Parent and stakeholder views of embedding The MapMe child healthy weight maintenance intervention in the National Child Measurement Programme: A qualitative study.

Lorraine McSweeney; Angela. R Jones; Laura Basterfield; Joao. Paulo de Aguiar Greca; Maddey Patterson; Alison Gahaghan; Ashley. J Adamson

doi:10.3310/nihropenres.14256.1

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Research Article

Parent and stakeholder views of embedding The MapMe child healthy weight maintenance intervention in the National Child Measurement Programme: A qualitative study.

[version 1; peer review: 1 approved]

Lorraine McSweeney ¹, Angela. R Jones¹, Laura Basterfield¹, [...] Joao. Paulo de Aguiar Greca¹, Maddey Patterson¹, Alison Gahaghan², Ashley. J Adamson¹

Lorraine McSweeney ¹, Angela. R Jones¹, [...] Laura Basterfield¹, Joao. Paulo de Aguiar Greca¹, Maddey Patterson¹, Alison Gahaghan², Ashley. J Adamson¹

PUBLISHED 20 Aug 2026

Author details Author details

¹ Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, England, UK
² National Child Measurement Delivery Manager at Department of Health and Social Care, Office for Health Improvement and Disparities UK, Bristol, UK

Lorraine McSweeney
Roles: Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation

Angela. R Jones
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Review & Editing

Laura Basterfield
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Review & Editing

Joao. Paulo de Aguiar Greca
Roles: Data Curation, Formal Analysis, Investigation, Validation, Visualization, Writing – Review & Editing

Maddey Patterson
Roles: Data Curation, Formal Analysis, Investigation, Visualization, Writing – Review & Editing

Alison Gahaghan
Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing

Ashley. J Adamson
Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

The National Child Measurement Programme (NCMP) measures the weight status of 4–5- and 10–11-year-olds and communicates results, via letter. Parents are sometimes surprised by these results. MapMe is a tool to improve parental acknowledgement and understanding of childhood overweight and obesity. Ten English Local Authorities (LAs) agreed to test MapMe and deliver the intervention to parents via an ‘enhanced’ NCMP results letter including Body Image Scales (BIS): images of NCMP age- and sex-appropriate children of different weight statuses, plus dedicated website. For the trial process evaluation, a qualitative study was conducted to determine the acceptability of the intervention, and views of embedding MapMe into usual practice.

Methods

Twenty-seven parents and 48 LA staff consented to an interview, focus group or online questionnaire. All interviews/focus groups were conducted online. Data were analysed using thematic Framework analysis.

Results

Twenty-seven parents were interviewed, 25 had received a healthy weight result letter for their child, one overweight and one very overweight. Parents receiving healthy weight result letters had no concerns about the letters, did not feel the need to visit the website and were happy to receive the BIS. Whilst some LA stakeholders described the enhanced letters as too long or not compassionate in tone, no increase in parental complaints were reported.

Conclusions

Overall, it was suggested that MapMe could add value to the NCMP and would be unlikely to have a detrimental effect on programme delivery. The MapMe intervention is now available as an optional resource for English local authorities.

Plain Language Summary

The National Childhood Measurement Programme (NCMP) in England measures the height and weight of children aged 4–5 and 10–11-years old. The results are sent to parents by letter; some parents are often surprised at the result. To help parents understand their child’s result and learn more about childhood overweight, an online tool called MapMe was created.

The MapMe tool was sent with the NCMP result letters by local authorities (LAs) to parents. The MapMe tool includes an updated result letter, body image scales (BIS): which are pictures of boys or girls aged 4–5 or 10–11 years showing different weights ranging from underweight to very overweight, a website, and healthy lifestyle information.

In this study a researcher collected information from parents and LA staff to find out what they thought of the MapMe tool. People taking part could share their thoughts in an interview, a discussion group or fill in a questionnaire.

Twenty-seven parents and 48 LA staff shared their views and experiences. Twenty-five of the parents who took part had a child who received a healthy weight NCMP letter. Whilst this was good, it meant that the parents were not worried about their child’s weight and did not visit the MapMe website or read the lifestyle information, so we did not know how helpful it was for parents. However, the parents did tell us that they liked the BIS and thought they were useful for parents. Some LA staff felt the new NCMP letters were a bit long, but they did not report any more complaints from parents than they would normally get.

As there were very little complaints about the new NCMP letter and the BIS were liked by the parents, the LA staff felt the MapMe tool being sent with the NCMP result letters would be helpful.

Keywords

National Child Measurement Programme; intervention acceptability; qualitative research

Corresponding author: Lorraine McSweeney

Competing interests: No competing interests were disclosed.

Grant information: This project is funded by the National Institute for Health and Care Research (NIHR) under its Public Health Research (PHR) Programme (NIHR 127745). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2026 McSweeney L et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: McSweeney L, Jones AR, Basterfield L et al. Parent and stakeholder views of embedding The MapMe child healthy weight maintenance intervention in the National Child Measurement Programme: A qualitative study. [version 1; peer review: 1 approved]. NIHR Open Res 2026, 6:122 (https://doi.org/10.3310/nihropenres.14256.1) First published: 20 Aug 2026, 6:122 (https://doi.org/10.3310/nihropenres.14256.1) Latest published: 20 Aug 2026, 6:122 (https://doi.org/10.3310/nihropenres.14256.1)

Introduction

The mandated National Child Measurement Programme (NCMP) in England shows that despite some reductions in childhood obesity rates post the COVID-19 pandemic, the prevalence in both age groups remains a concern: 10.5% of children aged 4–5 years (Reception) and 22.2% of 10–11 year olds (Year six).¹ Furthermore, for those living in deprived areas, prevalence was twice as high compared to least deprived areas.¹ As the risk of obesity increases throughout childhood, reducing prevalence of childhood overweight/obesity is a public health priority. However, numerous drivers, such as diet and physical inactivity, make addressing this complex issue challenging.²

Several studies examining parents’ perceptions of child body weight show that parents typically do not correctly categorise their child with overweight/obesity.^3–6 However, parents are important in addressing childhood overweight/obesity since they play a key role in the shaping and maintenance of their child’s health related behaviours, and in the case of children with overweight/obesity, seeking and accepting appropriate support for child weight management.⁴ Monitoring of child growth and identification of children with overweight/obesity is typically completed by health professionals using age- and sex-specific growth charts.^7–9 Parents themselves, tend to determine child weight status using visual assessments and comparisons with other children rather than relying on objective measures.^10–13 It has also been suggested that without recognition of childhood overweight/obesity, parents are unlikely to take appropriate action to change their child’s dietary and/or physical activity behaviours or to seek support to address their child’s weight status.¹⁴

In Local Authorities (LAs) in England the NCMP measures the weight status of children in Reception and Year 6 annually. Most LAs communicate the results to parents, usually via letter using the descriptions: underweight, healthy weight, overweight or very overweight (rather than obesity). However, parents are often surprised by and mistrust these results.¹⁵ More support is needed to help parents understand and act upon the information provided.¹⁶

The MapMe2 study was a Cluster Randomised Controlled Trial which investigated the impact of embedding the MapMe intervention in the NCMP on child weight outcomes at one year. MapMe is a web-based tool to improve parental acknowledgement and understanding of childhood overweight/very overweight.¹⁶ The MapMe intervention includes the following components: Body Image Scales (BIS) – images of underweight to very overweight children, NCMP age- and sex-specific, to help parents recognise their child’s weight status; information on healthy eating, physical activity, and consequences of child overweight, and seeking further support. The mode of delivery of MapMe in this study was by means of the NCMP results letter sent to parents post-measurement. The Standard NCMP result letter was modified to create a new ‘enhanced’ intervention letter, see trial registration for full trial and sub-study details.^16,17 For context, the trial was due to commence in March 2020, just as the UK went into lockdown due to the COVID-19 pandemic. Therefore, much of the project delivery processes moved to online and the NCMP halted routine measurements in schools until 2021.

This article examines data from the MapMe2 trial process evaluation which explored parents’ and LA staff’s views of the implementation of the MapMe intervention and the acceptability of the enhanced NCMP results letter.

Methods

Patient and public involvement

Two distinct public and patient involvement (PPI) stakeholder groups were recruited for the MapMe2 study prior to and during the study development phases. The Parent Involvement Panel (PIP), comprising parents and carers of primary school-aged children, was recruited through multiple channels including social media, University staff webpages, ethnic minority community groups, a support group for parents of children living with overweight, and pre-existing contacts. In parallel, a panel of relevant professionals, such as public health practitioners, academics, school nurses, and local authority/government stakeholders was convened. These individuals were identified and invited through professional networks, public health colleagues, and practice partners to form an “expert panel.”

Restrictions associated with the Covid-19 pandemic substantially increased the challenges of involving and engaging the public and stakeholders in the research, which had originally been intended to occur in person. Conducting PPI remotely through digital platforms, then a relatively new approach, required recognition that online communication introduces distinct challenges compared with face-to-face interaction. Nonetheless, remote engagement also offered advantages, including increased flexibility for stakeholders to contribute from any location and at times convenient to them. To achieve comparable levels of input, information sharing, and collaboration, additional efforts were required from the research team. These included developing a suite of brief study information and training videos, alongside a printed PIP information pack, to provide multiple modes of communication. PPI members were also kept informed and engaged through quarterly project update newsletters.

The original intervention materials¹⁸ were refined to incorporate advancements in Body Image Scale (BIS) technology and to enable integration of intervention delivery within the NCMP for use in MapMe2. Stakeholder contributions throughout the study informed enhancements to the BIS, NCMP result letters, and the study website, all of which were tested and refined based on input from parents, families, and members of the expert panel.

Two members of the PIP participated in Trial Steering Committee meetings to ensure parent representation in decision-making processes. PIP members also contributed to the drafting and review of study reports and academic publications.¹⁹ Ongoing consultation with PPI stakeholders continues to inform the development of appropriate dissemination strategies.

Despite the initial challenges of transitioning all engagement activities to online formats, an active and committed stakeholder group was successfully established. Their involvement led to valuable and meaningful refinements of the MapMe intervention, ensuring that the study’s outputs were relevant and responsive to the needs and lived experiences of families.

Study

Ten socio-economically diverse English LAs with a combined population of ~60,000 children agreed to collaborate and deliver the trial. LAs were randomised to deliver two of three conditions to their schools/families: 1: MapMe BIS (on paper) and link to MapMe website added to the ‘enhanced’ result letter (Intervention); 2: As Group 1 plus an additional ‘booster’ letter after six months to remind parents of their child’s weight status, the MapMe website, and another copy of the BIS (Intervention plus booster); 3: Standard NCMP letter (control group). LA staff were invited to attend online workshops to understand the study procedures.

Design

Semi-structured interviews, focus groups and online questionnaire. The interviews and focus groups were led and conducted by an experienced post-doctoral qualitative researcher (LM) who was not involved in the day-to-day running of the trial. LM was assisted by MP, a project research assistant.

Ethics

This study was approved by Newcastle University’s Faculty of Medical Sciences Ethics Committee (Reference 2073/9947/2020).

Sample

Parents who were part of the MapMe2 trial sub-study (n = 4 LAs)¹⁷ and who consented to be contacted for interview. Interviews took place between August 2022 – January 2023.

LA interviews/focus groups: The initial aim was to complete up to 30 stakeholder interviews, that is up to three in each of ten LAs. The interviews/focus groups were conducted at two-time points (i) October 2022, mid-way through the trial and, (ii) September – November 2023, post-intervention.

Recruitment

Parents were sampled by LA, trial arm, and age and weight status of their child and were invited by email, telephone, or WhatsApp to take part in an online interview. Those that agreed to take part were sent the participant information sheet and a convenient date for an online interview, lasting no more than 30 minutes was arranged. Those stakeholders working in participating LAs who were in regular contact with the trial administrator were sent an information sheet about the interviews/focus groups by email and were invited to attend either an online interview or focus group session with their colleagues. Once participation was agreed, a convenient date for an interview/focus group lasting no more than one hour, was arranged. All participants provided written consent before interview. At time point two, to aid feedback and provide flexible methods, LA stakeholders were also given the option to complete an online questionnaire (Suppl. 1). Participants were informed at the start of the interview that the interviewers (LM, MP) were not part of the main trial implementation.

Materials

Semi-structured interview topic guides were developed in consultation with two MapMe2 study coinvestigator health psychologists (Suppl. 2). Interviews/focus groups were conducted remotely. Electronic consent was obtained before the scheduled date/time. Interviews/focus groups were recorded, with participant consent using the Zoom/Teams platform inbuilt system and notes taken. Data were transcribed verbatim using a university approved vendor. On receipt of the transcripts, they were anonymised, and recordings deleted. The questionnaire was an electronic version of the questions included in the topic guide and was shared with participants who requested that format.

Analysis

Transcripts and questionnaires were coded by participant group (parents/staff ) by LM using NVivo software version 1.6.1²⁰ and thematic framework analysis applied.²¹ The Framework Method involves entering summarised data into a matrix, this allows for contrasting and comparison of data across cases as well as within individual cases providing an in-depth analysis.²² The two participant group matrices were compared to identify key themes across the groups. Ongoing analysis and results were shared regularly within the research project team for quality control and collective processing of the data.

Results

Eighty parents who consented to additional study participation in the form of an interview were contacted, 27 responded and agreed. Table 1 reports the breakdown of the participants according to LA, year group (age) of child, reported weight category of child and intervention arm. Seventeen of the children were in Reception, 25 were of a healthy weight, one received an overweight result, and one a very overweight result. Six families were in the ‘intervention’ arm, 13 in the ‘intervention + booster’, and 8 in the control group. Despite best efforts, we were unable to recruit more parents of children who had received an overweight/very overweight result. Therefore, the findings are mostly from parents whose child had a healthy weight status.

Table 1. Age and weight status of child and intervention arm of parent interviewees.

Local Authority (n = 4)	Year Group (Reception (R) age 4–5 years or Year 6 age 10–11 years)	Reported weight category result (HW = healthy weight OW = overweight VOW = very overweight)	Intervention trial arm
LA - B	R	HW	3
LA - B	R	HW	2
LA - B	Y6	HW	3
LA - B	Y6	HW	2
LA - B	R	OW	2
LA - B	R	HW	2
LA - B	R	HW	2
LA - C	R	HW	1
LA - C	R	HW	3
LA - C	Y6	HW	1
LA - C	R	HW	1
LA - C	R	HW	1
LA - C	R	HW	3
LA - E	R	HW	2
LA - E	Y6	HW	2
LA - E	R	HW	2
LA - E	R	HW	2
LA - E	R	HW	3
LA - E	Y6	HW	2
LA - E	R	HW	2
LA - E	Y6	HW	3
LA - E	Y6	HW	2
LA - E	Y6	HW	2
LA - E	Y6	HW	3
LA - E	R	HW	3
LA - H	Y6	HW	1
LA - H	R	VOW	1

Stakeholders across the ten participating LAs were contacted. At time point one, 11 participants from five of the LAs consented to be interviewed (n = 4) or take part in a focus group (n = 2). At time point two, there was representation from all LAs, either by focus group (n = 7), interview (n = 3) or questionnaire (n = 2) resulting in 37 participants, thus 48 in total overall ( Table 2). Note, a small sample of participants (n = 7) took part at both time points.

Table 2. Number of LA stakeholder interview, focus group or questionnaire participants at time points one and two.

LA	Data collection method at time point 1	n	Data collection method at time point 2	n
LA-A	Focus group	4	Focus Group	5
LA-A	Focus group	4	Interview	1
LA-B			Questionnaire	1
LA-C			Focus Group	4
LA-D			Focus Group	6
LA-E	Focus group	3	Focus Group	3
LA-E	Focus group	3	Interview	1
LA-F			Focus Group	5
LA-G	Interview	1	No further response
LA-H	Interview	1	Focus Group	6
LA-I	Interview	1	Focus Group	2
LA-I	Interview	1	Questionnaire	2
LA-J	Interview	1	Interview	1
Total participants		11		37

Stakeholder roles were public health specialists, public health practitioners, public health support workers, community lifestyle coach, commissioners, NCMP lead, school nurses/assistant nurse, research nurse, research advisor/officer, child/family health managers and business support staff ensuring a wide range of roles and responsibilities were included.

Four main themes were identified from the data: acceptability of the enhanced NCMP letter; views of paper BIS included with the enhanced letters/intervention; views of the MapMe intervention website; and embedding MapMe into usual practice. Results are supported by anonymised quotes ( Table 3).

Table 3. Parent and LA staff illustrative quotes.

Quote number	Illustrative quote
1	“Just to see his height and weight really and to know that obviously he was in that scale [HW] and that he’s okay, doing alright” (P-ID24).
2	“So, for me, I tend to look very quickly at whether it says normal range. I remember with my older daughter, I just … And if it’s normal range, then I don’t bother reading the rest. I think if it was to flash up as something else, I’d read the rest to see what was going on. But yes, I remember with my older daughter just checking it says normal and then … I don’t even think it says normal but, you know, within a normal range, and then I don’t bother too much after that” (P-ID183).
3	“So, yes, that’s kind of how I felt about it. If I’m completely frank, I was a bit grumpy about it to start with, but I’ve overcome that, quite a long time ago, having thought about it and rationalised it a bit… I disposed of the letter, because I didn’t want her to see it … because in my view, and you guys are experts, of course, but my view is that she isn’t [overweight]. So, yes, that’s how I covered it” (P-ID723).
4	“I would expect that there will be a certain amount of denial when parents are gauging the weight – probably not the height, but the weight – of their child. And I would imagine that it’s probably human nature to think that your child perhaps doesn’t have a problem when potentially they do” (P-ID218).
5	“I think you’ve got to be brutal with the truth. I think if it’s the truth, it’s the truth, so you’ve got to say it how it is” (P-ID67).
6	“And it just seemed a very lengthy letter for parents. It’s very hard- I mean, we’ve been doing the National Child Measurement Programme, since the government brought it out in 2004. And it’s been so difficult, with sending letters out to parents, that we’ve had to change, over the years, to make it a meaningful letter to them, but isn’t so lengthy. So, we just did think it was quite lengthy for parents, from our perspective” (FG-LA.H).
7	“I think we hadn’t expected there to be so many changes to the NCMP letter. We hadn’t expected it to be quite so significantly different. I think we just expect there to be some extra stuff about the study. But actually, it changed the wording of the whole letter. I think that was what was difficult” (FG-LA.D).
8	“We did have some concerns about the fact that that letter wasn’t … We try and use very compassionate conversations about weight approach to all of our letters around NCMP. The letters that we had to use, obviously we had to use specifically the study letter and we did have some concerns about whether that would generate a higher level of negative feedback. I wouldn’t say that was a significant … That didn’t really materialise significantly” (FG-LA.D).
9	“I guess for some people, a visual representation of what’s healthy and what’s not is easier than considering weight and measurements and stuff like that” (P-ID.67).
10	“I really liked it, and it was something that I looked at with my little boy. We talked about it together, we looked at the different sizes” (P-ID61).
11	“I think I’m a reasonably bright person, and looking at it, I have to say, I struggled to find much difference in the images. They certainly weren’t really distinct from each other” (P-ID723).
12	“We’ve had a couple of people angry. But, I mean, that’s quite normal. Considering the amount of people that we’re measuring; we get very few complaints. But we did have two that were specific to the MapMe. We had one who was very upset when she was told that her child was overweight, and when she looked at the MapMe [BIS], and it gave her the picture of her child, she was adamant that her child wasn’t overweight, and that [it] was wrong” (SH.ID7).
13	“So, I don’t think having that information [BIS] has made parents ring us I think it’s just that it’s the information about being overweight or very overweight that prompts that call. So, I think any additional information or support we can offer within that letter can only be a positive” (SH-ID8).
14	“Obviously I can’t … I remember looking at the images and putting the code in and things in, but don’t remember the ease of use of the website, no … I think, from what I remember, there were some tips on the website and in some of the links and some of the documentation that you provided about healthy eating, different ways to think about food, and different things to eat and encouraging exercise and things (P-ID657).
15	“I can’t categorically say that I remember there being a reference to the website in the letter, but I’m sure there was. I don’t recall visiting the website, as far as I remember” (P-ID723).
16	“Because, like I say, I’m not concerned about it, so I therefore didn’t feel the need to follow it up. Maybe if I was concerned that he was over or underweight, I would have done” (P-ID424).
17	“I think for me personally, I’m more likely to visit the website if it had come through email, rather than visiting a website from a letter. For me, that would be a big incentive” (P-ID61).
18	“We receive so much correspondence. So, I’d have to say the lines are a bit blurred as to whether that came from even an NHS body or from the school itself, I wouldn’t know” (P-ID218).
19	“I mean, part of me thinks the NCMP doesn’t achieve very much, other than get numbers for the government, useful as they are, and it is a missed opportunity. Whether the MapMe is the answer to raising awareness, and engaging parents, I don’t know yet. We’ll have to see what the results [are] …” (SH-ID7).
20	“I think my only thing is, at long last, I’ve been in school health a while and it feels like NCMP might become more than just a data collection exercise, and that there will be something positive. I know we give the links through for the various websites and where they can go, and there might be those interventions. But if there was a little bit more happening, it would be good” (SH-ID5).

* Parents are reported by (P-ID number) and LA stakeholders by (SH-ID number) or if a focus group, (FG-LA.X).

Acceptability of the enhanced NCMP results letter

Part of the MapMe2 trial was the development and distribution of the enhanced NCMP results letter to parents whose LAs were taking part; this included changes to the language used and features which used behaviour change theory which aimed to increase the usefulness and acceptability, information about local lifestyle services and family support and, a link to access the study intervention website. As most parents interviewed received a healthy weight result letter for their child, reactions to the NCMP results letter were mostly neutral (as a healthy weight result was expected), positive, or they were reassured (quote 1). Most parents read the result letter once and then discarded it as they were not concerned about the result (quote 2). Parents posited that if a parent received an overweight/very overweight result for their child, strong negative emotions would be felt such as being upset or angry, this was the case for one parent whose child had received an overweight result letter (quote 3). Additionally, it was suggested that some parents may be in denial when considering their child’s weight (quotes 4). There was a belief, that whilst the receipt of an unexpected NCMP result letter could be distressing for some parents, it was important to be honest (quote 5).

Overall, the LA stakeholders were happy to send out the enhanced NCMP results letter to parents. However, there was some apprehension that the enhanced letters were quite long (quote 6). Another LA had not expected the results letter to be so different (quote 7). Furthermore, staff from this LA had concerns around the tone of the letter and whether it would generate more parental complaints than in normal years (quote 8).

Views of paper BIS included with the Enhanced NCMP letters/intervention

Parents mostly reported receiving a visual representation of childhood weight statuses through the BIS useful. As most parents’ children had received a healthy weight result letter, there were no negative reactions to the inclusion of the BIS (quotes 9 & 10). Some parents however, reported difficulty in differentiating the visual weight statuses as illustrated on the BIS (quote 11).

Stakeholders reported that whilst they had received some parental complaints linked to the study enhanced letter and the inclusion of the BIS, they did not feel it was significantly more than what they would normally receive (quote 12). Those parents who took part in the interviews were mostly positive about receiving the BIS and LA stakeholders suggested that it is the receiving of information that their child has been categorised as overweight/very overweight that generates complaints (quote 13).

Views of the MapMe intervention website

Parents who were randomised to have access to the MapMe2 intervention website were asked if they had visited the website, if not, whether they remembered seeing the information link. Only two parents reported visiting the website, however their recollection of what it contained was vague (quotes 14, 15 & 16). Most parents who were in the intervention group of the study did not remember seeing information about the website. Parents reported that they might be inclined to visit the website if they had concerns about their child’s result letter, they were provided with an electronic link, or if the QR code had been printed on the BIS paper (rather than in the results letter) (quote 17). Furthermore, parents spoke of often being overwhelmed with information from schools/healthcare organisations, so may have missed/discarded information from the study: (quote 18).

Embedding MapMe into usual practice

Participants were asked whether they felt the MapMe intervention should be embedded into usual NCMP practice. Due to the lack of parents accessing the website, data was lacking for this aspect. However, despite some parents having difficulty in differentiating between the images on the BIS, overall, receiving a visual representation of children’s weight statuses was useful. The stakeholders were keen to learn of the results of the trial before deciding (quote 19). However, attempts to improve the NCMP process were described as a positive (quote 20).

Discussion

Ten English LAs agreed to collaborate to test MapMe and deliver the intervention to parents via an ‘enhanced’ NCMP results letter including Body Image Scales (BIS): images of NCMP age- and sex-appropriate children of different weight statuses, plus dedicated website with BIS and supportive information. This qualitative study with LA staff and parents, aimed to determine the acceptability and potential embedding of the intervention into usual practice.

The findings from the parent interviews were heavily biased to those parents having no concerns over their child’s weight status or not having experienced receiving an NCMP result letter that was unexpected. Whilst a substantial number of parents taking part in the sub-study consented to be contacted further for an interview, recruitment proved to be challenging with only 27 parents agreeing to take part, with those that did take part, mainly having a child who received a healthy weight NCMP result letter (n = 25). Despite best efforts, we were not able to recruit more parents whose child had not received a healthy weight result (n = 2). Reasons for not wanting to discuss their child’s overweight status may be due to it being perceived as a sensitive subject or a criticism of parenting skills.²³ Parents who are themselves living with obesity may find dealing with their child’s overweight result distressing.²⁴ Some parents may not recognise overweight in their child^3,6,25 or contest an overweight status result,²³ whilst others worry that acknowledging that their child has an unhealthy weight and providing strategies to help with weight management may trigger eating disorders in their child.^23,26 It has been suggested that parents who receive a healthy weight result for their child were ‘more likely to trivialise the impact of receiving healthy feedback’.¹⁵ Most parents in our study reported that they were expectant of a healthy weight result and were happy with their child’s health related behaviours which was why many parents said they did not access the intervention website and resources and disinclined them from seeking further information.

Very few LA stakeholders reported issues of complaints from parents relating to the MapMe2 study. Those that did, reported them to be about the same as previous years. Other studies too, describe that negative responses to the NCMP results letters are reported only for a small minority of parents but dealing with these types of complaints can be distressing for both parents and LA staff.²³ The NCMP provides resources for helping LA staff/practitioners discuss overweight/very overweight results with parents,^27,28 this includes a video which was developed as part of the MapMe2 study.²⁹

Despite some parents having difficulty in differentiating between the images on the BIS included with the letter, overall, receiving a visual representation of children’s weight statuses was useful. Growth charts to record young children’s development have been used for many years and enable children’s growth to be assessed by comparing them with a normal range for other children of the same age and sex, relative to a reference population.³⁰ However, many parents are unable to understand the data presented to them.³¹ Having a visual representation may provide a simpler way to illustrate the differences between weight categories. The lack of engagement with the online MapMe tool was disappointing as the web version of the body images allows parents to rotate the images, and to project forwards to see how their child may look as an adult if their current weight status is maintained. The novel aspect of this feature may have engaged more parents if explored.

Generally, parents stated that measuring and monitoring children’s heights and weights via the NCMP was a useful government exercise, and they were happy for their child to take part. However, it was conceded that receiving a result that was not reporting a healthy weight status for their child would be upsetting and could stir up negative emotions. There was some belief that even if it was distressing, it was important to be honest about unhealthy weight results for a parent/carer to be able to make changes to help their child.

Strengths and limitations

Despite the data collection periods coinciding with the COVID-19 pandemic restrictions and having to work around changed work and home practices, we were able to recruit and ‘meet’ with a substantial number of participants, albeit online. However, we were unable to explore in-depth the views of parents whose child was living with overweight/obesity. We were therefore unable to determine if the views of these parents in accessing (or not accessing) the website/tool and resources would be different. Providing other ways to access the link to the study website/tool, such as through emails or an app, may have encouraged additional engagement.

Implications for policy

Whilst our study limitations did not allow for comprehensive policy recommendations, it was suggested by parents and stakeholders that the inclusion of the BIS with the NCMP results letter could be helpful to parents to help them understand and acknowledge the weight category result their child received. The MapMe intervention is now available to all LAs as an optional resource (MapMe 2). Additionally, Post-COVID-19, the NCMP is moving to a more digitalised approach, therefore any web links/additional information can be incorporated digitally into the result letter providing easier access.

Conclusions

This study highlights the difficulties in seeking the views of parents whose child has received an unhealthy weight status letter from the NCMP. Parents whose child was of a healthy weight had no concerns about seeking further information to help maintain a healthy weight in their child. It was not thought by stakeholders that from the small number of complaints received from parents, that embedding MapMe in usual NCMP practice would have a detrimental effect.

Consent to participate

Written and verbal consent was collected from all participants prior to interview.

Consent for publication

Informed consent for publication was collected from all participants through the written consent form.

Trial registration

International Standard Randomised Controlled Trial Number registry ISRCTN12378125 (19/08/2021).

The MapMe2 study team (not listed as authors)

Ms Letitia Sermin-Reed, Dr Elizabeth Evans, Professor Vera Araujo-Soares, Dr Tomos Robinson, Dr Moha Shojaei, Professor Dawn Teare, Professor Louisa Ells, Professor Martin Tovee, Professor John Matthews.

Statements and declarations

Ethical considerations

This study was approved by Newcastle University’s Faculty of Medical Sciences Ethics Committee (Reference 2073/9947/2020). The research was conducted in accordance with the Declaration of Helsinki.

Data availability

Underlying data

Data.ncl: MapMe2 Study – Process Evaluation Qualitative Data https://doi.org/10.25405/data.ncl.31834753.³³ The project contains the following underlying data: Dataset – Anonymised process evaluation parent and professionals interview/focus group transcripts.

Extended data

Data.ncl: MapMe2 Study – Process Evaluation Qualitative Data https://doi.org/10.25405/data.ncl.31834753.³³ The project contains the following extended data:

Supplementary – Process evaluation interview and focus group topic guides for parents and professionals.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Reporting guidelines

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups (COREQ).³²

Acknowledgments

The authors would like to thank the parents and stakeholders who gave up time to share their views and experiences and offer sincere thanks to all ten LAs who worked with the research team to deliver the study.

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