing and continuing a trial resistance training intervention program conducted in Perth, Western Australia. As children and their parents are likely to influence program participation , both groups were included in the study. The method used in the study is outlined below, followed by a discussion of the findings.
The children involved in the study participated in a resistance training program designed for overweight and obese children aged 6 to 13 years. Ethics clearance for the study was obtained from the Edith Cowan University Human Ethics Research Committee (ethics referral number 05-178). Participants were randomly assigned to one of three groups that varied in program duration: 8 weeks, 16 weeks, and 24 weeks. The physiological results of the study can be found elsewhere , but in summary the study demonstrated that resistance training made a significant improvement in body composition, power measures, and strength. For example, there was a mean improvement of 74% in lower body strength in the first eight weeks. At 24 weeks, the group that had continued training had improved their lower body strength by 135%. All groups trained three times per week for approximately 45 minutes for the duration of their programs. Participants could select from a range of session times (7 am - 8 am and 3.30 pm - 5 pm on weekdays and 9 am - 11 am on Saturdays). In addition to the aim of improved body composition, the program was designed to be enjoyable for children. This was achieved through manageable workloads, music being played during sessions, and efforts to encourage interaction between participants. As an example of the latter, the instructors made friendly conversation with multiple participants at a time to stimulate ongoing interaction among the children. The program was initially free, but a fee was imposed for continued participation upon completion of the research phase. Those choosing to continue with the program were charged an initial fee of $250 plus $8 per exercise session thereafter.
Participants were recruited into the program over a period of two months through local general practitioners and an advertisement in the local community newspaper. Sixty-three children were screened for inclusion, at which stage 13 were deemed ineligible. The resistance training component of the trial program was conducted by third-year undergraduate exercise science students at the University under the supervision of the chief investigators. Parents could either stay to observe their children during sessions or return to collect them later. In total, 31 families took up the opportunity to participate in the program. Six (19%) of the children completed the 8 week program, nine (29%) completed the 16 week program, and 16 (52%) completed the 24 week program. On average, 87% of sessions were attended by participants. The attrition rate by the end of the program was 87%, with only four of the 31 children who commenced the program enrolling in the subsequent fee-paying version.
Eleven parent-child pairs participated in semi-structured individual interviews after completing the trial program. All families that started the program were invited to participate, including those who finished the program and those who withdrew. Of the participating children, one had completed the 8 week program, two had completed the 16 week program, and eight had completed the 24 week program. Table 1 provides the sample characteristics. Ten out of the 11 parents were mothers and one was a stepfather. Of the children, five were boys and six were girls. The interviewees were each reimbursed $AU50 for their time. At the time of the interviews, two children were normal weight, two children were overweight, and seven children were obese, as per Cole et al.'s international cut-offs for BMI .
Table 1. Sample characteristics
Parents and children were interviewed on the same day but separately to avoid contamination of responses. Informed consent was obtained from both the parents and the children. The interviewers had not previously met the interviewees and were not involved in program delivery, which encouraged the interviewees to give expansive and descriptive accounts of their experiences with the program. During the interviews, a wide range of topics was discussed including motivations to commence the program, perceptions of the program, and any problems that may have been experienced. Interviewees were also asked to reflect upon the positive and negative aspects of the program and to describe any barriers to their ongoing participation in similar programs in the future.
The interviews were digitally recorded with the interviewees' informed consent. The recordings were transcribed verbatim and imported into NVivo8 (a qualitative data analysis software program) for coding and analysis. Content codes were created to cover the topics listed in the interview guide and emergent concepts that were identified during analysis. Demographic characteristics of the interviewees were also captured.