Closing the preventive care chain for overweight children: evaluation of the implementation of an integrated, locally aligned approach, enforcing primary care.

In 2016, 11% of the children in 's-Hertogenbosch were overweight. Overweight
children in the Netherlands not always receive optimal, coordinated care.
Improving integrated care for overweight is a priority in many Dutch
municipalities. An integrated preventive care chain for children 4-12 years has
been developed in 's-Hertogenbosch and this innovative approach is implemented
in three neighborhoods: Noord, Maaspoort en Zuidoost. The approach is focused
on self management of the family and is based on principles of stepped and
matched care. There is close local collaboration between schools and all kinds
of (health)professionals. Youth health care professionals function as
coordinator and linking pin in the local network. With this approach we expect
to reach more children and parents. By matching care with needs of parents and
children and through the optimal use of strong local networks, we expect to
achieve durable effects on quality of life of overweight children and self
management of their families.

Get insight in the implementation and effectiveness of the integrated
preventive care chain for overweight children in 's-Hertogenbosch.
With the results we can optimize the support for overweight children and their
parents.

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The (PhD) research project runs from 2017 to 2020 and consists of an
implementation and effectiveness study.
In the implementation study we evaluate the degree of implementation of the
integrated preventive care chain (use of principles, tools as described) in the
three neighborhoods in 's-Hertogenbosch as well as determinants of
implementation (facilitating and/or impeding factors). In addition, we describe
experiences of professionals and parents, as well as the flow of children
(numbers reached, drop outs) in the new approach.
Based on documents about the preventive care chain in *s-Hertogenbosch and in
consultation with professionals, we draw up a checklist to measure the extent
to which youth health care professionals work according to the principles of
the new approach. We make use of the MIDI-model (measuring instrument for
determinants of Innovations) (Fleuren 2012) to determine potential determinants
for implementation, such as characteristics of youth health care nurses,
characteristics of participants and characteristics of the local network.
To determine these characteristics and to discuss experiences of professionals
with the new approach, semi-structured interviews are held with all youth
health care nurses (± 12), all youth health care physicians (± 6), a number of
general practitioners (± 6), a number of pediatricians (± 2) and a number of
other professionals (± 6) working in the three neighborhoods. Interviews are
also held with 10-15 parents (if possible with children) to discuss their
experiences with the support they received for their overweight child(ren).

To picture the flow of children in the preventive care chain, we document the
number of children identified with overweight (at school, or by GP or YHC
professionals). We also count how many children receive support by YHC
professionals, how many children accomplish care and how many children drop
out. Simple registries are kept by the professionals who are involved.


In the effectiveness study, 120 overweight children in *s-Hertogenbosch are
followed and compared with 60 overweight children outside *s-Hertogenbosch who
receive care as usual. Our primary outcome is the development in quality of
life of the child. Secondary outcomes are developments in BMI, physical
activity, nutrition, psychosocial problems of the child and empowerment of the
parents. Parents fill out digital questionnaires at the start, after three
months and after approximately one year of YHC involvement. Measurements are
aligned with regular contacts with youth health care nurses. After a year we
ask parents which professional support for overweight they received (including
life style interventions). We also ask them to rate the support they received
(both from YHC as in general). Information on BMI and referrals are subtracted
from regular YHC files of the child.

This study can only be conducted with input from (overweight) children and
their parents, since they are the target group of the preventive care chain
which is under study. Participation in the study is voluntary and has no risks.
The burden for parents and professionals in the implementation study is their
participation in interviews (30-60 minutes per person).

The burden for parents in the effectiveness study consists of filling out the
questionnaires: 30 minutes at baseline (t0), 20 minutes at three months (t1)
and 30 minutes after a year (t2). The questionnaires are filled out at home or
in a YHC waiting room, before or after a YHC contact.

BMI and referrals are documented by YHC nurses as usual in regular digital
child files. YHC nurses have an important role in informing and including
children and parents in the study. For children in 's-Hertogenbosch (dependent
on parent's permission), the results of the quality of life questionnaire can
be used/discussed in the YHC contacts. YHC nurses have additional time for
their contribution to the study.