Introduction

Early adulthood is a high-risk time for weight gain, particularly amongst young women [1,2,3,4]. Obesity increases physical health risks, such as metabolic abnormalities and chronic disease [5,6,7], and psychological risks such as body dissatisfaction, low self-esteem, depression, social withdrawal, interpersonal difficulties and stress [8,9,10].

Engaging young women in weight management programs involves unique challenges. This developmental stage involves major life transitions, balancing multiple priorities [2,3,4,5, 11,12,13] and changes to dietary habits [3, 5]. Furthermore, being overweight may not feature as a strong health priority for some in this age group [2, 5, 13,14,15] and a fear of judgement may also hinder participation [16, 17]. Sophisticated recruitment methods that target this population and generate interest are likely to be required [18].

To promote young women’s participation and retention in weight management programs, it is essential to understand interventions and program formats that are suitable for this cohort [14, 19]. However, the studies that have sought to examine this are not specific to young women with obesity and few consistent themes have emerged. A preference for programs that provide information on eating, exercise and lifestyle has been reported [19,20,21]. A study by Sherwood et al. [22], in contrast, reported that practical components such as cooking demonstrations, exercise and budgeting were favored. In terms of program format, some studies indicate a preference for individual face-to-face contact with a health professional [23] as opposed to group-level interventions, self-help programs [19, 21] or the internet [19]. Other studies suggest that mail-based correspondence [20] or a hybrid format that includes web-based and in-person interventions is preferred [21]. Cost, location and access to transport are also important considerations [17, 21, 23, 24]. Moreover, a preference for programs that are individualized, flexible [17, 19, 21, 23] and brief has been reported [21]. As the studies outlined above are not specific to young women with obesity, the purpose of this investigation was to gain an in-depth understanding of weight management program preferences from their perspective.

Methods

The conduct and reporting of this paper adhered to the guidelines outlined in the Consolidates Criteria for Reporting of Qualitative Research [COREQ] [25]. The methods and data analysis have been reported previously [16] but are described in brief here.

Participant recruitment and inclusion criteria

Women were recruited to the study in several ways: through flyers distributed at two university campuses, a university E newsletter, and using a database comprising previous study participants. A $100 (AUD) gift card was provided for participation. Participants were required to be between 18 and 35 years, female, to have a self-reported BMI (kg/m2) between 30 and 40, to have undertaken at least three serious weight loss attempts in the past, and be fluent in English. They were excluded if they had previous bariatric surgery, pregnant or breastfeeding. Fifty-two women expressed interest in participating. Twenty-four did not participate because their BMI (kg/m2) was lower than 30 (n = 4), they were not contactable for screening (n = 9), or there were scheduling difficulties (n = 11). One woman who agreed to participate did not attend (reason unknown). Eight focus groups were conducted with the remaining 27 women [mean age of 29.1 (± 5.1) years, mean BMI (kg/m2) of 35.8 (± 2.9)].

Focus groups

The participants were recruited to 90-minute focus groups (2–6 participants/group) with similar participant characteristics. The focus groups took place between February and November 2015. The groups were audio-recorded and held in a private meeting room on a university campus. A semi-structured interview protocol developed by the research team probed features of an ideal weight management program for young women.

Experienced facilitators conducted all sessions. All group interviews were recorded and uploaded to a secure commercial transcription website (Transcription Australia; https://www.transcription.net.au). Participants were asked to review a copy of the transcript from their group to ensure content accuracy. Comments and amendments returned by participants were incorporated into the relevant focus group transcript. Amended transcripts were then imported into NVivo (NVivo, v. 10.0, QRS International) [26] for initial coding. Qualitative content analysis was initially conducted by two of the researchers (KYL, EMG). The coding was then checked by another researcher (JAG). The themes identified across the focus groups were then reviewed by other members of the research team.

Results and discussion

Qualitative analyses generated six main themes (see Table 1).

Table 1 Themes and subthemes
Full size table

Theme 1: Program content

Programs with a strong educational content covering a range of components related to the weight management journey were preferred, such as healthy eating sessions (nutrition, meal plans, recipes, portion-control, social eating), psychology sessions (body image, body acceptance, mental health), and physical health and lifestyle (physical activity and sexual health). Previous studies have also reported that individuals prefer a weight management program that includes interventions addressing nutrition, physical activity and lifestyle [17, 19, 22]. The diversity of components is highlighted in this exchange:

I think that recipe ideas and that kind of thing would be good. Cooking is kind of cool these days, like there are so many TV shows and stuff I think people want to learn to do those things but don’t know how (ID14)

I think in the past it would have helped me- if at 65 kilos or at a goal weight I thought that I looked good, I think I would have been less likely to keep dieting. I think that if I had accepted the weight I was and thought my body was healthy then I probably could have maintained weight a lot easier. So I think sort of helping young women’s self-esteem about their weight that they’re at especially if they’re at a healthy weight is really important because I think it sort of reinforces the idea that- okay you’re at a healthy weight now, so let’s eat healthily rather than keep going on fad diets and trying to lose more and more weight (ID12)

Participants saw the psychological and nutritional components of weight management as interacting with each other, as demonstrated by the following quote:

I have depression and anxiety which is directly linked to my weight and it is like this horrible cycle because you’re bigger and you feel depressed about being bigger and then you eat to make yourself feel better and then it’s just this horrible cycle. I think a program that teaches you about the things that you should do, but addresses both lack of knowledge and the psychology side, like an integration of both, I think is great (ID9)

Participants also discussed including components not traditionally covered in weight management such as dressing and grooming.

I noticed that with women who are overweight don’t like going shopping. They hate it. Like me, I’ve got the weirdest body shape and no clothes look right on me. So I don’t feel I have many options for clothes. So if there was someone who was experienced in dressing people for their body weight, I’d like that. They need to have a little- discover the joy of it and re-discover how to feel good about themselves (ID8)

Moreover, participants expressed a preference for tailored interventions. Tailoring was referenced in two main ways: that is, interventions tailored to the needs of the individual based on a pre-assessment, and interventions tailored to the needs of young people. With regard to the former, the following excerpts highlight the need to examine the unique circumstances and preferences of the individual.

I’d like someone that looks at your entire lifestyle, like yes, your diet and experience but also how many hours I might work, what I do when I finish work, like for me, it’s usually pick up your kids straight away and it’s non-stop until they go to bed. So someone who looks at the ins and outs of when I’m eating in that time (ID21)

I think for me it’s just something achievable at the beginning that would be important and maybe for some people that is more food-related, for me that wouldn’t be- cause for me working out is more like a positive action while the food thing is more of that restriction and that’s harder (ID10)

Programs that take into consideration the unique challenges and life transitions associated with young adulthood were favored by participants.

Around the 18 age group, it was the partying. I mean I played a lot of sport but I also partied really hard with very little sleep, which isn’t great for weight control. Because you’re living on alcohol and sugar and all sorts of things and you’re studying at ridiculous hours and there’s no consistency to a schedule or anything. And then the next sort of phase, it was when I travelled. Again, it was really inconsistent with meals. And then after that, I came back with the intention to finish university. I met my husband instead and as I’ve said, relationships, I think are really bad for weight management. There was always something, I guess, that provided a challenge and then it was having kids and what that does to your body (ID18)

Supporting our findings, LaRose et al. [21] and Crawford and Ball [19] also found that young adults preferred a program that was adapted to their unique needs and preferences.

Theme 2: Format

Participants in this study expressed a preference for the use of a hybrid format which could include virtual, social, phone, in-person sessions, and novel methods such as sms support. However, in-person interventions (individual and group) were seen to be the primary method. Some studies have shown that individuals are concerned about sharing sensitive information in a group setting, therefore preferring individual sessions [17, 19, 21]. However, the participants in this study saw group interventions as having several positive functions, namely, reducing isolation, overcoming fear of judgement, providing social support and reducing that sense of vulnerability that comes from discussing issues one-to-one. Individual sessions, on the other hand, were seen as advantageous for tailoring advice and interventions.

I think that the group idea is pretty cool because you’ve got other people who are going through the same situation and that’s really encouraging because you don’t feel like “oh, it’s just me”. It’s not like, “it’s all my fault”. There are other people facing the same things, maybe if it’s just something that’s one-on-one, it feels more intimidating, cause it feels like “oh!, maybe I’m like one of the only people in the world that has that issue” and that can be scary, but if you advertise that as a group thing, I think that like “oh!, it’s not so tough, there are other people who understand me, who are not going to really judge me, who go through the same thing.” (ID5)

Regarding mode of delivery, participants considered internet-based methods to be a useful adjunct and a potential alternative to traveling to in-person appointments. Internet-based methods were also seen as a way to maintain contact and support by health professionals beyond the active intervention phase. These same themes were echoed by participants who had engaged in a workplace weight management program [23].

I think that the online presence and format of it coupled with somewhere that you can go, together work best. I think both are important because it’s good to do things by yourself but I think as you start to get more confident, it’s also good to have interactions with people (ID 9)

As suggested by our participants, the use of novel strategies such as text-messaging could be utilized to enhance therapist contact. Indeed, text messaging has been found to result in better weight loss outcomes compared to programs that did not include text-messaging [27]. This contact need only be of minimal intensity (i.e., one-way therapist-to-patient contact) to be effective [28].

The online stuff can only address things so far, and then having in-person meetings, can kind of go that step further. Even a phone call is good. Even receiving a daily affirmation or something maybe, receiving positive affirmations or a weekly affirmation. Yeah, that would be nice, like an SMS (ID2)

Theme 3: Program characteristics

Several program characteristics were identified by participants. Firstly, young women in the current study expressed value in having a credible team delivering the interventions. The need for credible staff was related to the importance participants placed on education and expert opinion. Crawford and Ball [19] have suggested that this may reflect limited access to good quality information regarding weight management and lack of trust in the information provided by mass media. Similarly, McVay et al. [17] reported that programs with a scientific evidence base increase trust and raise expectations about the effectiveness of the intervention. Participants in this study also spoke of the importance of having approachable, encouraging, nonjudgmental health professionals delivering the program. Fear of negative judgement can act as a major barrier for initiating a weight management program [16, 17].

It would be really encouraging to see someone who does my measurements and tells me that it is a good thing that I have lost some weight or lost centimetres off my waist- however small- and that it is really good progress I am making, and that apart from certain things, that my eating is really good. This would make a difference especially as I find it so embarrassing to get on a scale in front of others (ID 12)

Secondly, participants described the importance of accountability in a program. According to participants, individual-level accountability can be provided through the supportive therapeutic relationship with a health professional. Similarly, Clancy et al. [23] found that the “coach’s” ability to encourage, support and provide advice assisted individuals who participated in a workplace weight management program to be more accountable and motivated throughout the program. This also emerged as an important theme in the study by LaRose et al. [21], though in that study accountability was discussed in the context of peer interaction within a group.

Having a relationship with the therapist is important. And then the more that relationship develops, the more you’re kind of accountable. So when you do meet up, you tell them what’s happening and they’re kind of < sigh > - and you work through your problems so you become more accountable in the relationship (ID22)

Moreover, participants in our study also talked about accountability provided through the use of behavioral tracking procedures. Behavior change strategies such as pedometers, food diaries, and self-monitoring have been identified in the literature as important tools for creating new habits [29, 30]. Indeed, such methods may also lead to more effective weight loss [31]. In contrast, McVay et al. [17] found that in an older cohort, the use of dietary monitoring could be a barrier to initiating a weight management program.

I think that it is not just about the knowledge, but it is also about being accountable for what you eat. So I think tracking what you eat in terms of like apps and things like that are really helpful. Even though you might know how to lose weight or the healthy over the unhealthy food, you don’t really account for the throughout the day snacking and actually how much you’ve consumed (ID9)

Thirdly, participants reported that programs that are delivered flexibly so as to fit in with the individual’s busy schedule were preferred. This has been reported previously [17, 19, 21, 23].

For me, having somewhere to go sometimes if you want to, but not having to, like being able to have that flexibility to do things online or from home- maybe where there was some sort of initial session and then I largely do something on my own and maybe someone checked in on me on Skype, once in a while, that seems perfect (ID10)

Lastly, cost-effectiveness was identified as an important program characteristic. Program costs as well as the cost involved in changing one’s lifestyle based on program guidelines were highlighted. Both have been identified as important considerations in previous studies [17, 21,22,23]. The following quote exemplifies these sentiments:

I live off $450 a fortnight including rent. So I’ve- and when I am down, I go for the McDonalds or KFC meal a day, that’s what I do. But when I am healthy, I think it’s about planning and ensuring you are cooking and you are buying whole food. And if you do buy a healthy takeaway, they are a lot more expensive. But if you’re preparing it yourself, and you’re able to prepare your own portion sizes as well, it ends up being quite affordable (ID8)

Theme 4: Program name

Participants preferred program names that focussed on wellness, well-being, health and body positivity as it reflects the positive benefits that can be derived from participation in a way that does not engender weight stigma connotations. A preference for positive, enthusiastic and encouraging language that emphasises active healthy living, and a more relaxed attitude towards weight has been reported previously [21, 24, 32, 33]. For example:

I had one doctor who put something on my record that I had some sort of life chronic illness obesity, which is something I had never identified with before and it was really negative for me and even if it is medical, it just didn’t work and I think for me, it goes back to those positive phrasings, like a group that’s interested in health and fitness is much more appealing (ID10)

Themes 5 and 6: Location/session time and duration

Accessibility in terms of location (access to public transport, availability of parking), convenient session times and level of time-commitment were key considerations for our participants. Previous studies have found lack of time and scheduling difficulties to be significant barriers to weight loss and healthy lifestyle behaviors. [17, 21]. A preference for brief programs (less than 6 months) has been reported [21]. Both accessibility and time-commitment have been found to differentiate between those adolescents (and their families) who completed a family-based cognitive behavioral lifestyle intervention program for overweight and obesity versus those who dropped out [34].

Venue wise, it wouldn’t bother me if I was going to a clinic or doctor’s, a heath care centre, or university. It’s the actual location, as in, is it close to work?, is it on my way home?, How much out of my way do I have to go? Convenience and proximity to parking and the time as opposed to the location (ID7)

Limitations

The use of qualitative methods and focus groups is a strength of this study as it allowed for a deeper level analysis of the program features that appeal to young women. There are, however, some weaknesses. The limited information about the characteristics of the sample restricts the generalizability of the findings. Furthermore, as the focus of the research was on young women, a group that is gaining weight at a more rapid rate than other demographic groups in Australia [3], the findings do not apply to men or other female cohorts. Moreover, the program features that encourage participation may not be the same as those that keep people engaged in programs [15, 17]. This would be a worthy focus of future research.

Conclusions

A major finding from the study was that participants value the importance of a program with an educational focus that integrates nutritional, psychological, health and lifestyle interventions, and includes components that are not traditionally part of weight management programs such as body acceptance, sexual health and dressing and grooming. A program name that conveys wellness and body positivity was seen as valuable for engaging participants. Participants highlighted the importance of individualized programs that are also tailored to the needs of young adults, and delivered by credible and approachable staff, who provide accountability. Cost-effectiveness, flexibility, location, time-commitment and the use of a hybrid format combining virtual and in-person methods (including group interventions) were important considerations for these young adult women. The findings have implications for the design of future weight management programs. Knowledge of program features which resonate with young women facilitates development of innovative ways to engage and support evidence-based weight management in this vulnerable group.