Received: 27 March 2021 | Revised: 6 August 2021 | Accepted: 10 August 2021

DOI: 10.1111/hex.13357

S P E C I A L I S S U E PA P E R

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

Thomas L. Wykes PhD, Staff Psychologist | Andrea S. Worth MS, Graduate Student |

Kathryn A. Richardson MS, Graduate Student |

Tonja Woods PharmD, Clinical Associate Professor |

Morgan Longstreth MS, Graduate Student | Christine L. McKibbin PhD, Professor

Department of Psychology, University of

Wyoming, Laramie, Wyoming, USA

Correspondence

Christine L. McKibbin, Department of

Psychology, University of Wyoming, 3415,

1000 E. University Ave, Laramie, WY 82071,

USA.

Email: [email protected]

Present address

Thomas L. Wykes, Veterans Affairs Cheyenne

Healthcare System, 2360 E. Pershing

BlvdCheyenne, WY 82001, USA.

Funding information

No funding was received to undertake this

study.

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 re-

lationship 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 con-

trol), 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 ap-

pear to influence provider intentions to deliver weight loss interventions to youth

with SED. Findings suggest preliminary strategies to increase provider intentions.

Health Expectations. 2022;25:2056–2064.2056 | wileyonlinelibrary.com/journal/hex

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,

provided the original work is properly cited.

© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd

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 dis-

cussions with community mental health providers and administrators particularly

contributed to the study question asked as well as interpretation of results.

K E YWORD S

overweight and obesity, serious emotional disturbance, theory of planned behaviour, weight loss interventions, youth

1 | 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 ran-

domly 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 sta-

bilizing 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 dis-

proportionately affect youth with psychiatric disorders,5–8 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%), beha-

viour 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 sur-

rounding 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.

1.1 | 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 as-

sociated 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 first‐

episode 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 in-

volvement 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 system‐

level 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.15–19 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 profes-

sionals. 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 recommenda-

tions. 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 at-

tributed providers' decisions to convey weight‐related healthy life-

style 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 con-

structs 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.

1.2 | The theory of planned behaviour: Understanding provider intentions

The theory of planned behaviour21 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 for-

ward as alternatives (e.g., Health Action Process Approach),23 this parti-

cular 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 provi-

ders.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 Sev-

eral psychological constructs contribute to the development of beha-

vioural intentions. The theory states that salient beliefs drive the cognitive

constructs that contribute to behavioural intentions. Salient beliefs include

specific beliefs about (1) the target behaviour (i.e., behavioural beliefs), (2)

others who would approve or disapprove of engaging in the behaviour

(i.e., normative beliefs) and (3) the ability to control aspects of the beha-

viour (i.e., control beliefs). These salient beliefs correspond directly to the

following cognitive constructs (i.e., direct attitude variables): (1) attitude

towards the behaviour, (2) subjective norm and (3) perceived behavioural

control. Attitude towards the behaviour refers to favourable or un-

favourable appraisals held by an individual about the specific behaviour.

Subjective norm refers to social pressure regarding whether or not to

engage in the behaviour. This social pressure is influenced by the opinions

of others whom the individual deems important. Finally, perceived beha-

vioural control refers to an individual's appraisal of and corresponding

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 ‘… beha-

viors 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 hygiene28 and

participate in regular leisure‐time physical activity among individuals with

diabetes,29 among other behaviours.30

1.3 | 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 re-

searchers. 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 inter-

ventions. 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 self‐

reported 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.

2 | METHODS

2.1 | 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

2058 | WYKES ET AL.

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 internet‐

based 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.

2.2 | Measures

2.2.1 | Sociodemographics

A sociodemographic form was used to collect the personal and

professional characteristics of all participants (e.g., age, occupation

and years in practice).

2.2.2 | 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, nor-

mative beliefs and control beliefs), direct attitude variables (i.e., atti-

tude towards the behaviour, subjective norm and perceived

behavioural control), role beliefs, moral norms and behavioural in-

tention. 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 group33 and were added to questions addressing the direct

attitude and behavioural intention constructs of the theory of plan-

ned 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 beha-

viour. For each scale, a summary score was calculated as the simple

mean of the items.

2.2.3 | Clinical practice survey

A 26‐item survey, based partly on the measure used by Ashby

et al.,20 collected information about engagement in weight‐related

treatment activities (e.g., providers' assessment of weight and life-

style behaviours, types of dietary and physical activity services pro-

vided). The survey included Likert‐type items (e.g., ‘For your youth

clients with SED and OW/OB, how often do you directly address

your client's weight in your sessions?’) and open‐ended questions

(e.g., ‘What percentage of your youth clients with SED have OW/

OB?’). The survey allowed for the calculation of frequency counts of

reported weight‐related treatment activities and qualitative descrip-

tion of additional needs and preferences in relation to these

behaviours.

2.3 | Procedure

This study was conducted as part of a larger community‐based parti-

cipatory 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 is a community‐based, parti-

cipatory model, including patient and public involvement, which serves

as a blueprint for designing, implementing and evaluating an inter-

vention based on theoretical, empirical and practical information. A key

component of the IM protocol is the engagement of stakeholders in all

phases of intervention development from identification of the pro-

blem, to planning for research and needs assessments, to identification

of essential programme elements, to evaluation of the intervention. In

this case, a stakeholder board comprising parents and youth (n = 4),

community mental health providers (n = 4), administrators (n = 2) and

researchers (n = 6) met on a monthly basis. Feedback on design and

results from community mental health providers and administrators

was sought and incorporated into this study.

Participants in this study were recruited from community mental

health agencies listed in the United States SAMHSA national direc-

tory of mental health treatment facilities. The inclusion criteria were

applied to all 50 states and yielded a list of 1989 entries. Sites were

manually evaluated to verify eligibility for participation. Potential

participants were contacted via email and/or website‐based contact

forms.

All measures were administered through an internet‐based

survey platform (i.e., Qualtrics).35 Prospective participants first

navigated to a screening page to assess their inclusion criteria. All

participants had the opportunity to indicate informed consent and to

participate in the survey, which allowed administrators to review the

survey even if they were not direct service providers. However, those

who did not consent to participate were not included. The survey

took an average of 20min to complete. Responses for all survey

questions other than identity and survey completion status were

deidentified. Participants who completed the survey were entered in

a raffle for one of 15 Amazon gift cards, each worth $20. The Uni-

versity of Wyoming Institutional Review Board approved this study.

The study conforms to recognized standards of the US Federal Policy

for the Protection of Human Subjects.

2.4 | Data analysis

Descriptive statistics were calculated for all questionnaire items.

Responses to the Clinical Practice Survey were dichotomized as

‘Never or Almost Never’ and ‘Rarely’ versus ‘Sometimes’, ‘Frequently’

and ‘Always or Almost Always’. All relevant variables were checked

for normality (Kolmogorov–Smirnov test); transformations of

WYKES ET AL. | 2059

nonnormal variables did not result in improvements in normality, so

all analyses were performed with untransformed variables. Analyses

were performed using SPSS version 23 and Mplus version 7.2.

2.4.1 | 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 atti-

tudinal 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) standardized root mean square residual (SRMSR), (2) root

mean square error of approximation (RMSEA) and (3) the compara-

tive fit index (CFI).

2.4.2 | Direct attitude constructs as predictors of behavioural intention

A two‐step linear regression was conducted to evaluate the predic-

tion 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 R2 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 in-

tention and engagement in the behaviour. For all analyses, alpha was

set to p < .05, and all results were two‐tailed.

3 | RESULTS

3.1 | Sample

A total of 578 (59.3%) sites fulfilled the inclusion criteria. Participants

were distributed across at least 49 unique sites (missing n = 3). Par-

ticipants (n = 101) were located across 25 states, with the largest

representation in New Hampshire (n = 10) and Washington (n = 10)

states. The majority were female, had obtained a master's degree and

were employed as a licensed professional counsellor (see Table 1).

3.2 | Clinical practice and needs

Nearly one‐half of the providers (n = 47, 47%) reported directly ad-

dressing weight with clients in some capacity; 44% (n = 44) reported

dispensing specific dietary advice; and 70%

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