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

Currently, most overweight children do not receive appropriate care because there is a gap in the preventive care chain. General practitioners (GP's) can provide overweight patients with preventive advise on life style risk factors as part of their consultation, covered by health care insurance. However, overweight children do not visit the GP frequently, because generally they are not ill, nor considered at risk of becoming ill. GP’s therefore cannot provide structured preventive advise and adequate follow up care. The result of this is a serious flaw in the preventive care chain for overweight children, whereas early intervention can prevent our society from the burden of severe adverse health consequences such as diabetes and cardiovascular disease (WHO, 2016). In the Netherlands YHC has the legal task (laid down in the Public Health Act) to monitor health and healthy development of all children in the ages 0 to 18 years. In this respect, YHC doctors and especially nurses, are in frequent and direct contact with overweight children and their parents. The newest national YHC guideline on overweight and obesity in children (JGZ richtlijn overgewicht) prescribes three extra sittings to be added in YHC specifically to be applied for prevention of overweight in children. However, it appears that in general, those sittings mainly adress life style change, while identifying underlying causes, solving initial problems and motivating children and parents towards self-management may be more appropriate and effective. To close the gap in the preventive care chain for overweight children a new approach to overweight prevention (for children 4-12 years) is being implemented in three neighborhoods in ’s-Hertogenbosch as part of an ongoing national pilot (Proeftuin Ketenaanpak overgewicht bij kinderen). In this approach, GP’s and YHC professionals collaborate to provide adequate preventive care for overweight children; thereby closing the gap in the preventive care chain. GP’s (and schools) identify overweight children through structured screening and refer them to YHC. YHC and GP’s share information on the advice they give to the children and their parents. Within the new approach, GP’s and YHC professionals work according to the same underlying methods. The methods and tools used are well described (van Mil & Struik), based on existing guidelines and protocols, but with a stronger emphasis on cooperation between health professionals, and guidance of parents and children towards self-management according to stepped- and matched care principles. Preliminary results and experience with this approach are positive; parents and children, are more confident and feel more responsibility to initiate necessary life style changes by themselves. In 2016, the new approach is fully implemented in three neighborhoods in ’s-Hertogenbosch [Noord, Maaspoort and Zuidoost]. First YHC professionals and GP’s will be trained to further optimize their competences. Main topics of the training will be: using protocols and (diagnostic) instruments in a non-accusatory manner, analysis of underlying problems, education about these problems towards child and parents, helping them to find support from existing social networks, supporting them to focus on reward and enjoyment instead of punishment and debt. Lastly, guidance towards follow up care or transfer within the stepped and matched up approach will be covered using the same model, keeping the family part of the decision process. In the proposed study a PhD student appointed at the Academic collaborative center of Public Health Brabant (supervised by a research team) will monitor and evaluate this implementation by addressing two research questions: 1) Which factors are associated with successful implementation of the intervention? and 2) What are the effects of the intervention as compared to regular preventive care for overweight children? The processes and results of preventive care of 120 overweight children (4-12) in the three neighborhoods in ’s-Hertogenbosch will be followed over 1,5 years. In addition, outcomes will be compared with results of preventive care for 60 overweight children in two control neighborhoods (outside ’s-Hertogenbosch), where YHC and GP’s provide care according to recent guidelines. Data collection will include both qualitative and quantitative methods. The first research question will focus on reach and on (determinants of) use and appreciation of the implemented approach. Main outcomes for the second research question are (changes in) stage of behavior change, current lifestyle, BMI-SD and overweight related quality of life. Different partners from research, public health, primary and secondary care and ‘clients’(overweight children and their parents) collaborate in the development and conduction of this project. This broad collaboration enhances the study’s relevance and facilitates the implementation and the dissemination of the project's results.