Pediatric obesity is an epidemic in the United States, with approximately one third of youth identified as overweight or obese [1, 2]. Obesity in youth is associated with a number of health risks, including elevations in cholesterol, diastolic and systolic blood pressure, triglycerides, and fasting insulin levels as well as increased risk for type 2 diabetes [3, 4]. Furthermore, obesity in children tracks into adulthood, which in turn is related to increased rates of morbidity and mortality . In addition to health risks, youth who struggle with excess weight are at greater risk for a range of psychosocial difficulties including decreased self-esteem, challenges in peer relationships [6, 7], and impairments in health related quality of life (HRQOL) [7, 8].
Family-based behavioral weight control programs have demonstrated efficacy in the treatment of overweight children between the ages of 8 and 12 years, with some promise regarding long-term outcomes. While effective, these interventions have been administered through carefully controlled clinical trials [9, 10] or delivered in specialized/tertiary clinical settings affiliated with academic medical centers. As a result, they are available for only a small percentage of children and adolescents struggling with excess weight. The need for identifying alternative, more broadly accessible delivery systems for these interventions increased with the USPSTF recommendation that primary care providers refer youth to behavioral intervention programs .
There are very few examples of interventions to assist children and adolescents who are already overweight/obese that are delivered in community settings and available to a greater segment of the population. We are aware of only three studies explicitly designed to examine effectiveness of pediatric obesity interventions in a community setting. Project STORY  examined the utility of Cooperative Extension Service offices in rural settings for delivery of a weight control intervention for children 8–12 years. Children assigned to both a family based and parent only condition demonstrated greater decrease in BMI z-score than those assigned to wait list control at 10-month assessment. A second effectiveness study involved examination of the MEND Program developed in the United Kingdom . Children between 8–12 years randomized to receive the intervention demonstrated significant decreases in BMI (-1.2 kg/m2) and waist circumference (-4.1 cm) compared to those assigned to a delayed treatment control. More recently, the JOIN program, developed by UnitedHealth Group and delivered through the YMCA, was shown to significantly decrease percent overweight among school age children .
While these interventions have been effective, little is known regarding the fidelity of treatment implementation, including adherence to treatment protocols and facilitator characteristics. Such information is critical for scalability of health change interventions, as it has direct implications for interpretation and potential generalizability of study findings. In a recent review, only 5% of more than 75 weight control studies reported on the extent to which the intervention content was delivered as intended . Attention to treatment fidelity is also highlighted by the NIH Behavior Change Workgroup, which includes recommendations for defining, evaluating, and enhancing treatment fidelity in behavioral interventions . In addition to examining the extent to which the intervention was delivered as intended, the Workgroup further emphasized the importance of assessing provider characteristics (e.g. warmth) .
The importance of treatment fidelity is further highlighted in the RE-AIM framework , a model helping to increase the external validity and public health impact of health interventions. Within this framework, “Implementation” is a key domain that includes the extent to which project staff delivered an intervention as intended . Historically, both weight control prevention and intervention studies have provided minimal information regarding the consistency with which interventions are delivered and potential differences of treatment efficacy across interventionists [15, 19]. We are not aware of any previous research that has examined the combination of treatment fidelity and provider characteristics as related to outcomes for pediatric behavioral weight control interventions. Assessment of fidelity is particularly important in the context of development and implementation of a scalable intervention, given the absence of a tightly controlled environment and the broad scale implications for dissemination.
We had the opportunity to examine treatment fidelity and facilitator characteristics in the context of a recently delivered 24-week community based pediatric weight control program for youth ages 6–17 years old. The JOIN program  involved a collaboration between UnitedHealth Center for Health Reform and Modernization and the YMCA of Greater Providence to deliver an empirically supported family based behavioral weight control intervention. Intervention components from evidence based treatments were modified to reduce cost and increase scalability. Specific modifications included: intervention delivery by YMCA facilitators with no previous training in pediatric obesity, combined child and parent groups, and 12 in-person sessions (efficacy trials typically include a greater number of sessions), with 12 additional sessions conducted by parents at home. Findings from the initial pilot were recently published and indicated a 4.3% reduction in percent overweight for children between 6–12 years, with a smaller decrease for adolescents . These results have significant implications for continued development of scalable interventions to address pediatric obesity that can be delivered in community settings. To be effective, such interventions will require replicable models for training paraprofessional facilitators as well as identification of key facilitator characteristics that are related to positive outcomes.
The purpose of this study was to examine two key components of treatment fidelity: facilitator adherence to treatment content and non-specific facilitator characteristics in the context of a community based pediatric weight control intervention. Primary study objectives were to: 1) provide descriptive information regarding adherence to the treatment protocol and non-specific facilitator characteristics (e.g. interpersonal characteristics, group management skills); and 2) examine the relationships among facilitator adherence and characteristics and rate of change in percent overweight demonstrated by youth over the course of the 24-week intervention.