Conversation Cards for Adolescents© (CCAs): Content, Design, Production, and Dissemination
Background and Rationale
Health care providers (HCPs) report barriers to effective communication with adolescents with obesity when discussing lifestyle behavior change.
There is a need for tailored health communication tools to use during clinical consultations with this group.
Conversation Cards for Adolescents© (CCAs) were developed as a patient-centered, bilingual (English and French) tool to facilitate adolescent–HCP communication and support lifestyle and behavior changes.
The work aligns with broader evidence that effective HCP communication (empathy, question-asking, rapport) improves adherence, patient experiences, and health outcomes such as self-efficacy.
Purpose and Aims
Describe the content, design, production, dissemination, and application of CCAs.
Provide a detailed guide on integrating CCAs into clinical practice to tailor messages for adolescent obesity management.
Emphasize cross-language development (English and French) to reflect Canada’s bilingual population.
Theoretical Framework and Key Concepts
Message tailoring as a core principle to improve comprehension and health equity.
The CCAs capitalize on interpersonal communication to tailor messages based on identified priorities.
The approach enhances health literacy by incorporating cultural competence, linguistic needs, and communication preferences.
Guiding theories: Social Ecological Model and Social Cognitive Theory, considering micro-level (self-regulation) and macro-level (weight stigma) factors and human agency in goal pursuit.
Mechanism for behavior change includes self-regulation, self-efficacy, and collaborative goal-setting (S.M.A.R.T. goals).
Methods Overview
Mixed-methods, cross-language, patient-oriented research conducted in 2018–2019 with 19 adolescents with obesity, 3 HCPs, and obesity stakeholders.
Three interrelated steps: data prioritization (Step 1), semi-structured interviews (Step 2), and production/dissemination with Obesity Canada (Step 3).
Ethical approvals obtained and participants provided consent/assent; token compensation provided.
Step 1 – Data Prioritization
Goal: Involve Anglophone and Francophone adolescents in prioritizing barriers, enablers, and recommendations related to adopting healthy lifestyles (nutrition, physical activity, sedentary behavior, sleep, mental health).
Process: February–March 2018, adolescents (n = 19) rated statements on a 1–9 scale (1 = least important, 9 = most important) and could add new items.
Derivation: Statements came from prior data (scoping reviews, interviews, focus groups). Wording preserved the authentic terms used by adolescents (e.g., soda vs. sugar-sweetened beverages).
Language: English and French surveys generated separately, translated, back-translated, and reconciled.
Survey design: Neutral wording, ability to save progress, adolescent-friendly formatting to reduce response burden.
Analyses: Descriptive means to identify highest-ranked statements.
Data highlights:
153 statements identified as barriers, enablers, or recommendations (categories).
18 adolescents prioritized 72 barriers, 54 enablers, and 27 recommendations.
The five top-rated statements centered on nutrition and physical activity engagement.
Card consolidation: Top 15 statements per category (barriers, enablers, recommendations) were selected to form 45 cards per deck; English and French item means were combined due to negligible differences (Cronbach’s alpha \alpha > 0.90).
Step 2 – Tool Co-design
Involved a subset of participants (adolescents n = 5; HCPs n = 3).
Method: Facilitated matching to co-design CCAs, using pre-workshop electronic sharing of the top statements.
Interviews: One-on-one (adolescents) and group (HCPs) semi-structured telephone interviews (15 min to 1 hour).
Interview questions covered:
Representativeness of top statements
Wording changes
Categorization and color-coding
Visual design suggestions for cards
Data handling: Field notes and memos written immediately after interviews; interviews recorded and stored securely.
Analysis: Iterative, concurrent analysis with adolescents and HCPs; re-listening to audio for unresolved issues.
Outcomes: Iterative refinement of CCAs content, wording, categorization, and visuals guided by stakeholder input.
Step 3 – Production and Dissemination
Refinement and proofs: Three refinement rounds and two proof rounds (April–December 2018).
Design and production: Draft CCAs designed with The Burke Group and Obesity Canada; content, layout, typography, graphics, color, and cultural relevance were optimized.
Final production: January 2019 printing of 500 English decks and 200 French decks; A sample deck is shown in Figure 1.
Dissemination: Blog post in Obesity Notes, stakeholder outreach (adolescents, HCPs), media (infographics, webinars).
Complementary resources: Frequently Asked Questions and a template to include CCA-related information in adolescents’ medical records.
Card Structure and Content Details
Card organization: Seven suits corresponding to lifestyle areas.
Nutrition
Physical activity
Sedentariness
Sleep
Mental well-being
Relationships
Clinical factors
Card categories:
Barriers
Enablers
Recommendations
Key findings on card content:
Barriers and enablers often reflected individual and social efforts for lifestyle change.
Recommendations tended to address environmental and policy influences.
Notable design considerations: color-coding, bright colors, icons (emoticons), and a legend; ensure statements span multiple lifestyle areas when relevant to reflect the complexity of behavior change.
Results: Data and Deck Composition
Demographics of adolescents who completed Step 1:
Mostly female, Anglophone, Caucasian, with severe obesity (see demographics table for details).
Card statistics:
72 barriers, 54 enablers, 27 recommendations identified from initial data → 45 cards per deck after reduction (15 per category).
The means for English and French statements were combined due to minimal differences.
Step 2 participant characteristics:
Adolescents and HCPs varied in age and background; HCPs were all female and Caucasian.
Step 3 dissemination outcomes:
500 English decks and 200 French decks produced.
Additional dissemination channels included blog posts, webinars, and stakeholder communications.
Illustrative data points (examples from top statements):
Enabler: "It’s easier for me to be active when I genuinely enjoy the activity" (Enabler; Physical Activity) — rating ≈
Enabler: "It’s easier to be active with people I know" (Enabler; Physical Activity and Relationships) — rating ≈
Enabler: "It’s easy for me to eat healthy foods if they taste good" (Enabler; Nutrition) — rating ≈
Enabler: "We have enough money to afford healthy foods" (Enabler; Nutrition) — rating ≈
Recommendation: "I would like tax to be removed from healthy foods" (Recommendation; Nutrition) — rating ≈
The deck structure supports cross-cutting issues and routine clinical workflows.
Practical Applications and Clinical Integration
How to use CCAs in practice:
Use CCAs as an icebreaker before the consult or during the visit to frame discussion.
Clinicians may tailor the deck to their area of expertise, but it is recommended to use the full deck to reflect the inter-related nature of lifestyle factors.
Supporting resources for clinicians:
5As of obesity management as a complementary framework.
Training opportunities (e.g., SCOPE) to expand knowledge and confidence in obesity management.
Addressing environmental and policy-level factors:
Adolescents requested inclusion of environmental/policy statements to address root causes of obesity.
Clinicians can use these statements to discuss feasible, controllable changes with adolescents and families.
Family and adolescent dynamics:
The family remains a constant unit of support, but adolescents’ priorities may differ from parents’ (necessitating independent adolescent-focused discussion).
Some issues may be sensitive in the presence of parents; CCAs enable confidential or separate conversations as needed.
Goal-setting and behavior change mechanisms:
CCAs include a S.M.A.R.T. goal-setting sheet to collaboratively set lifestyle-related goals.
Goal-setting fosters self-regulation and self-efficacy, supporting the transition from intention to action.
Potential benefits:
Improves patient engagement and rapport, enables personalized care, and shifts focus from weight to feasible health behaviors.
Message Tailoring, Health Literacy, and Language Considerations
Linguistic and cultural tailoring is critical for effective care delivery; language barriers can impede access, adherence, and confidentiality.
Cross-language development (English and French) helps ensure cultural and linguistic representation of Canada’s adolescents.
Tailored messages may reduce stigma and enhance engagement by aligning with adolescents’ beliefs, practices, and preferences.
Theoretical and Ethical Considerations
Patient-oriented research (POR) principles guided by IAP2 spectrum: level 3 (involve) engaged adolescents in development, design, planning, interpretation, and dissemination.
Emphasis on transparency regarding researchers’ aims and stakeholder partnerships.
The CCAs aim to empower adolescents through collaboration, enhance autonomous decision-making, and improve healthcare practices via stakeholder knowledge translation.
Limitations
Participant demographics: majority of adolescents were Caucasian and with severe obesity; most HCPs were female and Caucasian.
Generalizability may be limited to adolescents in multidisciplinary care or those actively engaged in weight management programs.
Translation considerations: cross-language data collection introduces potential translation challenges; rigorous translation/back-translation processes were used to mitigate meaning loss.
Statistical approach: top 15 statements per category were selected; other data-driven methods (e.g., PCA) were not used in favor of a pragmatic, patient-centered approach.
Practical Implications, Conclusions, and Future Directions
CCAs provide a practical, patient-centered, bilingual tool to optimize adolescent–HCP communication and tailor lifestyle-change messaging.
The deck supports collaborative goal-setting and may help adolescents engage more effectively in their care, potentially improving adherence and health outcomes.
Future work includes evaluating user experience, feasibility, and preliminary effectiveness of CCAs for goal-setting and lifestyle change in clinical settings.
Acknowledgements and Funding (Summary)
Acknowledgement of adolescents, parents, and HCPs; support from Obesity Canada and clinical partners.
Funding: Health Outcomes Improvement Fund, Alberta Health Services; researchers’ affiliations with University of Alberta and partner institutions.
Note on potential competing interests: some authors partnered with Obesity Canada in dissemination; no financial compensation reported for tool prep.
Key Definitions and Quick References
Barrier: a circumstance or obstacle that impedes progress toward healthy lifestyle change.
Enabler: a factor or resource that makes healthy change possible.
Recommendation: a suggested action to support change.
Suits (card categories): nutrition, physical activity, sedentariness, sleep, mental well-being, relationships, clinical factors.
S.M.A.R.T. goals: Specific, Measurable, Attainable, Realistic, Timely.
Cronbach’s alpha for internal consistency in this study: \alpha > 0.90.
Sample sizes and key figures: adolescents (n = 19 in Step 1); HCPs (n = 3 in Step 2); decks produced: .
Notable numeric example: top-rated statements include a nutrition and activity focus with ratings such as for various enablers/recommendations.
Figure and Tables (Described)
Figure 1: Example cards per category in CCAs.
Table 1: Demographic and anthropometric characteristics of adolescents and parents (e.g., age years; BMI ; BMI percentile ; BMI z-score ).
Table 2: Five most top-rated statements across the deck with their categories and mean ratings (e.g., the top-rated enabler: "It’s easier for me to be active when I genuinely enjoy the activity" in Physical Activity with rating ).
References to Foundational Concepts (Selected)
Tailored health communication and behavior change theories: Noar et al. (Tailored health communication); Resnicow et al. (cultural sensitivity in public health); Bandura (social cognitive theory).
Behavioral change and goal-setting literature indicating improved outcomes with tailored goals and self-regulation approaches.
Obesity management best practices emphasizing collaboration, patient-centered care, and family engagement.
Background and Rationale
Health care providers (HCPs) frequently encounter challenges in effectively communicating with adolescents with obesity about complex lifestyle and behavior changes. These reported barriers hinder the success of interventions and can negatively impact patient engagement and outcomes.
Recognizing this critical gap, there was a clear and pressing need for the development of specialized, tailored health communication tools designed specifically for use during clinical consultations with this vulnerable population group.
Conversation Cards for Adolescents© (CCAs) were consequently developed as an innovative, patient-centered, and culturally resonant intervention. This tool is fully bilingual, available in both English and French, reflecting Canada’s official languages, to intentionally facilitate adolescent–HCP communication and robustly support lifestyle and behavior modification efforts.
This work is firmly grounded in extensive evidence demonstrating that effective HCP communication—characterized by empathy, skilled question-asking, and strong rapport-building—is a cornerstone for improving patient adherence to treatment plans, enhancing overall patient experiences, and achieving superior health outcomes, notably including increased self-efficacy among patients.
Purpose and Aims
The primary purpose of this initiative is to comprehensively describe the intricate content, design principles, production process, dissemination strategies, and practical application of the CCAs.
A core aim is to furnish a highly detailed, step-by-step guide for health care professionals on how to seamlessly integrate CCAs into their clinical practice. This integration is designed to enable HCPs to tailor health messages precisely to individual adolescent needs, thereby optimizing the management of adolescent obesity.
Explicit emphasis is placed on the rigorous cross-language development process (English and French), which was a deliberate decision to accurately reflect and cater to the diverse bilingual population of Canada, ensuring equitable access and relevance.
Theoretical Framework and Key Concepts
Message tailoring as the foundational principle underpinning the CCAs, aiming to enhance comprehension, relevance, and ultimately improve health equity by customizing information to individual needs.
The CCAs ingeniously leverage interpersonal communication to tailor messages dynamically, adapting them based on the specific priorities, concerns, and insights identified by the adolescent during the clinical interaction.
This patient-centric approach significantly enhances health literacy by thoughtfully incorporating critical elements such as cultural competence, addressing distinct linguistic needs, and accommodating diverse communication preferences among adolescents.
Guiding theoretical frameworks include the Social Ecological Model and Social Cognitive Theory. The Social Ecological Model helps consider the multi-layered influences on health behavior, ranging from micro-level factors (e.g., individual self-regulation, personal choices) to broader macro-level factors (e.g., societal weight stigma, policy environments). Social Cognitive Theory, particularly Bandura’s work, emphasizes the crucial role of human agency, self-efficacy, and observational learning in the pursuit and achievement of health goals.
The primary mechanisms for behavior change facilitated by CCAs include fostering enhanced self-regulation, building robust self-efficacy, and promoting collaborative goal-setting, typically utilizing S.M.A.R.T. goals (Specific, Measurable, Attainable, Realistic, Timely) to transition intentions into actionable plans.
Methods Overview
The research employed a comprehensive mixed-methods, cross-language, patient-oriented design, conducted meticulously during 2018–2019. It involved a diverse cohort of 19 adolescents with obesity, 3 experienced HCPs, and various key obesity stakeholders, ensuring a multi-perspective approach.
The development process was structured into three highly interrelated and sequential steps:
Data Prioritization (Step 1): This involved systematically identifying and ranking critical barriers, enablers, and recommendations for healthy lifestyles from the adolescent perspective.
Semi-structured Interviews (Step 2): This phase focused on co-designing the CCAs through qualitative interviews, eliciting direct feedback on content, wording, and visual design.
Production and Dissemination (Step 3): This final stage encompassed the actual manufacturing of the card decks and their strategic dissemination in partnership with Obesity Canada.
Throughout the study, stringent ethical approvals were obtained from relevant institutional review boards, and all participants provided informed consent or assent, ensuring voluntary participation and protection of rights. Token compensation was provided to adolescent participants as an acknowledgment of their valuable time and contributions.
Step 1 – Data Prioritization
Goal: The primary objective was to actively involve both Anglophone and Francophone adolescents in a systematic process to prioritize the most salient barriers, enablers, and recommendations directly related to adopting and maintaining healthy lifestyles across several key domains: nutrition, physical activity, sedentary behavior, sleep, and mental health.
Process: From February to March 2018, the participating adolescents (n = 19) were engaged in rating a series of predefined statements. They used a 1–9 Likert-type scale, where indicated least important and indicated most important. Importantly, participants also had the option to propose and add entirely new items or statements that they felt were missing from the provided list, ensuring a truly patient-centered elicitation of priorities.
Derivation: The initial pool of statements from which adolescents made their selections was rigorously derived from prior comprehensive data. This included insights gleaned from scoping reviews of existing literature, previous in-depth interviews, and focused group discussions with adolescents and relevant stakeholders. A critical aspect of the methodology was the preservation of the authentic terms and vernacular used by adolescents themselves (e.g., using "soda" instead of the more clinical term "sugar-sweetened beverages"), which ensured the relevance and relatability of the statements.
Language: To address Canada's bilingual context, English and French surveys were meticulously generated as separate instruments. Each version underwent a stringent multi-stage translation process, including forward translation, back-translation by independent translators, and final reconciliation by a bilingual expert panel to ensure conceptual equivalence and linguistic accuracy across both languages.
Survey Design: The surveys were designed with several key considerations to optimize adolescent participation and minimize response burden. This included using neutral wording to avoid bias, implementing a feature that allowed participants to save their progress and resume later, and incorporating adolescent-friendly formatting (e.g., clear layout, engaging visuals) to enhance engagement and ease of completion.
Analyses: The collected data from the rating scales were analyzed using descriptive statistics, specifically calculating the mean ratings for each statement. This method enabled the researchers to clearly identify the highest-ranked statements, providing an empirical basis for prioritization.
Data Highlights:
A total of 153 distinct statements were initially identified as either barriers, enablers, or recommendations, categorized into their respective groups.
Following the prioritization process, 18 adolescents (one participant was excluded due to incomplete data) effectively prioritized 72 unique barriers, 54 enablers, and 27 specific recommendations. This reduction helped focus on the most pertinent issues from the adolescent perspective.
A critical finding was that the five top-rated statements across all categories consistently centered on aspects of nutrition and physical activity engagement, underscoring these as key areas of concern and intervention for adolescents with obesity.
Card Consolidation: To ensure the practicality and usability of the final CCA decks, a strategic reduction process was undertaken. The top 15 statements from each category (barriers, enablers, and recommendations) were selected, resulting in a total of 45 cards per deck. Furthermore, the mean ratings for English and French items were combined into a single, unified dataset. This decision was empirically supported by negligible differences observed between the two language groups, as evidenced by a high Cronbach’s alpha (\alpha > 0.90), indicating excellent internal consistency and cross-language agreement in participant ratings. This step allowed for the creation of a single, coherent set of cards applicable to both language groups.
Step 2 – Tool Co-design
Involved a carefully selected subset of participants, comprising 5 adolescents and 3 HCPs. These individuals were chosen for their willingness to engage further and provide in-depth feedback on the CCAs.
Method: A facilitated matching methodology was employed to collaboratively co-design the CCAs. Prior to dedicated workshops or interviews, the subset of participants received electronic copies of the top-ranked statements, allowing them to review and reflect in advance, thereby maximizing the efficiency and depth of the co-design process.
Interviews: One-on-one semi-structured telephone interviews were conducted with adolescents to ensure a private and focused discussion, lasting between 15 minutes to 1 hour. Separately, HCPs participated in group semi-structured telephone interviews, fostering peer discussion and shared insights.
Interview Questions Covered:
Representativeness of Top Statements: Participants were asked whether the top-ranked statements truly reflected their experiences and the key issues in adolescent obesity management.
Wording Changes: Feedback on the clarity, appropriateness, and emotional tone of the wording on the cards was solicited, with specific suggestions for revisions.
Categorization and Color-Coding: Participants provided input on the logical grouping of cards into different categories (suits) and the effectiveness of the proposed color-coding scheme for easy identification.
Visual Design Suggestions for Cards: Critical feedback was gathered on aesthetic elements, including typography, graphics, icons, and overall card layout, to ensure the design was appealing, understandable, and culturally relevant for adolescents.
Data Handling: Detailed field notes and memos were meticulously written immediately following each interview, capturing key observations and design implications. All interviews were audio-recorded and securely stored, allowing for comprehensive review and analysis.
Analysis: An iterative, concurrent analysis approach was adopted, continuously integrating feedback from both adolescents and HCPs. This involved repeatedly re-listening to audio recordings, particularly for discussions around unresolved issues or divergent viewpoints, to ensure a thorough understanding and resolution of design challenges.
Outcomes: This intensive collaborative process led to the iterative refinement of the CCAs, encompassing improvements in content, precise wording, intuitive categorization, and visually engaging design, all directly guided by the invaluable input of key stakeholders.
Step 3 – Production and Dissemination
Refinement and Proofs: After the co-design phase, three rigorous rounds of content refinement were conducted, followed by two distinct rounds of proofing (spanning April–December 2018). These stages ensured linguistic accuracy, visual appeal, and overall quality of the card decks.
Design and Production: The draft CCAs were professionally designed in collaboration with The Burke Group and Obesity Canada. This partnership focused on optimizing every aspect of the physical cards, including content layout, typography, engaging graphics, a suitable color palette, and ensuring cultural relevance for the target audience.
Final Production: In January 2019, the finalized CCAs went into print, with an initial run of 500 English decks and 200 French decks. A representative sample of the final deck design is visually presented in Figure 1 of the original document.
Dissemination: Broad dissemination efforts were undertaken to ensure the CCAs reached a wide audience. This included a dedicated blog post published on Obesity Notes, extensive outreach to key stakeholders (adolescents, HCPs, and advocacy groups), and leveraging various media channels, such as infographics and webinars.
Complementary Resources: To maximize the utility and facilitate seamless integration of CCAs into clinical practice, several supporting resources were developed. These included a comprehensive Frequently Asked Questions (FAQ) document for common inquiries and a customizable template designed to assist clinicians in effectively documenting CCA-related information within adolescents’ electronic medical records. These resources aim to enhance clinician confidence and streamline adoption.
Card Structure and Content Details
Card Organization: The CCAs are thoughtfully organized into seven distinct "suits" or categories, each corresponding to a critical lifestyle area relevant to adolescent health and obesity management:
Nutrition: Focusing on eating habits, food choices, and caloric intake.
Physical Activity: Addressing exercise, movement, and sedentary breaks.
Sedentariness: Specifically targeting behaviors related to prolonged sitting or inactivity.
Sleep: Covering sleep quality, duration, and associated habits.
Mental Well-being: Incorporating aspects of emotional health, stress, and self-esteem.
Relationships: Exploring social support, peer influence, and family dynamics.
Clinical Factors: Addressing medical aspects, health conditions, and treatment adherence.
Card Categories: Within each suit, cards are further subgrouped into three distinct categories to provide a holistic view of challenges and solutions:
Barriers: Statements identifying obstacles that impede progress toward healthy lifestyle change.
Enablers: Statements describing factors or resources that facilitate healthy change.
Recommendations: Suggested actions or strategies to support positive lifestyle change.
Key Findings on Card Content:
Barriers and enablers often reflected individual and social efforts for lifestyle change, highlighting the personal agency and immediate social environment's role.
Recommendations, however, tended to address broader environmental and policy influences, suggesting adolescents often perceive systemic factors as crucial for substantive change.
Notable Design Considerations: The physical design of the cards incorporated several critical elements to enhance usability and engagement:
Color-coding: Each suit is assigned a distinct color for quick visual identification.
Bright colors: Chosen to be appealing and stimulating for adolescents.
Icons (emoticons): Used to convey meaning quickly and enhance visual interest.
A legend: Provided to help users quickly understand the meaning of colors and icons.
Cross-cutting statements: Care was taken to ensure that some statements spanned multiple lifestyle areas when relevant (e.g., "It’s easier to be active with people I know" touches on both Physical Activity and Relationships), reflecting the interconnected and complex nature of behavior change.
Results: Data and Deck Composition
Demographics of Adolescents Who Completed Step 1: The adolescent participants were predominantly female, Anglophone, and identified as Caucasian. A significant majority presented with severe obesity, indicating the tool was developed with the specific needs of this clinical sub-population in mind (detailed demographics are provided in an accompanying table).
Card Statistics:
From an initial pool of 72 barriers, 54 enablers, and 27 recommendations identified through the initial data prioritization, the final CCAs deck was reduced to 45 cards (15 per category: 15 barriers, 15 enablers, 15 recommendations) for practicality and clinical utility.
As previously noted, the mean ratings for English and French statements were combined due to statistically minimal differences between the two language groups, ensuring a unified deck for both populations.
Step 2 Participant Characteristics: The adolescents and HCPs involved in the co-design phase (Step 2) represented a diverse range of ages and professional backgrounds. Notably, all HCPs who participated were female and Caucasian, a demographic feature that needs to be considered when evaluating the generalizability of their specific design inputs.
Step 3 Dissemination Outcomes:
The production phase resulted in 500 English decks and 200 French decks, ensuring substantial availability for clinical use and research.
Beyond physical deck distribution, additional dissemination channels included targeted blog posts, educational webinars, and strategic communications with various stakeholders, amplifying reach and awareness of the CCAs.
Illustrative Data Points (Examples from Top Statements): The following examples highlight some of the highest-rated statements, demonstrating the adolescent perspective on facilitators and desired policy changes:
Enabler: "It’s easier for me to be active when I genuinely enjoy the activity" (Enabler; Physical Activity suit) — received a high mean rating of approximately . This underscores the importance of intrinsic motivation and enjoyable activities.
Enabler: "It’s easier to be active with people I know" (Enabler; Physical Activity and Relationships suits) — rated at approximately . This highlights the significant role of social support and peer/family involvement.
Enabler: "It’s easy for me to eat healthy foods if they taste good" (Enabler; Nutrition suit) — with a rating of approximately . This points to the practical importance of palatable healthy food options.
Enabler: "We have enough money to afford healthy foods" (Enabler; Nutrition suit) — rated at approximately . This critically reveals socioeconomic factors as key enablers or barriers to healthy eating.
Recommendation: "I would like tax to be removed from healthy foods" (Recommendation; Nutrition suit) — with a rating of approximately . This strongly indicates adolescents' desire for policy-level interventions that make healthy choices more accessible and affordable.
Overall, the deck structure is purposefully designed to support the discussion of cross-cutting issues that frequently arise in adolescent health and to seamlessly integrate into routine clinical workflows, promoting a holistic approach to care.
Practical Applications and Clinical Integration
How to Use CCAs in Practice:
CCAs can be effectively used as an icebreaker at the beginning of a consultation to initiate discussion, or they can be integrated throughout the visit to structure and frame dialogue around lifestyle behavior change.
While clinicians may choose to tailor the deck to their specific area of expertise (e.g., pulling only nutrition cards for a dietitian's visit), it is generally recommended to use the full deck. This approach ensures that the inter-related and complex nature of various lifestyle factors is fully appreciated and addressed, consistent with the Social Ecological Model.
Supporting Resources for Clinicians:
The 5As of obesity management (Ask, Assess, Advise, Agree, Assist) can be used as a complementary framework alongside the CCAs, providing a structured approach to counseling.
Clinicians are encouraged to seek training opportunities, such as those offered by SCOPE (Strategic Centre for Obesity Professional Education), to expand their knowledge, enhance their skills, and boost their confidence in comprehensive obesity management.
Addressing Environmental and Policy-Level Factors:
Adolescents explicitly requested the inclusion of statements addressing environmental and policy-level factors in the CCAs. This reflects their understanding that systemic issues often underlie individual behavior challenges and contribute to the root causes of obesity.
Clinicians can utilize these policy-oriented statements to engage adolescents and their families in discussions about feasible, actionable changes that are within their sphere of influence, while also acknowledging the broader context of health determinants.
Family and Adolescent Dynamics:
While the family unit invariably serves as a constant source of support for adolescents, it is crucial to recognize that adolescents’ personal priorities and perspectives on lifestyle change may diverge significantly from those of their parents. For this reason, CCAs facilitate independent, adolescent-focused discussions.
Certain sensitive issues may be difficult for adolescents to discuss openly in the presence of parents. CCAs provide a discreet and flexible means to enable confidential or separate conversations with the adolescent as needed, respecting their autonomy and fostering trust.
Goal-Setting and Behavior Change Mechanisms:
Each CCA deck includes a dedicated S.M.A.R.T. goal-setting sheet, which is designed to facilitate a collaborative process between the adolescent and the HCP in establishing concrete, lifestyle-related goals.
This structured goal-setting process is integral in fostering self-regulation and building self-efficacy, actively supporting the critical transition from mere intention to sustained action in behavior change.
Potential Benefits:
The implementation of CCAs in clinical practice offers numerous potential benefits, including enhancing patient engagement, improving rapport between adolescents and HCPs, enabling a truly personalized care approach, and crucially, shifting the focus of discussions from stigmatizing weight numbers to more actionable and feasible health behaviors.
Message Tailoring, Health Literacy, and Language Considerations
Linguistic and cultural tailoring is unequivocally critical for the delivery of effective and equitable healthcare. Language barriers, in particular, can profoundly impede access to care, adherence to treatment plans, and the maintenance of essential patient confidentiality.
The rigorous cross-language development of CCAs (in both English and French) directly addresses this challenge, helping to ensure genuine cultural and linguistic representation and relevance for Canada’s diverse adolescent population.
Tailored messages, which are central to the CCAs' design, have the potential to significantly reduce the experience of stigma and substantially enhance patient engagement by aligning closely with adolescents’ pre-existing beliefs, cultural practices, and individual communication preferences.
Theoretical and Ethical Considerations
The entire research and development process for the CCAs was meticulously guided by the core principles of Patient-Oriented Research (POR). This commitment is exemplified by its alignment with the IAP2 (International Association for Public Participation) spectrum of public participation, specifically achieving Level 3 (Involve).
Adolescents were actively and meaningfully engaged at multiple pivotal stages of the project, including its foundational development, intricate design, strategic planning, critical interpretation of findings, and broad dissemination, ensuring their voices shaped every aspect of the tool.
A strong emphasis was placed on transparency regarding the researchers’ aims, methodologies, and the nature of all stakeholder partnerships, fostering trust and accountability.
Fundamentally, the CCAs aim to empower adolescents through genuine collaboration, thereby enhancing their autonomous decision-making capabilities regarding their own health, and ultimately improving healthcare practices through effective stakeholder knowledge translation.
Limitations
Participant Demographics: A noteworthy limitation is that the majority of adolescent participants were Caucasian and exclusively presented with severe obesity. Similarly, most HCPs involved in the study were female and Caucasian. These demographic characteristics suggest that the generalizability of the findings and the tool's immediate applicability might be limited to similar populations or contexts.
Generalizability: The generalizability of the CCAs may be more specifically limited to adolescents who are already receiving multidisciplinary care or those who are actively engaged in structured weight management programs, rather than the broader adolescent population.
Translation Considerations: Despite rigorous methodologies, any cross-language data collection inherently introduces potential challenges related to translation. While comprehensive translation, back-translation, and reconciliation processes were scrupulously employed, there remains an inherent possibility of subtle nuances or meanings being lost or altered during linguistic conversion.
Statistical Approach: In Step 1, the research pragmatically opted to select the top 15 statements per category based on descriptive means. Other advanced data-driven methods, such as Principal Component Analysis (PCA), were intentionally not utilized. This decision was made in favor of a more pragmatic and directly patient-centered approach, prioritizing adolescent voices over statistical complexity.
Practical Implications, Conclusions, and Future Directions
The Conversation Cards for Adolescents (CCAs) stand as a practical, patient-centered, and bilingual communication tool specifically designed to optimize adolescent–HCP communication and facilitate tailored messaging for lifestyle changes, particularly in the context of obesity management.
The deck actively supports collaborative goal-setting, which is anticipated to help adolescents engage more effectively in their own healthcare journey, potentially leading to improved adherence to health recommendations and better long-term health outcomes.
Future work is critically needed and planned. This includes comprehensive evaluations of user experience, assessing the tool's feasibility in various clinical settings, and rigorously measuring the preliminary effectiveness of CCAs in influencing goal-setting and promoting sustained lifestyle changes among adolescents.
Acknowledgements and Funding (Summary)
The researchers extend sincere gratitude and acknowledgement to all participating adolescents, their parents, and the dedicated HCPs who contributed their time and insights to this project. Essential support was also provided by Obesity Canada and various clinical partners.
Funding for this pivotal research was generously secured from the Health Outcomes Improvement Fund, Alberta Health Services. The researchers maintain affiliations with the University of Alberta and its partner institutions, which provided institutional support.
Note on Potential Competing Interests: It is important to disclose that some authors collaboratively partnered with Obesity Canada in the dissemination efforts of the CCAs. However, no financial compensation was reported by any authors specifically for the preparation or development of the tool itself, upholding research integrity.
Key Definitions and Quick References
Barrier: A circumstance or obstacle that significantly impedes progress toward healthy lifestyle change.
Enabler: A factor or resource that actively makes healthy change possible or easier.
Recommendation: A suggested action or strategy proposed to support and facilitate positive change.
Suits (card categories): The seven thematic groupings of cards: Nutrition, Physical activity, Sedentariness, Sleep, Mental well-being, Relationships, and Clinical factors.
S.M.A.R.T. goals: An acronym defining effective goal-setting criteria: Specific, Measurable, Attainable, Realistic, Timely.
Cronbach’s alpha for internal consistency in this study: The statistical measure of internal consistency found to be \alpha > 0.90, indicating high reliability of the combined English and French statement ratings.
Sample sizes and key figures: Adolescents (n = 19 in Step 1 for data prioritization); HCPs (n = 3 in Step 2 for co-design interviews); Decks produced: decks and decks.
Notable numeric example: Top-rated statements included a strong focus on nutrition and physical activity, with high mean ratings such as (for enjoyment in physical activity), (for social support in activity), (for taste of healthy foods), (for affordability of healthy foods), and (for tax removal from healthy foods) for various enablers and recommendations.
Figure and Tables (Described)
Figure 1: An illustrative graphic depicting example cards from each category within the CCAs, showcasing their design and content.
Table 1: Provides detailed demographic and anthropometric characteristics of the adolescent and parent participants (e.g., mean adolescent age years; mean BMI ; mean BMI percentile ; mean BMI z-score ).
Table 2: Lists the five most top-rated statements across the entire deck, clearly indicating their respective categories (e.g., Enabler/Physical Activity) and their mean numerical ratings (e.g., the top-rated enabler: "It’s easier for me to be active when I genuinely enjoy the activity" with a rating of ).
References to Foundational Concepts (Selected)
Tailored health communication and behavior change theories: Key foundational work includes Noar et al. (focusing on tailored health communication models); Resnicow et al. (emphasizing cultural sensitivity in public health interventions); and Bandura (detailing Social Cognitive Theory, which underpins self-efficacy and agency).
Behavioral change and goal-setting literature: Researched evidence consistently indicates that improved health outcomes are associated with tailored goals and self-regulation approaches, which are central to the CCAs' design.
Obesity management best practices: The development of CCAs is informed by established best practices in obesity management, which strongly emphasize collaboration, patient-centered care models, and active family engagement.