Background
Childhood obesity is becoming more prevalent around the world and represents an increasingly salient pediatric health concern [
1]. The Netherlands has seen a two to three-fold increase in overweight and a four to six-fold increase in obesity since 1980 [
2]. In 2009, the prevalence of overweight and obesity amongst children aged 2 to 21 years was 12.8 % and 1.8 % for boys and 14.8 % and 2.2 % for girls, respectively. Overweight and obesity at a young age have important short-and long-term health and social consequences [
3]. Obese children have an increased risk of multiple medical co-morbidities [
4‐
7] as well as psychosocial problems [
8‐
10]. Furthermore, childhood obesity has been shown to have a high likelihood of persisting into adolescence and adulthood [
1,
11,
12].
Current care for child obesity is constrained by a number of factors. Firstly, care is delivered by a variety of health care professionals and is fragmented, as coordination between health care providers is insufficient [
13‐
16]. Secondly, obese children and their parents experience uncertainty in the care process due to a lack of control and continuity of care [
15]. Finally, the health care risks specific to obese children remain unidentified and are insufficiently monitored [
15,
17‐
19].
European guidelines acknowledge the need for a multi-disciplinary approach to the primary and secondary prevention of chronic diseases [
20‐
22]. The internationally recommended treatment of childhood obesity is a family behavioral lifestyle intervention including dietary and physical activity advice and a family-targeted approach in children under 12 years of age [
22‐
24]. While these clinical guidelines do describe the recommended care in some detail, including how, when and by whom care should be provided, they do not specify how this multidisciplinary care should be organized. In its effort to systematically organize the services provided to, and treatment of, children who are overweight or obese on an aggregate level, the Netherlands can be regarded as unique in its use of an integrated health care standard [
13]. This integrated health care standard highlights the importance of a central care coordinator whose role it is to oversee the multidisciplinary care process consisting of five key components: 1) identification; 2) diagnosis and risk stratification; 3) individual health care plan and treatment; 4) continuity of care; and 5) multidisciplinary approach [
13]. The Cole criteria for childhood obesity were used in the development and dissemination of the integrated health care standard in 2010 [
25].
In many European countries, the GP plays an important role in identifying obesity in children and in subsequent interventions [
13,
14,
16,
20]. According to the integrated health care standard principles, the majority of overweight and obese children can be managed by GPs, provided that a multidisciplinary team supporting lifestyle changes in children is also available. For only a few obese children with extreme weight-related health risks is referral to specialized health care required [
13].
While the integrated health care standard principles specify an ideal of multidisciplinary care of obese children, their feasibility in current practice has never been investigated. It is well established that dissemination alone is unlikely to result in effective implementation in practice; therefore, more active strategies are recommended [
16,
26].
Known barriers to implementing change in current practice exist at the level of the individual care provider (e.g. competence, attitude, motivation for change), social setting (e.g. patients, care providers) and system (e.g. organizational structure, financial reimbursement) [
26]. Due to the complexity of multidisciplinary care, barriers and needs must first be identified in order to formulate strategies for effective implementation [
16,
26]. Understanding the discrepancies between desired and current care is a starting point for initiating change and could generate more support for the implementation of the integrated health care standard on the part of health care providers [
26]. Therefore, the aim of this study is to acquire more insight into the barriers to and needs for the implementation of the integrated health care standard as perceived by GPs and other health care providers who manage or treat obesity in children.
Methods
We have used the consolidated criteria for reporting qualitative research (COREQ) to describe our methods [
27].
Design
We used a mixed-methods technique, combining quantitative and qualitative research [
28]. There is broad consensus that mixing different types of methods has the capacity to strengthen a study’s results and conclusions [
29]. The barriers to and needs for the implementation of the integrated health care standard are so complex that the use of different kinds of methods was warranted in our efforts to fully account for this complexity. The qualitative study consisted of focus groups with GPs and face-to-face, semi-structured interviews with different health care providers in an effort to identify the barriers to and the necessary requirements for the implementation of the integrated health care standard. A conscious decision was made to keep the nature of the focus groups and face-to-face, semi-structured interviews open in order to allow GPs and health care providers to provide detailed accounts and voluntarily raise issues that were of importance to them. Subsequently, we conducted a large-scale, e-mail-based internet survey amongst health care providers involved in youth health in order to corroborate and complement the qualitative results and increase generalizability. All the health care providers involved were active in the region around Amsterdam.
Theoretical framework
This study was carried out using Grol and Wensing’s implementation of change model [
26]. It focused on the first steps to implementing the integrated health care standard in the Amsterdam area, focusing on the analysis of the context in which changes must occur. It explored barriers and needs grouped according to the five key components of the integrated health care standard: 1) identification; 2) diagnosis and risk stratification; 3) individual health care plan and treatment; 4) continuity of care and 5) a multidisciplinary approach. These components were then divided further into three levels: individual health care providers, social setting and system [
26].
Participants and procedures
Amsterdam, an urban area, was chosen as the research setting, as health care professionals here have experience in the care of obese children due to the implementation of governmental programs and the increasing prevalence of childhood obesity.
Focus groups and interviews
GPs from the Academic Network of General Practitioners of the VU University Medical Centre in Amsterdam (ANH-VUMC) were invited to participate in the focus groups. The GPs were also asked to identify health care providers to whom they refer obese children. These individuals were then approached by e-mail or telephone and were invited to participate in face-to-face, semi-structured interviews. These health care providers included a Youth Health Care (YHC) nurse, a YHC doctor, a pediatrician, a dietician, a psychologist, a physiotherapist, a social worker, a remedial educationalist and a GP. We choose to approach a variety of health care workers involved in youth care to reflect the integrated health care standard criteria pertaining to multidisciplinary care.
Internet survey
An e-mail-based internet survey was conducted amongst GPs, dieticians, psychologists, physiotherapists, pediatricians, YHC providers and remedial educationalists. Respondents were approached by email via their different organizations to increase accessibility. These organizations included the principle primary care organization, pediatric departmental secretariats, the management team of the municipal youth health care organization (GG&GD) and various paramedic al services organizations (for dieticians, psychologists, physiotherapists and remedial educationalists).
GPs associated with the ANH-VUMC were only asked to respond to the 21 items in the “importance of need” part of the questionnaire to corroborate their contributions during the focus groups.
Ethical approval for the study was obtained from the VU University Medical Centre Research Ethics Committee. The informed consent procedure was waived by the Ethical Committee. Data collection took place between May 2011 and February 2012.
Data collection
Focus group
The four GP focus groups took place simultaneously in adjoining rooms during the half-yearly meeting of the ANH-VUMC. Each focus group was led by a GP and included at least two observers (vocational GPs) who took notes. We had GPs lead these focus groups to engender mutual confidence between the leaders and participants. The GPs that led the groups were members of the ANH-VUMC research team. Each focus group lasted approximately 60 min, was audio recorded and transcribed verbatim. Each of the groups discussed barriers and needs in the context of current care and the implementation of the integrated health care standard for obese children. Six main questions were developed (Additional file
1) based on the literature on integrated care and the implementation of integrated health care standard.
Interview
Each face-to-face, semi-structured interview started with a general introduction and the opening question: “What do you think your role is in the care of obese children?”. First, current care was discussed, followed by an explanation of the integrated health care standard and a discussion of barriers and needs (Additional file
2). At the end of the interview, the researcher ensured that all items had been covered [
30]. The interviews were conducted by two trained medical students. Each interview lasted between 60 and 90 min and was audio recorded and transcribed verbatim.
E-mail-based internet survey
Statements included in the internet survey were constructed based on the themes that were identified during the analysis of data from both the focus groups and the semi-structured interviews. All statements were measured on a five-point Likert scale ranging from 1 (totally agree) to 5 (totally disagree). Additionally, the survey participants were asked about “importance of need” in the context of 21 themes related to the provision of optimal care according to the integrated health care standard. These themes were constructed after the analysis of the focus group and semi-structured interviews. All statements were measured on a five-point Likert scale ranging from 1 (absolutely not important) to 5 (absolutely important) or on a two-point scale (not important/important). Furthermore, demographic information was gathered for each participant and open questions were included to acquire additional information on experiences and barriers and need related to working according to the integrated health care standard.
Data analysis
Focus group
The transcripts were coded thematically according to the five components of the integrated health care standard and themes that emerged in the discussions. The transcripts of the four focus groups were coded separately by two trained medical students. They then discussed any discrepancies and reached a consensus on the coding. Using a matrix, the codes were then grouped according to the five key components of the integrated health care standard and were divided further into three levels in accordance with the theoretical framework. From these groupings, themes were extracted that represented the main messages conveyed by the focus group data. Themes were identified across the data with regard to the research question [
31]. After the analysis had been completed, one researcher (AS) read all of the focus group data and confirmed the themes that had been extracted from the data [
30]. The respondents did not provide feedback on the findings.
Interview
The themes identified in the focus groups were used to analyze the interviews. The transcripts were coded thematically according to the components of the integrated health care standard. The transcripts of the interviews were coded separately by two trained medical students. Each interview was transcribed and analyzed immediately after the interview to confirm the validity of the theme list. In the subsequent interviews, these themes were developed further with respect to the research question. The themes were ordered using a matrix and were categorized according to the five key components of the integrated health care standard and divided further into three levels in accordance with the theoretical framework. The respondents did not provide feedback on the findings.
E-mail-based internet survey
Incomplete questionnaires, surveys completed by underage respondents (e.g. under 21) and those missing information on the respondent’s position were excluded from analysis. Responses to items measured with the 5-point Likert scale were categorized into three outcomes: ‘agree’ or ‘important’ (response categories 1 and 2); ‘disagree’ or ‘not important’ (response categories 4 and 5) and ‘neutral’ (category 3). SPSS version 20.0 for Windows (International Business Machines (IBM) Corp., SPSS Statistics, Armonk, New York, USA) was used to obtain descriptive statistics based on the internet survey.
Quotes
Quotes were selected on the basis of critical discussion on the part of the research team (AS, PE, GN).
Discussion
This study investigated the barriers to and needs for the implementation of the integrated health care standard on care of overweight and obese children as perceived by health care providers. We identified a number of important barriers to the implementation of the five key components of the integrated health care standard (i.e. reluctance to raise the subject of weight; lack of time for optimal treatment; lack of long-term interventions; no structured multidisciplinary approach; financial constraints and lack of feedback) and several needs (i.e. obesity knowledge and awareness; financial reimbursement; task rearrangement; feedback information and a central care coordinator). These barriers and needs are of great importance in defining strategies for the implementation of the integrated health care standard.
GPs experienced difficulties in identifying obese children and indicated a lack of competence in this area. They were reluctant to raise the issue of a child’s excessive weight due to several factors: fear of harming the relationship with the children and/or parents; expectations of non-compliance; no clear role identification; lack of knowledge; negative previous experience and insufficient obesity awareness. Similar barriers have been identified in other studies [
16,
32‐
35]. It is important that GPs raise the subject because most parents do not seek support in dealing with overweight children [
36]. Whereas GPs believe involvement in a patient’s weight management is part of their role, only a small group of GPs regularly provides care in this area, which may be due to their own (lack of) confidence and knowledge [
34]. Previous research has indicated that parents of obese children are also reluctant to consult a GP due to a fear of being blamed for their child’s weight and a concern about their child’s mental well-being [
36]. Parents want to protect their child from developing low self-esteem and some parents prefer that their child not be present when discussing his or her weight problem [
37]. A systematic review of parental perception of overweight status in children found that more than half of parents are not able to identify their child as being overweight [
38]. This is an important factor for health care providers as it indicates that they need to make parents more aware of obesity in their children. As is confirmed in the literature, training GPs in increased awareness and knowledge of obesity may result in improved identification and discussion of weight problems and diminishing the fear of harming the relationship [
39].
All health care providers recognized the difficulties of treatment (i.e. lack of interventions, financial constrains); continuity of care (i.e. lack of monitoring) and a multidisciplinary approach (i.e. lack of coordination, absence of task rearrangements). Furthermore, our results show that health care providers are less motivated to provide treatment due to poor results from previous treatment and unmotivated children. The aforementioned difficulties related to the different components of the integrated health care standard were also reported in earlier studies [
13‐
17,
39,
40]. Successful implementation of the integrated health care standard for the management of childhood obesity is in part dependent upon the identification of these barriers. As described in the literature, the critical problem is not the creation of an integrated health care standard, but the creation of support systems for its implementation at the level of primary health care [
16,
40,
41]. The fact that these barriers have also been identified in previous research highlights the need to take them into consideration in the implementation process. The novel contribution of this study is the finding that the majority of health care providers see the appointment of a central care coordinator as a viable solution to these barriers.
This study provides qualitative and quantitative information on health care providers’ perceptions of the barriers to and needs for the implementation of integrated childhood obesity care. The open nature of the focus groups and the face-to-face, semi-structured interviews meant that the health care providers could offer more detailed viewpoints and raise issues that were of importance to them.
The internet survey provided more quantitative insight into how specific themes are important to health care providers and the differences between the views of the different health care providers. A limitation of our study is the low response rate of the internet survey. We previously speculated that the low response rate of the internet survey might have been due to our recruitment approach. We were concerned for a low response rate due to the fact that the health care workers were invited indirectly (not personally) to fill in the online questionnaire by health care organizations and services that tend to send many regular e-mails each week. Therefore, we decided to send a high number of invitations out in order to recruit a large enough sample. E-mail was chosen because it is cost effective, both in terms of time and money and the method yields fewer unanswered items than other modes [
42]. We cannot speculate as to the way in which the low response rate may have influenced the results of the study. The internet survey had added value in that it showed that the health care providers’ perceived barriers and needs were less pronounced in the survey than in the interviews and the focus groups. However, a substantial part of the survey identified the same barriers as the qualitative part of the study did. This shows that qualitative research is useful in the identification of different points of view, but might overestimate the importance of these points of view. Another possible explanation is that the survey and interviews were subject to a selection bias. Another limitation of the study is that the health care providers were employed in a large urban area, which may limit the generalizability of our findings. However, in this area, health care providers have experience in the care of obese children because of the implementation of governmental programs and the increasing prevalence of childhood obesity. It is unlikely that barriers and needs differ in other regions.
Conclusions
This study focused on context analysis as a first step in the implementation process of the integrated health care standard. We identified the central barriers and needs in each of the five key components of the integrated health care standard. The findings of this study suggest that the mere publication of the integrated health care standard is unlikely to elicit meaningful change in integrated childhood obesity care. In order to improve care, the next step is the development of strategies to change practice.
For progress to be made, emphasis should be placed on the awareness of health care providers of the barriers children and parents face during treatment. Strategies should be defined to elicit change at different levels (i.e. at the level of the individual care provider, the system and social setting) by using the five components of the integrated health care standard. Task rearrangements and coordination agreements also need to be made and feedback needs to be provided on the condition that financial reimbursement be available to improve integrated childhood obesity care.
Acknowledgements
This study is part of a project aimed at implementing integrated care for children with overweight or obesity in the city of Amsterdam. It is carried out by the Department of General Practice & Elderly Care Medicine at the EMGO+ Institute for Health and Care Research. The infrastructure of this project consisted of a research group and a project group consisting of four coordinating GPs, two members of the YHC and three involved pediatricians. Achmea Health Care partly funded this project.
We would like to thank all the participants of the focus groups, face-to-face interviews and the e-mail based internet survey carried out in this study: Furthermore, we would like to thank Judith van Tiel and Inge Bonnemayers for the study.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AS contributed to research design, data collection and analysis and led the drafting of the manuscript. SB contributed to research design, analysis and drafting of the manuscript. GN and PE contributed to research design and drafting of the manuscript. All authors read and approved the final manuscript.