Assertive outreach care in Preventive Child Healthcare: an effectiveness study

Families who experience a chronic complex of socio-economic and psycho-social
problems have impaired contact with healthcare and welfare services. Evidence
exists that the core of this problem lies in a problematic interaction between
this type of families and current systems of care and services. The adults and
children involved have continues needs in multiple domains like finance,
labour, housing and parenting. Their complex and interwoven difficulties do not
fit in with the fragmented nature of care systems, highlighting well-defined,
single problems and short-term services. Especially, the splitting of
socio-economic and psycho-social support systems appears to be difficult for
problem families. Psycho-social care often ignores socio-economic troubles,
whereas these two fields are interrelated for this target group. From the
practice of social workers and service providers it is known that they
experience that problem families are one of the hardest populations to serve.
It has been shown that the term *multi-problem families*, to point out the
target group, mainly originates from the context of care and services facing
difficulties in dealing with this group of clients. It is estimated that 2-5%
of Dutch children (0-19) grow up in this type of families.
Assertive outreach care in Preventive Child Healthcare is an intervention that
focuses on this target group. The aim of the intervention is to get in touch
with care-avoiding problem families in the first place by using assertive
outreach approaches. After that, the child health professionals help the family
to accept care or support, and liaise between them and appropriate care. The
intervention focuses on improving the situation of the children by means of a
system-approach: the needs of all family members are taken into account.
Earlier studies to this intervention were established to make a start with its
scientific underpinning. These studies were aimed at getting detailed insight
into characteristics of the target group and the content of the intervention.
Furthermore, early outcomes were assessed on the level of direct intervention
results and client satisfaction. It has been shown that the intervention
deliverers were able to reach the target group. Linking to care and services
was attained in the majority of the cases (79%-92%) and parents expressed
satisfaction. Based on this research, the intervention has been stipulated in
an intervention guide.

The goal of this study is to determine the effectiveness of Assertive outreach
care in Preventive Child Healthcare. The research question is: what are the
effects of this intervention (delivered as stipulated in the intervention
guide) in an intervention group compared to a control group receiving *care as
usual*?

The present study has a quasi-experimental design. The intervention condition
consists of Assertive outreach care as stipulated in the intervention guide.
The control condition consists of *care as usual* as routinely delivered by
Preventive Child Healthcare. This condition is delivered to families eligible
for Assertive outreach care as identified by Preventive Child Healthcare. In
this study, no random assignment of families takes place. For ethical and
practical reasons randomisation is deemed unfeasible.
A power calculation has shown that both study groups should encompass 40
families. Drop out of families could happen at several moments during the
study. Therefore, the intervention group as well as the control group should
consist of 66 families.
In both the intervention group and the control group three assessments take
place: baseline, post-intervention and half-year follow-up. Three measures are
used: a registration to assess care consumption, the Family Questionnaire and
the Strengths and Difficulties Questionnaire. All measures are used at
baseline, post-intervention and half-year follow-up.

Assertive outreach care originates in public mental healthcare settings for
marginalised persons with severe and complex problems not receiving help they
objectively need, like homeless people and persons with complex addiction
problems. Nowadays, these types of interventions are entering the field of
child care, and are applied to marginalised problem families as well. Assertive
outreach care in Preventive Child Healthcare focuses on:
- problem families
- their social network and
- services and healthcare providers that could provide help or support.
The intervention consists of an active approach of problem families in their
own environments to get in touch with them, motivate them to accept suitable
care and liaise between them and appropriate support or care. The intervention
primarily focuses on the parent(s) aimed at so-called *shared care*, i.e.
parent(s) and Preventive Child Healthcare reach a shared understanding that the
development of the child(ren) is severely threatened. The ultimate goal is to
improve the situation of the child.
The family*s social network and formal agencies can provide help or support.
The intervention aims that this is actively and coherently done. Within
existing models of assertive outreach care, this is the so-called *broker*s
model*. The broker*s model is the form of assertive outreach where care is
*brokered* between clients and agencies. Clients are typically transferred to
regular care facilities after an assessment and development of a plan. This
means that Assertive outreach care in Preventive Child Healthcare provides no
treatment for specific underlying problems, like relationship or psychiatric
problems of the parents. Assertive outreach care is voluntary, using gentle
pressure motivated from the child being threatened.
Assertive outreach care in Preventive Child Healthcare temporarily provides
practical support (i.e. apply for social benefit, seeking solutions for
transportation of children to school/nursery) as a tool in building rapport and
to make room for follow-up help. The intervention takes approximately 6 months
and consists of 5 main steps (i.e. 1. case finding, 2. making contact, 3.
sustaining contact, 4. developing a family plan, 5. linking (arranging for
services to be delivered)).
Several components seem to contribute to the results of the intervention,
including the outreach approach, family empowerment, the system approach,
practical support, and building bridges between the family and (in)formal
support and assistance.

Families who participate in this study are asked to complete two questionnaires
and to answer some questions on care consumption. This takes place three times
during the study. Total time to be invested is 2,5 hours within a period of one
year. Some questions could be perceived as an incursion on one's privacy,
specifically the questions from the Family Questionnaire concerning
partnership.