Nurses’ Role in Childhood Obesity Prevention Programs Within Primary Care Settings

Introduction

Childhood obesity remains a substantial public health concern, with national guidance consistently identifying the primary care well-child visit as a key opportunity for early identification and prevention, given its near-universal reach across the pediatric population during the developmental period when weight trajectories are most modifiable (Barlow & the Expert Committee, 2007; National Academies of Sciences, Engineering, and Medicine, 2016). Clinical guidelines from this expert committee and subsequent updates specify a staged approach to obesity prevention and management in primary care, encompassing routine body mass index (BMI) percentile screening, brief behavioral counseling regarding nutrition and physical activity, and, where indicated, referral to more intensive weight-management resources (Story et al., 2002).

Nurses, including registered nurses, licensed practical nurses, and nurse practitioners, are frequently positioned as central to the practical delivery of this guidance, given their consistent presence during intake, vital sign and growth measurement, and, in many practice models, portions of anticipatory guidance historically delegated from physician to nursing staff (Klein et al., 2013; Small et al., 2009). Despite this frequently stated role expectation, the existing literature examining childhood obesity prevention in primary care has disproportionately emphasized physician attitudes, knowledge, and self-efficacy, with comparatively less attention paid specifically to how nurses themselves understand, prioritize, and experience this role under the time and workflow constraints of routine practice (Perrin et al., 2005; Rausch et al., 2011).

This gap is important because a role that is formally assigned in guidelines but not clearly integrated into workflow, training, and available referral infrastructure may be inconsistently enacted regardless of individual nurse motivation or belief in its value, a distinction with direct implications for how health systems might most effectively support this role. The purpose of this mixed-methods study was to examine, concurrently, the frequency and self-efficacy with which primary care nurses perform childhood obesity prevention practices, the barriers they perceive to performing this role consistently, and how nurses themselves describe and experience their role in obesity prevention within routine primary care practice, integrating quantitative and qualitative findings to develop a more complete account than either data type could provide alone.

Methods

Design. This study used a convergent parallel mixed-methods design, in which quantitative survey data and qualitative interview data were collected concurrently, analyzed separately using methods appropriate to each data type, and subsequently integrated through a joint display to examine convergence, divergence, and complementarity across data strands (Creswell & Plano Clark, 2018; Fetters et al., 2013).

Setting and quantitative sample. A cross-sectional survey was distributed to all nursing staff (registered nurses, licensed practical nurses, and nurse practitioners) across 18 primary care practices within a single academic-affiliated health system between April and September 2025. Of 287 eligible nurses, 210 completed the survey (73.2% response rate).

Quantitative measures. The survey included investigator-developed items assessing the frequency of five core obesity-prevention practices (BMI percentile plotting, growth trajectory discussion, nutrition and activity screening, structured behavior-change counseling, and referral to weight-management resources), rated on a five-point frequency scale from “never” to “always.” Role self-efficacy was assessed using an adapted 10-item obesity-prevention self-efficacy scale (range 0–100), derived from prior provider self-efficacy instruments (Perrin et al., 2005). Perceived barriers were assessed using a 12-item checklist developed from prior primary care obesity prevention literature, with nurses indicating whether each barrier substantially affected their practice.

Qualitative sample and data collection. A subsample of 20 survey respondents was purposively selected to achieve variation in role type (registered nurse, licensed practical nurse, nurse practitioner), years of primary care experience, and practice location (urban and rural sites). Semi-structured interviews, lasting a median of 34 minutes, explored participants’ understanding of their obesity-prevention role, their experience delivering related practices, and their perceived barriers and support needs. Interviews were audio-recorded and transcribed verbatim.

Quantitative analysis. Descriptive statistics summarized practice frequency, self-efficacy, and barrier endorsement. Self-efficacy scores for screening-related versus counseling-related survey items were compared using a paired t-test.

Qualitative analysis. Interview transcripts were analyzed using reflexive thematic analysis (Braun & Clarke, 2019). Two researchers independently coded an initial subset of transcripts, developed a shared coding framework through discussion, and applied it to the remaining transcripts, iteratively refining themes against the full data set.

Integration. Quantitative and qualitative findings were integrated using a joint display, a table structure that aligns quantitative results with corresponding qualitative themes and illustrative data to visually and analytically examine the degree of convergence between the two data strands (Fetters et al., 2013), presented in Figure 3.

Results

Quantitative strand. Among 210 surveyed nurses, practice frequency varied substantially across the five core obesity-prevention practices, with screening-related tasks reported far more consistently than counseling or referral tasks, as shown in Figure 1.

Mean overall role self-efficacy was moderate (61.4 out of 100, SD 18.2). When self-efficacy items were separated by practice type, mean self-efficacy for screening-related items (74.8, SD 15.1) was significantly higher than for counseling-related items (52.3, SD 20.4; paired t-test, p < .001), mirroring the practice frequency pattern observed in Figure 1. Among the 12 barriers assessed, three were endorsed by more than half of respondents, as shown in Figure 2: insufficient time during visits (78.1%), perceived lack of family receptiveness to counseling (66.2%), and insufficient training in behavior-change counseling technique (58.6%). Lack of awareness of local referral resources (49.5%) and lack of clarity about role expectations relative to the provider (44.3%) were also frequently endorsed.

Qualitative strand. Analysis of the 20 interviews produced four themes. Role ambiguity beyond routine screening captured nurses’ descriptions of clear expectations around measurement and documentation tasks alongside considerably less clarity about the extent of their expected involvement in counseling and follow-up, which several participants described as informally negotiated with individual providers rather than formally defined. Time and workflow constraints as the dominant structural barrier reflected near-universal description of counseling as the first task compressed or omitted when visits ran behind schedule, regardless of individual nurse motivation to provide it. The nurse as a relationship-based motivator captured participants’ description of their role as distinct from, and in their view complementary to, the physician’s diagnostic role, with several nurses describing their longer-term, lower-stakes rapport with families as uniquely suited to raising a sensitive topic like weight over repeated visits rather than in a single encounter. Need for structured counseling training and referral infrastructure reflected a consistent request, raised independent of years of experience, for brief, practical counseling technique training and a clearer, more consistently available local referral pathway, which several participants contrasted with training they had received on screening and documentation procedures, described as comparatively thorough.

Discussion

This mixed-methods study found strong convergence between quantitative and qualitative findings: nurses consistently and confidently performed obesity-related screening and documentation tasks but reported, and described, markedly lower frequency and self-efficacy for counseling and referral tasks, attributing this gap primarily to time, training, and infrastructure constraints rather than to disagreement about the value of the counseling role itself. This pattern is consistent with prior literature identifying time pressure as a near-universal barrier to preventive counseling across primary care disciplines (Rausch et al., 2011), while extending this literature by directly linking the barrier to a specific, quantifiable gap between screening and counseling self-efficacy within the same nursing sample.

The qualitative theme characterizing the nurse as a relationship-based motivator, distinct from but complementary to the physician’s diagnostic role, offers a conceptually useful frame for future role development. Rather than positioning nursing counseling as a redundant extension of physician counseling, participants described their longitudinal, lower-stakes rapport with families as a distinct asset for raising a sensitive topic gradually across visits, a framing consistent with prior conceptual work describing nurses’ relational continuity as a distinct mechanism of influence in preventive health behavior change (Small et al., 2009; Resnicow et al., 2006).

The consistent request for structured counseling training and clearer referral infrastructure, raised across experience levels and practice locations, suggests that role ambiguity in this study was less a matter of nurses lacking a conceptual understanding of what family-centered obesity counseling should involve, and more a matter of lacking the specific technique training and system-level referral pathways needed to enact it confidently and efficiently within a time-constrained visit. This distinction has direct implications for intervention design: brief, structured counseling technique training, of the kind evaluated in prior motivational interviewing dissemination research, may address the self-efficacy gap identified quantitatively, while standardized, readily available local referral pathways may address the workflow-level barrier described qualitatively (Resnicow et al., 2006; Rice et al., 2020).

Several limitations should be considered. This study was conducted within a single health system, and while 18 practices spanning urban and rural locations provided some variation, generalizability to health systems with different staffing models, visit lengths, or existing referral infrastructure should be considered carefully. The quantitative barriers checklist, while grounded in prior literature, was investigator-developed rather than independently validated, and self-report practice frequency may not fully correspond to observed clinical behavior. As with the qualitative interview data in general, findings reflect nurses’ retrospective accounts of their practice and experience rather than direct observation of clinical encounters.

Future research should incorporate direct observation of well-child visits to examine the correspondence between self-reported and observed counseling practice, and should evaluate whether brief counseling technique training and structured referral pathway interventions, the two most concretely actionable findings from this study, produce measurable improvement in nurse-reported self-efficacy and counseling frequency. Extending this work to examine family perspectives on nurse-delivered obesity counseling would further clarify whether the relational advantage nurses described in this study is similarly perceived by the families receiving it. Taken together, these findings suggest that expanding nurses’ role in childhood obesity prevention in primary care may depend less on further clarifying or reinforcing the value of the role, which nurses in this study largely already endorsed, and more on providing the structural supports, protected counseling time, brief technique training, and accessible referral pathways, needed to enact an already-accepted role consistently under real-world primary care conditions.

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