National and Local Strategies in the Netherlands for Obesity Prevention and Management in Children and Adolescents

Public health nurses' experiences following up children with overweight and obesity according to national guidelines. A qualitative study

PURPOSE

This study aimed to develop knowledge of how the follow-up regarding overweight and obesity among children in primary school is experienced by the PHN and how the guidelines may be used to improve health services in this follow-up.

METHODS

We analysed semi-structured interviews of 9 PHNs using qualitative content analysis.

RESULTS

Two themes emerged: Following up with children with overweight and obesity is an important but challenging duty; The PHNs call for clearer guidelines. Following five sub-themes: PHNs strive to adhere to the guidelines, show compassion in the follow-up, have difficulty handling parents' feelings and reactions, feel alone with the responsibility, and have suggestions for clearer guidelines.

CONCLUSIONS

PHNs call for enough resources to communicate the results of the child's weight in a sufficient form. PHNs and families should establish common goals. The PHN should avoid one-way communication but meet the parents' concerns and needs. This requires the PHN to focus on building a secure relation to the child and the families, as described by Peplau. Guidelines must include instructions and tools on how to communicate and meet the family's concerns. Political action and increased funding could strengthen the follow-up and thereby prevent more obesity among children, which can be a predictor of poorer health outcomes later in life.

Qualitative multi-stakeholder evaluation of the adoption, implementation and sustainment of the school-based dietary intervention "Jump-in"

BACKGROUND

Comprehensive school-based programs applying the WHO Health Promoting School Model have the potential to initiate and sustain behavior change and impact health. However, since they often include intervention efforts on a school's policies, physical environment, curriculum, health care and involving parents and communities, they significantly 'intrude' on a complex system that is aimed primarily at education, not health promotion. More insights into and concrete strategies are therefore needed regarding their adoption, implementation, and sustainment processes to address the challenge to sustainable implementation of HPS initiatives in a primarily educational setting. This study consequently evaluates adoption, implementation and sustainment processes of Amsterdam's Jump-in healthy nutrition HPS intervention from a multi-stakeholder perspective.

METHODS

We conducted semi-structured interviews and focus groups with all involved stakeholders (n = 131), i.e., Jump-in health promotion professionals (n = 5), school principals (n = 7), at-school Jump-in coordinators (n = 7), teachers (n = 20), parents (n = 50, 9 groups) and children (n = 42, 7 groups) from 10 primary schools that enrolled in Jump-in in the school year 2016-2017. Included schools had a higher prevalence of overweight and/or obesity than the Dutch average and they were all located in Amsterdam's low-SEP neighborhoods. Data were analyzed using a directed content analysis, in which the Determinants of Innovation Model was used for obtaining theory-based predetermined codes, supplemented with new codes emerging from the data.

RESULTS

During intervention adoption, all stakeholders emphasized the importance of parental support, and accompanying workshops and promotional materials. Additionally, parents and teachers indicated that a shared responsibility for children's health and nuanced framing of health messages were important. During implementation, all stakeholders needed clear guidelines and support structures. Teachers and children highlighted the importance of peer influence, social norms, and uniform application of guidelines. School staff also found further tailoring of the intervention and dealing with financial constraints important. For long-term intervention sustainment, incorporating the intervention policies into the school statutes was crucial according to health promotion professionals.

CONCLUSIONS

This qualitative evaluation provides valuable insights into factors influencing the adoption, implementation, and sustainment processes of dietary interventions, such as the importance of transparent and consistent intervention guidelines, clear communication regarding the rationale behind intervention guidelines, and, stakeholders' involvement in decision-making.

Bored, afraid, alone: What can we learn from children with paediatric obesity about the impact of the COVID-19 pandemic for future pandemics, care practices and policies?

PURPOSE

The aim of this study was to gain insight into the perspectives of children with paediatric obesity themselves, during the pandemic and afterwards, regarding their wellbeing and health, and to solicit their advice on tailoring obesity care to match their daily realities.

DESIGN AND METHODS

We used a 'draw, write and tell' interview technique, conducted walk-alongs, participant observations and a group session with children with paediatric obesity from seldom-heard communities in Amsterdam, the Netherlands. Data was analysed using reflexive thematic analysis.

RESULTS

Children reported that during lockdowns they were confined to the house, causing them to feel bored and alone. This triggered them to fall into previous unhealthy patterns, such as an increase in sitting on the couch or lying in bed, gaming or watching TV, feeling hungry a lot and eating more. Some children experienced major events, such as mourning the death of a loved one or taking care of other family members, and thus felt they had to grow up fast.

CONCLUSION

Our study adds to our understanding of the mechanisms of the impact of the COVID-19 pandemic from the perspectives of children with paediatric obesity from seldom-heard communities and emphasizes the importance of considering how the pandemic (and related measures) affected the daily - as well as future - lives of children in vulnerable circumstances.

PRACTICAL IMPLICATIONS

The recommendations children gave could be explored as pathways for more child-centred, successful and tailored obesity care practices and policies in order to support their (mental) wellbeing and health.

Leverage point themes within Dutch municipalities' healthy weight approaches: A qualitative study from a systems perspective

INTRODUCTION

Despite all efforts of national and local approaches, obesity rates continue to rise worldwide. It is increasingly recognized that the complexity of obesity should be further addressed by incorporating a systems perspective when implementing approaches. Such an approach has four interconnected system levels: events, structures, goals, and beliefs, in which small changes ('leverage points') can lead to substantial changes in the functioning of the entire system. The current research examined the functioning of five Dutch municipalities' healthy weight approaches (HWAs) and the leverage point themes that can be identified in their system.

METHODS

Thirty-four semi-structured interviews were conducted with various stakeholders about the HWA, including policy advisors, care professionals, practice professionals, and citizens. An inductive thematic analysis was performed.

RESULTS

Three main themes were identified: 1) HWA organization structure, 2) collaboration between professionals, and 3) citizen participation. Across all system levels, we identified leverage point themes. The upper-levels events and structures occurred the most and were explained by underlying goals and beliefs. Leverage point themes regarding "HWA organization structure" were municipal processes, such as perceived impact; diversity of themes, activities, and tasks; network; and communication strategies, such as messages about the HWA. Leverage point themes regarding "collaboration between professionals" were linking pins, indicating central players within the network; motivation and commitment including support base; and stimulating one another to work on the HWA by spurring other professionals into action. Lastly, leverage point themes under "citizen participation" included reaching the target group, e.g., look for entry points; and citizens' motivation, including customization.

DISCUSSION

This paper provides unique insights into HWAs' leverage point themes that can lead to substantial changes in how the entire system functions and makes suggestions about underlying leverage points to help stakeholders improve their HWA. Future research could focus on studying leverage points within leverage point themes.

The development of the Dutch "National model integrated care for childhood overweight and obesity"

BACKGROUND

Childhood obesity is a chronic disease with negative physical and psychosocial health consequences. To manage childhood overweight and obesity, integrated care as part of an integrated approach is needed. To realise implementation of this integrated care, practical guidance for policy and practice is needed. The aim of this study is to describe the development of a Dutch national model of integrated care for childhood overweight and obesity and accompanying materials for policy and practice.

METHODS

The development of the national model was led by a university-based team in collaboration with eight selected Dutch municipalities who were responsible for the local realisation of the integrated care and with frequent input from other stakeholders. Learning communities were organised to exchange knowledge, experiences and tools between the participating municipalities.

RESULTS

The developed national model describes the vision, process, partners and finance of the integrated care. It sets out a structure that provides a basis for local integrated care that should facilitate support and care for children with overweight or obesity and their families. The accompanying materials are divided into materials for policymakers to support local realisation of the integrated care and materials for healthcare professionals to support them in delivering the needed support and care.

CONCLUSIONS

The developed national model and accompanying materials can contribute to improvement of support and care for children with overweight or obesity and their families, and thereby help improve the health, quality of life and societal participation of these children. Further implementation of the evidence- and practice-based integrated care while evaluating on the way is needed.

The implications of defining obesity as a disease: a report from the Association for the Study of Obesity 2021 annual conference

Unlike various countries and organisations, including the World Health Organisation and the European Parliament, the United Kingdom does not formally recognise obesity as a disease. This report presents the discussion on the potential impact of defining obesity as a disease on the patient, the healthcare system, the economy, and the wider society. A group of speakers from a wide range of disciplines came together to debate the topic bringing their knowledge and expertise from backgrounds in medicine, psychology, economics, and politics as well as the experience of people living with obesity. The aim of their debate was not to decide whether obesity should be classified as a disease but rather to explore what the implications of doing so would be, what the gaps in the available data are, as well as to provide up-to-date information on the topic from experts in the field. There were four topics where speakers presented their viewpoints, each one including a question-and-answer section for debate. The first one focused on the impact that the recognition of obesity could have on people living with obesity regarding the change in their behaviour, either positive and empowering or more stigmatising. During the second one, the impact of defining obesity as a disease on the National Health Service and the wider economy was discussed. The primary outcome was the need for more robust data as the one available does not represent the actual cost of obesity. The third topic was related to the policy implications regarding treatment provision, focusing on the public's power to influence policy. Finally, the last issue discussed, included the implications of public health actions, highlighting the importance of the government's actions and private stakeholders. The speakers agreed that no matter where they stand on this debate, the goal is common: to provide a healthcare system that supports and protects the patients, strategies that protect the economy and broader society, and policies that reduce stigma and promote health equity. Many questions are left to be answered regarding how these goals can be achieved. However, this discussion has set a good foundation providing evidence that can be used by the public, clinicians, and policymakers to make that happen.

Implementation of Combined Lifestyle Interventions for Children with Overweight or Obesity: Experiences of Healthcare Professionals in Multiple Communities

BACKGROUND

To counteract children with obesity, different protocols for combined lifestyle interventions (CLIs) are implemented by healthcare providers (HCPs). To understand the effects of CLI, we studied the implementation process, facilitators and barriers experienced by HCPs.

METHODS

A multiple case study design in which community-based CLIs (n = 4), implemented in a total of ten different communities, are conceptualized as a "case". Qualitative data were collected via group interviews among HCPs (n = 48) regarding their implementation protocol, their network involvement and the adoption of the CLI in a community. Transcripts were coded and analysed using ATLAS.ti.

RESULTS

Barriers were the absence of a proper protocol, the low emphasis on the construction of the network and difficulty in embedding the CLI into the community. Funding for these activities was lacking. Facilitating factors were the involvement of a coordinator and to have everyone's role regarding signalling, diagnosis, guidance and treatment clearly defined and protocolled. HCPs suggested adding certain professions to their team because they lacked expertise in parenting advice and providing mental support to children.

CONCLUSIONS

Carrying out and adapting the content of the CLI to the community was experienced as easier compared to the management of the organizational aspects of the CLI. For these aspects, separate funding is essential. In the future, mapping the characteristics of a community will help to clarify this influence on the implementation even better.

Mechanisms and contextual factors related to key elements of a successful integrated community-based approach aimed at reducing socioeconomic health inequalities in the Netherlands: A realist evaluation perspective

BACKGROUND

Reducing health inequalities is a challenge for policymakers and civil society. A multisectoral and multilevel approach is most promising to reduce those inequalities. Previous research showed what key elements of Zwolle Healthy City, an integrated community-based approach aimed at reducing socioeconomic health inequalities, are. To fully understand approaches that are complex and context dependent, questions as 'how does the intervention work' and 'in what context does it work' are just as important as 'what works'. The current study aimed to identify mechanisms and contextual factors associated with the key elements of Zwolle Healthy City, using a realist evaluation perspective.

METHODS

Transcripts of semi-structured interviews with a wide range of local professionals were used (n = 29). Following realist evaluation logic in the analysis of this primary data, context-mechanism-outcome configurations were identified and thereafter discussed with experts (n = 5).

RESULTS

How mechanisms (M) in certain contexts (C) were of influence on the key elements (O) of the Zwolle Healthy City approach are described. For example, how, in the context of the responsible aldermen embracing the approach (C), regular meetings with the aldermen (M) increased support for the approach among involved professionals (O). Or, how, in the context of available financial resources (C), assigning a program manager (M) contributed positively to coordination and communication (O). All 36 context-mechanism-outcome configurations can be found in the repository.

CONCLUSION

This study showed what mechanisms and contextual factors are associated with the key elements of Zwolle Healthy City. By applying realist evaluation logic in the analysis of primary qualitative data we were able to disentangle the complexity of processes of this whole system approach and show this complexity in a structured manner. Also, by describing the context in which the Zwolle Healthy City approach is implemented, we contribute to the transferability of this approach across different contexts.

Parents' and Children's Experiences with a Coordinating Professional in Integrated Care for Childhood Overweight and Obesity-A Novel Dutch Approach

Background: In the new integrated program of care for childhood overweight and obesity (ICCO), a Youth Health Care (YHC) nurse has the role of a coordinating professional. After a broad assessment of strengths and weaknesses in the family setting, this coordinating professional makes a plan of action with the child and parents and involves other professionals when needed. The aim of this study was to explore the experiences of parents and children with the coordinating professional in the ICCO. Material & Methods: Semi-structured interviews were conducted with eight families. Interview data were analyzed using content analysis. In addition, descriptive data on involved professionals and referrals was collected with an online questionnaire in 38 families. Results: In total, eight families (8 mothers, 2 fathers, four boys and three girls aged 10–12 yrs) were interviewed and 38 children and parents filled in (three consecutive) online questionnaires. Findings: The main themes related to the experiences of parents and children with the CP: parents and children felt supported and understood by the coordinating professional. They appreciated the broad perspective and personal approach. Contacts with the coordinating professional were not always frequent. Major points of improvement concerned the intensity of the follow-up and collaboration. Only few parents experienced collaboration between the coordinating professional and other professionals in the ICCO. Conclusions: Parents and children appreciated the personal approach of the Youth Health Care nurse as a CP. The role of the coordinating professional, however, appears not fully implemented yet. Strengthening the promising role of the coordinating professional in the ICCO is recommended.

How can National Government Policies Improve Food Environments in the Netherlands?

Objectives: Government policies are essential to create food environments that support healthy diets. The aims of this study were 1) to benchmark the implementation of Dutch government policies influencing food environments, and 2) to identify and prioritize actions to improve food environments in the Netherlands.

Methods: The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI includes 46 indicators of food environment policy and infrastructure support. Independent experts (n = 28) rated the extent of implementation on these indicators against international best practices, and formulated and prioritized policy and infrastructure support actions to improve food environments.

Results: Most policy indicators were rated as having a low (50%) or very low (41%) level of implementation. Most infrastructure support indicators were rated as having a fair (42%) or medium (42%) level of implementation. 18 policy and 11 infrastructure support actions were recommended by experts to improve food environments in the Netherlands.

Conclusion: There is large potential for the Dutch national government to strengthen its policy action and infrastructure support in order to improve the healthiness of food environments in the Netherlands.

Preferences on how to measure and discuss health related quality of life within integrated care for children with obesity

BACKGROUND

Childhood obesity can affect physical as well as psychosocial wellbeing. Therefore, childhood obesity care aims to improve all dimensions of health related quality of life (HRQoL). HRQoL can be measured with the generic questionnaire PedsQL4.0 and the weight-specific IWQOL-Kids. In the Netherlands, HRQoL assessment is conducted by the coordinating professional (CP). The aim of this qualitative study was to examine how and when to implement the measurement and discussion of HRQoL using the PedsQL4.0 and IWQOL-Kids within the integrated care for children with obesity in the Netherlands. Semi-structured interviews were conducted with fourteen CPs, in which the following was discussed: a) familiarity and attributions with regard to the assessment of HRQoL; b) wishes and needs with regard to the usage of the questionnaires; c) its practical incorporation.

RESULTS

Interviews revealed that most CPs gained insight into the HRQoL by talking with families. One CP used the PedsQL4.0, the remaining CPs were unfamiliar with the two questionnaires. Even though some barriers, for instance a lack of time, might hinder the implementation of the PedsQL4.0 and IWQOL-Kids, all participants think the usage of either one or both questionnaires would have additional value to the support and care for children with obesity. There was no consensus about the questionnaire of preference.

CONCLUSIONS

When the right preconditions are met, HRQoL questionnaires have the potential to support CPs in improving the care for children with obesity, tailored to each individual child.

Conducting a psychosocial and lifestyle assessment as part of an integrated care approach for childhood obesity: experiences, needs and wishes of Dutch healthcare professionals

BACKGROUND

The causes and consequences of childhood obesity are complex and multifaceted. Therefore, an integrated care approach is required to address weight-related issues and improve children's health, societal participation and quality of life. Conducting a psychosocial and lifestyle assessment is an essential part of an integrated care approach. The aim of this study was to explore the experiences, needs and wishes of healthcare professionals with respect to carrying out a psychosocial and lifestyle assessment of childhood obesity.

METHODS

Fourteen semi-structured interviews were conducted with Dutch healthcare professionals, who are responsible for coordinating the support and care for children with obesity (coordinating professionals, 'CPs'). The following topics were addressed in our interviews with these professionals: CPs' experiences of both using childhood obesity assessment tools and their content, and CPs' needs and wishes related to content, circumstances and required competences. The interviews comprised open-ended questions and were recorded and transcribed verbatim. The data was analysed using template analyses and complemented with open coding in MAXQDA.

RESULTS

Most CPs experienced both developing a trusting relationship with the children and their parents, as well as establishing the right tone when engaging in weight-related conversations as important. CPs indicated that visual materials were helpful in such conversations. All CPs used a supporting assessment tool to conduct the psychosocial and lifestyle assessment but they also indicated that a more optimal tool was desirable. They recognized the need for specific attributes that helped them to carry out these assessments, namely: sufficient knowledge about the complexity of obesity; having an affinity with obesity-related issues; their experience as a CP; using conversational techniques, such as solution-focused counselling and motivational interviewing; peer-to-peer coaching; and finally, maintaining an open-minded, non-stigmatizing stance and harmonizing their attitude with that of the child and their parents.

CONCLUSIONS

Alongside the need for a suitable tool for conducting a psychosocial and lifestyle assessment, CPs expressed the need for requisite knowledge, skills and attitudes. Further developing a supporting assessment tool is necessary in order to facilitate CPs and thereby improve the support and care for children with obesity and their families.