Behavior Theory (Health Communication)

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: cmckibbi@uwyo.edu

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% (n = 70) dispensed spe-

cific 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%).

3.3 | 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

TABLE 1 Sample characteristics (n = 101)

Characteristic M (SD) n (%)

Agea 37.6 (10.2)

Years in practice 9.3 (8.7)

Female gender 87 (86.1)

Primary roleb

Licensed professional counsellor 39 (38.6)

Social worker 23 (22.8)

Marriage and family therapist 9 (8.9)

Psychiatrist 6 (5.9)

Psychologist 6 (5.9)

Nurse 2 (2.1)

Other clinician 12 (12.4)

Education levelc

Doctoral 13 (12.9)

Master's 50 (49.5)

Bachelor's 10 (9.9)

Otherd 25 (24.8)

an = 96. bn = 97. cn = 98. dTwenty‐five participants noted some aspect of their occupation or

licensure rather than a degree level.

2060 | WYKES ET AL.

OW/OB is beyond my control’; ‘Whether I provide structured weight

loss intervention to my youth clients with SED and OW/OB is en-

tirely up to me’) from the perceived behavioural control scale resulted

in stronger internal consistency reliability (α = .80) and corrected

item–total correlations (ranging from r = .57 to r = .70). Role beliefs

had acceptable reliability (α = .77), while moral norms had poor re-

liability (α = .57). Removing one item with poor fit (i.e., ‘I do feel/

would feel guilty about providing structured weight loss intervention

to my youth clients with SED and OW/OB’) from the moral norms

scale resulted in stronger internal consistency reliability (α = .72) and

correlation between the two remaining items (r = .57). Finally, the

behavioural intention scale demonstrated strong internal consistency

reliability (α = .87).

3.4 | Theory of planned behaviour questionnaire scale validity/factor structure

Confirmatory factor analysis was conducted with items measuring

attitude towards the behaviour, subjective norm and perceived be-

havioural control (after removing two items with poor fit). Results

indicated adequate‐to‐good model fit37,38 across the three goodness‐

of‐fit indices. The absolute model fit result (SRMSR = 0.067), the

parsimony correction analysis result (RMSEA = 0.073) and the com-

parative fit analysis (CFI = 0.949) all fell within ranges indicative of

good fit. Thus, the confirmatory factor analysis supported the factor

structure of the theory of planned behaviour model as applied in the

present study.

3.5 | Direct attitude scales as predictors of behavioural intention

Descriptive statistics were calculated for each scale. Means and

standard deviations revealed moderate to high endorsement of items

on attitude towards the behaviour (M = 3.98, SD = 0.70), perceived

behavioural control (M = 3.01, SD = 0.89), moral norm (M = 3.18,

SD = 0.84) and role beliefs (M = 2.55, SD = 0.81) scales and lower

endorsement of items on the subjective norm (M = 1.79, SD = 0.71)

scale. Means and standard deviations were also calculated for be-

havioural intention to provide structured weight loss interventions

(M = 2.61, SD = 0.93) and engagement in this behaviour (M = 1.61,

SD = 0.95).

The associations between the direct attitude scales and beha-

vioural 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. The model accounted for

approximately 48% of the variance, and each direct attitude scale

predicted behavioural intention. Role beliefs and moral norm scales

were entered into Block 2, resulting in approximately 67% of the

variance being accounted for by the model, a statistically significant

increase. In Block 2, all predictors except attitude towards the

behaviour were statistically significant. Finally, a Pearson correlation

was computed between behavioural intention and engagement in the

behaviour. The variables were significantly correlated (r = .63, p < .01).

4 | DISCUSSION

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

tween community mental health providers' attitudes and their in-

tentions to engage in the delivery of structured weight loss

interventions designed for vulnerable youth with SED and OW/OB.

This study examined the value of attitudinal constructs, outlined by

the theory of planned behaviour, to understand provider intentions. It

is important to note that there has been debate in the literature

regarding the ongoing usefulness of the theory of planned behaviour

in general. Specifically, a paper by Sneihotta et al.22 called into

question the validity of the theory of planned behaviour and noted

that its parsimony may limit its ability to explain a sufficient pro-

portion of variance in behaviour. We used a systematic approach25 to

design a measure of the theory of planned behaviour to measure

attitudinal influences of community mental health providers on their

intentions to engage youth with SED and OW/OB in structured

weight loss interventions. Results of a confirmatory factor analysis

and two‐step linear regression in the present study indicated that the

measure was consistent with the theory of planned behaviour and

showed support for the relationship between theory‐driven attitu-

dinal constructs and community mental health providers' behavioural

intentions. Results from this study were consistent with previous

literature examining provider behavioural intentions.24

The efforts of researchers to expand the theory of planned be-

haviour to include new and relevant constructs and criticisms of

others identify the lack of ability to falsify both the traditional as well

as newly added constructs. Ajzen21 himself acknowledged flaws of

the theory, and indicated that a determinant should not be

TABLE 2 Predictors of intention to provide a structured weight loss intervention (n = 99)a

Model β R2 R2 p

Block 1 .542 .542 <.001

Attitude towards the behaviour .338 <.001

Subjective norm .288 .001

Perceived behavioural control .381 <.001

Block 2 .693 .151 <.001

Attitude towards the behaviour .127 .082

Subjective norm .155 .033

Perceived behavioural control .234 .001

Role belief .217 .011

Moral norms .372 <.001

aSample size was n = 99 for the regression analysis, due to missing data.

WYKES ET AL. | 2061

introduced unless it offers more variance than the others already

included in the model. In our study, expert feedback was solicited

regarding the theory‐driven, attitudinal measures, which resulted in

the addition of two new attitudinal constructs to the model (i.e., role

belief and moral norm). The inclusion of these constructs significantly

added to the prediction behavioural intention even above the sub-

stantial variability accounted for by the traditional model. This finding

was also consistent with previous research.39 However, in the pre-

sent study, the addition of the moral norms construct to the re-

gression model also resulted in attitude towards the behaviour

becoming a weaker and nonsignificant predictor of behavioural in-

tention. Multicollinearity was not a factor in this change. It is possible

that some of the traditional constructs may hold less value when

compared to newer constructs such as moral norms. It is also possible

that the role of individual constructs may vary by target behaviour.

In addition to attitudinal constructs, a survey of existing practices

of community mental health providers in this study provided in-

formation about what is currently happening in practice regarding

OW/OB among clients with mental health disorders. The survey

showed that providers in this study directly addressed weight con-

cerns with clients and most often did so by dispensing dietary or

physical activity suggestions or advice. Many providers also reported

a lack of training opportunities to enhance their knowledge and skills

for addressing weight concerns or creating health behaviour change.

These results are somewhat different from a study conducted in an

adult sample from Australia20 in which a minority of providers re-

ported dispensing weight‐related advice. While unclear, sources of

discrepancy between our results and those of Ashby et al.20 may

include important differences in methodology, sampling procedures

(including the countries in which the studies were conducted) and

target treatment considered. The results of our study indicate that

workforce skill development may be needed to enhance providers'

abilities to increase access to evidence‐based, structured weight

management services designed for youth with SED and OW/OB.40

4.1 | Limitations and future research directions

The present study is one of the first, to our knowledge, to design and

implement a theory of planned behaviour‐informed measure of

provider intentions to provide structured weight loss interventions to

youth with SED and OW/OB and do so within the context of a

community‐based participatory approach to intervention develop-

ment. While the project hypotheses were supported, the results

should be considered within the context of their limitations. First,

behavioural intention in the present study focused on the broad

concept of providing weight loss intervention in general. There may

be important differences in providers' intentions to address diet and

to address physical activity. Future studies should address weight‐

related interventions (e.g., diet and physical activity) separately to

reduce ambiguity and to elucidate causes for differential engagement

in various aspects of weight‐related treatments. Second, limitations

related to recruitment procedures and sample characteristics should

be noted. First, recruitment was conducted via impersonal and

electronic means. It is possible that centres and individuals who

chose to participate were more likely than nonparticipants to engage

in weight management discussions with their clients. Lack of data

from nonparticipants limits our understanding of the generalisability

of the findings. In addition, participants were also engaged in the

provision of mental health services within the community mental

health system in the United States and may not reflect attitudinal

influences on provider behaviours in other mental health systems in

other countries. The present study was also limited by the lack of an

objective measure of clinician engagement in the target behaviour.

This construct was addressed with a single self‐report item scored on

a 5‐point, Likert‐type scale. A single, self‐report item was not deemed

sufficient to support more complex analyses such as path modelling

or structural equation modelling. Future studies could include a more

thorough measures of behavioural engagement. It would be ideal if

such an indicator could include an outcome based on objective

evidence, such as activity logs of direct researcher observation.

Finally, the identification of cross‐sectional predictors of behavioural

intention provides only promising ideas and generates future hy-

potheses for examination in future studies. Longitudinal studies and

experimental studies may identify predictors of behavioural intention

over time. Experimental examination of strategies to alter provider

attitudes regarding engagement in structured weight management

services may also add to the theory's utility for use in practice in

community mental health settings.

4.2 | Summary and conclusions

In summary, the present study, included within a larger community‐

based, participatory intervention development effort, examined atti-

tudinal 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 in-

terventions to meet their specific needs. This population may be

especially likely to benefit from the integration of weight loss treat-

ment 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 providers41 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 pro-

viders may benefit from workforce education regarding how to

2062 | WYKES ET AL.

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.

Andrea S. Worth was responsible for substantial manuscript con-

ceptualisation, writing and revision. Kathryn A. Richardson was re-

sponsible for literature review and substantial contribution to writing

and revision of the introduction. Tonja Woods was responsible for

substantive contribution to interpretation of results and writing of

the discussion. Morgan Longstreth was responsible for literature

review and manuscript editing. Christine L. McKibbin assisted with

study conceptualisation, study design, oversight of data collection,

analysis, interpretation, manuscript writing and editing.

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.

ORCID

Christine L. McKibbin http://orcid.org/0000-0002-3359-7849

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How to cite this article: Wykes TL, Worth AS, Richardson KA,

Woods T, Longstreth M, McKibbin CL. 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. Health Expect.

2022;25:2056‐2064. https://doi.org/10.1111/hex.13357

2064 | WYKES ET AL.

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