Examining community mental health providers' delivery of structured weight loss intervention to youth with serious emotional disturbance: An application of the theory of planned behaviour

Abstract Background Rates of overweight and obesity are disproportionately high among youth with serious emotional disturbance (SED). Little is known about community mental health providers' delivery of weight loss interventions to this vulnerable population. Objective This study examined attitudinal predictors of their providers' intentions to deliver weight loss interventions to youth with SED using the theory of planned behaviour. Design This study used a cross‐sectional, single‐time‐point design to examine the relationship of the theory of planned behaviour constructs with behavioural intention. Setting and Participants Community mental health providers (n = 101) serving youth with SED in the United States completed online clinical practice and theory of planned behaviour surveys. Main Variables Studied We examined the relationship of direct attitude constructs (i.e., attitude towards the behaviour, social norms and perceived behavioural control), role beliefs and moral norms with behavioural intention. Analyses included a confirmatory factor analysis and two‐step linear regression. Results The structure of the model and the reliability of the questionnaire were supported. Direct attitude constructs, role beliefs and moral norms predicted behavioural intention to deliver weight loss interventions. Discussion While there is debate about the usefulness of the theory of planned behaviour, our results showed that traditional and newer attitudinal constructs appear to influence provider intentions to deliver weight loss interventions to youth with SED. Findings suggest preliminary strategies to increase provider intentions. Public Contribution This study was designed and the results were interpreted as part of a larger, community‐based participatory research effort that included input from youth, families, providers, administrators and researchers. Collaborative discussions with community mental health providers and administrators particularly contributed to the study question asked as well as interpretation of results.


| INTRODUCTION
Overweight and obesity (OW/OB) among youth are major global public health problems. 1,2 In the United States, the National Survey of Children's Health in 2016-2017 calculated the prevalence of OW/OB among randomly sampled children aged 10-17 years in the United States and found that 9.5 million of these youth were either overweight (15.2%) or obese (15.8%). 3 A recent evidence report and systematic review of obesity screening for the U.S. Preventive Services Task Force also indicated that the prevalence of obesity among youth has increased over the past three decades. While the authors suggest that the rate of obesity may be stabilizing overall, they emphasized the importance of addressing OW/OB in youth as a public health priority. 4 Work over the last two decades suggests that OW/OB may disproportionately affect youth with psychiatric disorders, [5][6][7][8] referred to by the Substance Abuse and Mental Health Services Administration (SAMHSA) as serious emotional disturbance (SED). For example, a recent large study utilizing the 2016 National Survey of Children's Health was conducted to examine the prevalence of overweight among youth aged 10-17 years across 19 chronic conditions (n = 10,997) compared to those without chronic conditions (n = 13,408). They found a significantly greater prevalence of overweight among youth with depression (40.7%), behaviour problems (39.3%) and anxiety (36.6%) relative to youth without these chronic conditions (27.8%). 9 The authors of a smaller cross-sectional chart review study of adolescents (n = 114) admitted to a behavioural health partial hospitalisation programme found rates of overweight (25.4%) and obesity (30.0%) that were significantly higher than those of samples of youth in the general population of both the surrounding county and across the nation. 10 In another study of youth aged 8-11 years, Lumeng et al. 11,12 found that clinically meaningful behaviour problems were independently associated with an increased risk of concurrent overweight and increased risk of becoming overweight among previously normal-weight children.

| Addressing OW/OB among youth with SED
Interventions are needed to address OW/OB among youth with both SED and OW/OB. Despite risk for long-term deleterious outcomes associated with SED, and the need for specialized interventions for this vulnerable population, few programmes have been developed. A small body of research to address healthy lifestyle has shown promising health outcomes among emerging adult and adult populations with firstepisode psychosis and across both community and mental health centre settings. 13,14 Mental health providers have either led or collaborated in the delivery of these interventions. However, information about the involvement of key stakeholders (e.g., youth and families, mental health providers and administrators) in the development of these interventions is less clear. Mental health providers may also be uniquely positioned to contribute, along with researchers and both youth and families, to the development of an intervention designed to be implemented within existing mental health service systems. It is well known that mental health providers have knowledge and expertize in working with youth with SED and their family members, knowledge of the important systemlevel influences and barriers to service delivery, knowledge of social determinants of health-influencing outcomes in these populations and expertize in the self-management and behaviour change strategies that are commonly used in mental health interventions. [15][16][17][18][19] In general, however, the degree to which these professional stakeholders are ready and willing to engage vulnerable populations such as youth with SED and OW/OB and family members is less well known.
Ashby et al. 20 examined provider readiness to address healthy lifestyles among 259 nonphysician, Australian, healthcare professionals. A total of 21 of these providers were psychologists and were serving adult mental health clients with OW/OB. The psychologists in the sample observed substantial deficits in perceived abilities to provide healthy lifestyle advice to clients, as well as low knowledge about weight loss, low confidence for setting weight loss goals and low confidence in making dietary and physical activity recommendations. Despite these doubts, 42% (n = 8) of the psychologists in the sample reported providing dietary advice and 60% (n = 12) believed that doing so was within their professional role. Ashby et al. 20 attributed providers' decisions to convey weight-related healthy lifestyle advice to patients with OW/OB to the influence of several factors, including providers' beliefs regarding the scope of their practice, their confidence in providing weight-related healthy lifestyle advice and access to supportive resources. Although the study carried out by Ashby et al. 20 is one of the first to examine engagement in and attitudes towards providing weight-related lifestyle advice among mental health providers, their report of only descriptive data and unclear operationalization of the theory of planned behaviour constructs limited the inferential power of their results. In addition, the WYKES ET AL. | 2057 degree to which providers and the community of individuals with mental health disorders was involved in developing the survey questions was less clear.

| The theory of planned behaviour: Understanding provider intentions
The theory of planned behaviour 21 may be a valuable framework for understanding provider intentions to engage youth with SED and OW/OB and their families in weight loss interventions. While the theory of planned behaviour has received some criticism (e.g., limited validity, lack of ability to empirically disprove the theory, lacking sufficient belief altering guidelines) 22 and other motivational theories have been put forward as alternatives (e.g., Health Action Process Approach), 23 this particular theory has been widely used in previous research to efficiently characterize the decision-making process regarding specific behaviours and to predict future decisions to perform those behaviours. Unlike other motivational theories, the Theory of Planned Behaviour has also been extended to studies of provider behaviour. A systematic review of 78 studies seeking to predict healthcare professionals' intentions to perform specific behaviours found that the theory of planned behaviour (or its parent theory, the theory of reasoned action) was the most commonly used model in investigations of healthcare professionals' intentions. The theory of planned behaviour also demonstrated the strongest association between theoretical components and the actual behaviours of providers. 24 The theory of planned behaviour is founded on the assumption that individuals develop intentions to perform a target behaviour (i.e., behavioural intentions) that lead to engagement in the behaviour. 21  beliefs about his or her own ability to carry out the behaviour in question. 21,25 The theory of planned behaviour also allows for the inclusion of additional constructs when there is sufficient evidence to support doing so. For example, the additional influence of role beliefs and moral norms on the behavioural intentions of healthcare providers has received some empirical support. 24 These additional constructs stem from Triandis' 26 theory of interpersonal behaviour. Role beliefs are defined as '… behaviors appropriate for persons holding a particular position in a group, society, or social system', 26 (p. 208) and moral norms are defined as '… feelings of personal responsibility regarding the performance… of a given action' 26 (p. 94). In their review of healthcare provider behaviour, Godin et al. 24 reported that role beliefs were a significant predictor of intention in 8 of 14 studies that used the construct. Moral norms were a significant predictor of intention in 10 of 14 studies that used the construct. The authors identified role beliefs and moral norms as among 'the most consistently significant cognitive factors' (p. 5) related to intention in the context of healthcare provider behaviour. More recent studies have also shown the value of moral norms in predicting intention to receive an human papillomavirus vaccine, 27 to comply with hand hygiene 28 and participate in regular leisure-time physical activity among individuals with diabetes, 29 among other behaviours. 30

| Aim of the present study
The present study was conducted by researchers in collaboration with a group of key stakeholders including youth and families, mental health providers, community mental health administrators and academic researchers. This study is one of several steps towards the development of a specialized intervention to promote healthy lifestyles among youth with SED and OW/OB. For this study, the group sought to characterize community mental health providers' engagement of youth with both SED and OW/OB and their family members in weight loss programmes as well as identify the key attitudinal predictors of providers' intentions to engage this vulnerable population in structured weight loss interventions. Understanding the attitudinal factors that may influence the availability of much-needed and specialized health promotion services for youth with OW/OB and their family members is expected to provide additional avenues for provider education and programme development.
We first hypothesized that each direct attitude construct (i.e., attitude towards the behaviour, subjective norm, perceived behavioural control) as well as added constructs (i.e., role beliefs and moral norms) would be positively associated with the intention to provide structured weight loss interventions to youth with SED and OW/OB. We then hypothesized that the intention to provide structured weight loss interventions to youth with SED and OW/OB would be positively associated with selfreported history of providing such interventions. Given these specific aims and existing gaps in the literature, a measure was developed for use in the present study. As a result, additional aims of the present study included assessing and reporting the fit of the observed provider data to the expected factor structure.

| Sample
Community mental health providers who serve vulnerable youth with SED were recruited from eligible mental health centres in the United States. SED is defined by the United States SAMHSA as any youth from birth to age 18 who has a diagnosable mental, behavioural or emotional disorder that substantially interferes with or limits the youth's role or functioning in family, school or community activities. 31 Eligible mental health centres were those that (1) provide mental health treatment services to children, adolescents, young adults or adults; (2) provide crisis or emergency treatment options; (3) operate in an outpatient setting; (4) provide specialty services for SED; and (5) provide internetbased contact options for administration of study materials. Individuals who were 18 years of age or older, who worked as a mental health provider, who worked in an eligible mental health centre and who expressed informed consent were eligible to participate.

| Sociodemographics
A sociodemographic form was used to collect the personal and professional characteristics of all participants (e.g., age, occupation and years in practice).

| Theory of planned behaviour questionnaire
A 41-item theory of planned behaviour questionnaire was developed for the study, based on published theory of planned behaviour guidelines, 25,32 and was revised by three experts in the field. The questionnaire addresses salient beliefs (i.e., behavioural beliefs, normative beliefs and control beliefs), direct attitude variables (i.e., attitude towards the behaviour, subjective norm and perceived behavioural control), role beliefs, moral norms and behavioural intention. Role beliefs and moral norms were added to the measure based on feedback from researchers with expertize in the theory. The salient belief items were identified in a previous elicitation study from this study group 33 and were added to questions addressing the direct attitude and behavioural intention constructs of the theory of planned behaviour. A single item (i.e., "I provide structured weight loss intervention to my youth clients with SED and OW/OB") measured engagement in the target behaviour. All items were structured as 5-point, Likert-type items, and were coded such that higher scores reflect more favourable beliefs and engagement in the target behaviour. For each scale, a summary score was calculated as the simple mean of the items.

| Procedure
This study was conducted as part of a larger community-based participatory research effort to develop a healthy lifestyle intervention for youth with SED and OW/OB and their family members. The tool that was used, intervention mapping (IM), 34  The study conforms to recognized standards of the US Federal Policy for the Protection of Human Subjects.

| Data analysis
Descriptive statistics were calculated for all questionnaire items.

| Theory of planned behaviour questionnaire psychometrics
The internal consistency reliability of the direct attitude, role beliefs, moral norms and behavioural intention scales was evaluated using Cronbach's α. Item-total correlations were also calculated. Pearson correlations were calculated between each item on each salient belief scale and the total score on its corresponding direct attitude scale to determine which beliefs have the strongest relationships with attitudinal constructs. 32 Finally, construct validity for the direct attitude scales was tested with a confirmatory factor analysis and a maximum likelihood estimation approach. Model fit was evaluated with three tests: 36 (1)

| Direct attitude constructs as predictors of behavioural intention
A two-step linear regression was conducted to evaluate the prediction of behavioural intention by direct attitude constructs. The three direct attitude scales (i.e., attitude towards the behaviour, subjective norm and perceived behavioural control) were entered in Block 1, and the role beliefs and moral norms scales were entered in Block 2.
The R 2 change statistic was calculated to evaluate the incremental change in the overall model caused by adding these constructs.
A Pearson correlation was also computed between behavioural intention and engagement in the behaviour. For all analyses, alpha was set to p < .05, and all results were two-tailed. states. The majority were female, had obtained a master's degree and were employed as a licensed professional counsellor (see Table 1).

| Clinical practice and needs
Nearly one-half of the providers (n = 47, 47%) reported directly addressing weight with clients in some capacity; 44% (n = 44) reported dispensing specific dietary advice; and 70% (n = 70) dispensed specific physical activity advice. A majority of the sample (n = 86, 86%) reported addressing psychosocial issues related to their clients' weight (e.g., bullying). However, nearly all participants (n = 91, 91%) reported that they 'Never' use a manualized weight loss intervention.
Providers reported strongest preferences for (n = 50, 50%) and highest use of (n = 59, 59%) the internet as a source for obtaining information about OW/OB and its treatment. Frequently reported barriers to receiving training included few opportunities for training on this topic (n = 44, 44%) and little knowledge of how to access such training (n = 44, 44%). A large majority of providers reported that their workplace has neither guidelines pertaining to providing weight loss interventions (n = 92, 92%) nor a system for referring clients for weight loss treatment (n = 69, 69%).

| Theory of planned behaviour questionnaire scores and scale reliability
Reliability for the direct attitude scales varied. Reliability was acceptable for attitude towards the behaviour (α = .84) and subjective norm (α = .72), but poor for perceived behavioural control (α = .53).
Removing two items with poor fit (i.e., 'The decision for me to provide structured weight loss intervention to my youth clients with SED and  The associations between the direct attitude scales and behavioural intention were evaluated using a two-step linear regression analysis (see Table 2). The direct attitude scales (i.e., attitude towards the behaviour, subjective norm and perceived behavioural control) were entered into Block 1 simultaneously.

| DISCUSSION
The primary goal of this study was to examine the relationship be-

| Summary and conclusions
In summary, the present study, included within a larger communitybased, participatory intervention development effort, examined attitudinal predictors of community mental health providers' intentions to engage in weight management interventions with youth clients with SED and OW/OB. Youth with SED who experience OW/OB comprise a vulnerable population that lacks access to specialty interventions to meet their specific needs. This population may be especially likely to benefit from the integration of weight loss treatment into the mental health setting, as they may have no other regular access to these services. The results of the present study suggest that peers with whom providers interact as well as providers' perceived control in offering structured weight loss interventions are potentially important factors in their decisions to offer these services.
Importantly, the additional value of constructs such as role belief and moral norms suggests that providers who are reluctant to offer these services may have concerns about whether addressing bodyweight is within their role and whether it is the right thing to do. Our previous qualitative work with youth, parents and providers 41 echoes these results. Specifically, interviews with providers revealed concerns about whether they should address OW/OB amid mental health concerns as well as fear that they may offend their clients when discussing bodyweight. Results from these studies suggest that providers may benefit from workforce education regarding how to effectively discuss and monitor OW/OB among their clients. Indeed, the results from our study indicated that many providers may already be discussing healthy lifestyles and offering advice. Further formative and experimental research, collaborating with youth and families as well as providers, may help to develop workforce messaging and specific training to increase their capacity and willingness to integrate evidence-based strategies to reduce OW/OB among youth with SED as a part of the overall plan of care.

CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS
Thomas Wykes was responsible for conceptualisation of the study and design, data collection, analysis and initial manuscript writing.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.