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general practitioner, allied health care including dietician visits, medical specialist care and prescribed and non-prescribed medications. In addition, direct costs outside health care, such as travel expenses to the obesity clinic or dietician, complementary care, sports costs and attendance at the parents sessions were also collected. The costs of the intervention was estimated by adding the costs of personnel, development, information sheets and workbooks, pedometers and the rent of the room for the group sessions. Cost data was collected monthly in cost diaries completed by the parents.
Of the 122 adolescents, 39 participants completed none of the cost diaries, despite all the reminders. Reasons for not filling in, were refusal (financial matters are private), or the questionnaire was too complicated, or they already forgot if they were ill or had an appointment with the general practitioner. Of the remaining 83 cost diaries, only 30 were of participants who were present at five or more Go4it intervention sessions. Because of this large amount of missing data, we were not able to draw conclusions about the cost effectiveness of Go4it. Further research is needed on the development and validation of self- administered or digital cost diaries in this population given their important role in the evaluation of health intervention programs.
Generalizability
Before implementation of a multidisciplinary group treatment, its generalizability needs to be considered. In 2011, 14% of the youth were overweight, and 2 percent obese (20). Our study population existed of mainly obese adolescents (n=110); only a small number of the adolescents were overweight (n=12, 10%).
The low adherence to the Go4it program limits the generalizability of our findings. At 18 months follow-up the level of attrition was 44% (49% in the intervention group and 37% in the control group). Ball et al. found an attrition rate of 20-40% on the short term (20 weeks) in this target group (8). Also, Nguyen et al. reported 38%, and Savoye et al. even 56% attrition (10,21). Therefore, this level of attrition is comparable to other studies concerning obesity treatment in adolescents (12-47%) (8-10,21-26). Many adolescents were not motivated to attend the Go4it sessions every other week. Even after signing the informed consent form, some adolescents and their families were not willing to complete participation. We encouraged participant compliance by sending reminders using text messages and phone contact one week before the sessions. The main reasons for not attending the Go4it sessions were the travel distance and the limited time of working parents and schoolchildren. Therefore, we recommend implementation of Go4it in a setting closer to the home environment, such as the child health care environment or school setting.
General discussion
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