Lieke G.M. Raaijmakers

Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands

BackgroundThe need to understand barriers to the implementation of health care innovations in daily practice has been widely documented, but perceived facilitators and barriers in diabetes care by Dutch health care professionals remain unknown. The aim of this study was to investigate these factors among health care professionals (HCPs) using a qualitative research design.MethodsData were collected from 18 semi-structured interviews with HCPs from all professions relevant to diabetes care. The interviews were recorded and transcribed verbatim and the data were analyzed using NVivo 8.0.ResultsMajor facilitators were the more prominent role of the practice nurses and diabetes nurses in diabetes care, benchmarking, the Care Standard (CS) of the Netherlands Diabetes federation and multidisciplinary collaboration, although collaboration with certain professional groups (i.e. dieticians, physical therapists and pharmacists), as well as the collaboration between primary and secondary care, could still be improved. The bundled payment system for the funding of diabetes care and the role of the health insurers were perceived as major barriers within the health care system. Other important barriers were reported to be the lack of motivation among patients and the lack of awareness of lifestyle programs and prevention initiatives for diabetes patients among professionals.ConclusionsOrganizational changes in diabetes care, as a result of the increased attention given to management continuity of care, have led to an increased need for multidisciplinary collaboration within and between health care sectors (e.g. public health, primary care and secondary care). To date, daily routines for shared care are still sub-optimal and improvements in facilities, such as registration systems, should be implemented to further optimize communication and exchange of information.

Dietary intake by dutch 1- to 3-year-old children at childcare and at home

The goal of the current study was to assess dietary intake in a large sample (N = 1016) of Dutch toddlers (1–3 years old), both at childcare and at home. Dietary intake during two weekdays was recorded using an observation format applied by childcare staff for intake at childcare, and partially pre-coded dietary journals filled out by parents for intake at home. Children’s intake of energy, macronutrients and energy balance-related food groups (fruit, vegetables, sweet snacks, savoury snacks) were compared with Dutch dietary guidelines. In addition, differences between the dietary intake by various subgroups (based on gender, age, childcare attendance, socio-economic status of childcare centre) were explored using multilevel regression analyses, adjusting for nesting of children within centres. Energy intake was high relative to dietary guidelines, and children consumed more or less equal amounts of energy at home and at childcare. Dietary fibre, fruit and vegetable and snack intakes were low. Intake at childcare mainly consisted of carbohydrates, while intake at home contained more proteins and fat. The findings imply various opportunities for childcare centres to improve children’s dietary intake, such as providing fruit and vegetables at snacking moments. In addition, the findings underline the importance of assessing dietary intake over a whole day, both at childcare and at home, to allow intake to be compared with dietary guidelines.

Appreciation and implementation of the Krachtvoer healthy diet promotion programme for 12- to 14- year-old students of prevocational schools

BackgroundKrachtvoer is a school-based healthy diet programme, developed in 2001 and revised in 2007 to meet the needs of particular segments of the target population as well as a wider target group. The main aims of the present process evaluation of the revised programme were to examine student and teacher appreciation of the programme, completeness of and adherence to its implementation, and relations between appreciation and completeness of implementation.MethodsData were collected among 22 teachers and 1117 students of 13 schools, using student evaluation forms, teacher logbooks, telephone interviews, and classroom observations.ResultsResults indicate favourable levels of teacher and student appreciation for the programme in general and the revised elements. Girls, first-year students and students with more favourable dietary intakes particularly appreciated individual programme elements. Levels of completeness of implementation were high, but several teachers did not adhere to the intended implementation period. Some moderately strong relations were found between teacher appreciation and completeness of implementation scores.ConclusionWe conclude that the revisions have resulted in a programme that was appreciated well, also by the extended target group, and was implemented with a high degree of completeness. Teacher appreciation proved potentially important for completeness of implementation. We identified several aspects requiring improvement, indicating the importance of continued programme updates and repeated evaluation.

Healthier food choices as a result of the revised healthy diet programme Krachtvoer for students of prevocational schools

BackgroundKrachtvoer is a Dutch healthy diet programme for prevocational schools, developed in 2001 and revised for a broader target group in 2007, based on the findings of an evaluation of the first version. The goal of this study was to report on the short- and longer-term total and subgroup effects of the revised programme on students’ fruit, fruit juice, breakfast, and snack consumption.MethodsSchools were randomized to the experimental condition, teaching the Krachtvoer programme, or to the control condition teaching the regular nutrition lessons. Self-reported consumption of fruit, fruit juice, breakfast and snacks was measured at baseline directly before programme implementation, one to four weeks after finishing programme implementation, and after six months. Mixed linear and logistic regression analyses were conducted.ResultsIn total 1117 students of 13 experimental schools and 758 students of 11 control schools participated in the study. Short- and longer-term favourable intervention effects were found on fruit consumption (mean difference between experimental and control group 0.15 servings at both posttests). Regarding fruit juice consumption, only short-term favourable effects were revealed (mean difference between experimental and control group 0.05 glasses). Intervention effects on breakfast intakes were limited. No changes in snack frequency were reported, but students made healthier snack choices as a result of the programme. Some favourable as well as unfavourable effects occurred in subgroups of students.ConclusionsThe effects on fruit consumption and snack choices justify the current nationwide dissemination of the programme. Achieving changes in breakfast consumption may, however, require other strategies.

Correlates of perceived self-care activities and diabetes control among Dutch type 1 and type 2 diabetics

This study examined how Dutch type 1 and type 2 diabetes patients’ perceived autonomy support, as well as their perceived competence and treatment self-regulation, are associated with their diabetes self-care activities (healthy diet, physical activity, monitoring blood glucose, medication use) and general diabetes control. A cross-sectional questionnaire study was conducted among 143 type 1 diabetics and 384 type 2 diabetics. Overall, participants felt competent, supported in their autonomy, and perceived to autonomously self-regulate their diabetes. Our results underline the importance of perceived competence in type 1 and 2 diabetics, as this was strongly associated with adhering to a healthy diet and general diabetes control. Our findings also emphasize the need for autonomy supportive health care professionals in diabetes care. Interestingly, perceived competence partially mediated the influence of autonomy support on general diabetes control.

Perceptions of Dutch health care professionals regarding the Care Standard for diabetes

BackgroundThe Netherlands can be regarded as unique in the use of the Netherlands Diabetes Federation (NDF) Care Standard (CS) for diabetes. The need to understand the barriers obstructing optimal health care, the dissemination and implementation of health care innovations into daily practice and the extent to which health care professionals actually adhere to guidelines has been emphasized repeatedly. Therefore, the aim of the present study was to suggest ways to optimize the implementation of the CS by examining the perceptions of Dutch health care professionals regarding the CS and the barriers to using it.MethodsA cross-sectional questionnaire survey was conducted among health care professionals (N = 1547) in 2010.ResultsA total of 39.6% (N = 1323) of the participating health care professionals possessed the CS. Only 15.5% of the professionals who were to some extent familiar with the CS (N = 1100) described themselves as working in complete accordance with the CS. The majority (83.9%) thought the CS contributed greatly to ensuring the quality of care; the judgment on the feasibility of working in accordance with the CS was positive (mean = 3.9 on a 5-point Likert scale). However, professionals tended to perceive the guidelines issued by the own professional association as the norm for high quality diabetes care, rather than the CS. The main barrier to using the CS was the lack of effective lifestyle interventions (or access to them) to provide care for people with diabetes or those at increased risk for the disorder.ConclusionsA limited percentage of health care professionals were found to posses the CS. It is questionable whether possession of the CS is a prerequisite for delivering high quality care. Overall, professionals were largely positive about the CS, although only a minority indicated they were working in complete accordance with it. Professionals and professional organizations should be further educated about the content of the CS and especially its added value with respect to the guidelines for their own professional group, in terms of the multidisciplinary approach to diabetes care. Furthermore, attention should be given to the most important perceived barriers, to facilitate adherence to the CS.

Restrictive rules of Dutch mothers regarding their children's dietary intake between meals

The use of restrictive food rules by parents has been found to be associated with dietary intake in their children. The aim of this study was to explore the use of restrictive rules of Dutch mothers regarding their childs food intake between main meals in detail, to generate necessary input for setting priorities for further research and intervention development. A cross-sectional questionnaire study on nine restrictive rules was completed by 359 mothers of primary school children aged 4-12years. Mothers reported to use an average of 4.1 (SD 2.1) out of nine restrictive food rules and all rules measured in this study were used. The rules mothers reported to use most were not eating shortly before meals, not eating certain foods too often and not eating too much of certain foods. The rules varied according to different foods, but particularly applied to the intake of potato chips, nuts and savory snacks, candy and chocolate. Mothers of a younger age, lower educated mothers and mothers with a higher BMI were less likely to use (certain) restrictive rules. This study showed that mothers use a large variety of rules, particularly to restrict the intake of unhealthy foods and reported on several subgroups that were less likely to use (certain) rules. Our results direct further research and inform the development of interventions.

Gecombineerde leefstijl interventies in Nederland: ervaringen uit de Beweegkuur

Vanwege de dreiging van onbeheersbare kosten in de gezondheidszorg gaf minister Klink van Volksgezondheid, Welzijn en Sport (VWS) in 2007 aan te willen bezuinigen door middel van preventie. In zijn ‘Kaderbrief 2007-2011, Visie op gezondheid en preventie’, beschreef de minister het belang van preventie en benoemde het als een speerpunt voor het gezondheidsbeleid. Eind 2007 startte het Nederlands Instituut voor Sport en Bewegen (NISB), in opdracht van het ministerie van VWS, met de ontwikkeling van de BeweegKuur ter preventie van diabetes mellitus type 2. De BeweegKuur is een gecombineerde leefstijl interventie waarin deelnemers vanuit de huisartsenpraktijk doorverwezen worden naar een leefstijladviseur (meestal de praktijkondersteuner of een fysiotherapeut), die de deelnemer gedurende een jaar begeleidt naar een gezondere leefstijl. De deelnemer kan zelfstandig gaan bewegen of wordt, indien nodig, door de leefstijladviseur verwezen naar de fysiotherapeut om daar te starten met bewegen. Ook worden alle deelnemers verwezen naar de diëtist voor zowel individuele als groepsbijeenkomsten. De intentie op lange termijn was om de BeweegKuur en in essentie vergelijkbare gecombineerde leefstijlinterventies zoals Bewegen op Recept,1 van Klacht naar Kracht2 en Big!- Move3-4op te nemen in het basispakket van de zorgverzekering. In dit artikel geven we een beschouwing van het implementatieproces van de BeweegKuur, als een sprekend voorbeeld van de ontwikkelingen ten aanzien van gecombineerde leefstijlinterventies in de eerstelijns zorg in Nederland.AbstractCombined lifestyle interventions in the Netherlands: experiences gained with the BeweegKuur intervention This paper gives a reflection on the development, implementation and dissemination processes of the BeweegKuur in primary care. The implementation of the programme took a lot of time and energy on the part of the health care providers. During the implementation process, multidisciplinary networks were formed and the contacts with local exercise facilities improved. Although it is plausible that without BeweegKuur, some of these processes would also have come about, they would probably have taken more time and effort and would have remained more local.

Evaluatie van een online actieplanprogramma over fruit, ontbijt en tussendoortjes voor leerlingen van het VMBO

AbstractEvaluation of an online action planning program on fruit, breakfast and snack consumption for students of prevocational schools To turn behavioral change intentions into actual behavioral change, an online action plan program about fruit, snacks and breakfast intake was developed for the Krachtvoer program for prevocational school students. This paper describes the content of the action planning program and the results of an evaluation study among 539 students concerning the usage of the program and implementation of action plans in practice. Further, program appreciation by teachers and students was assessed. More than 64% of the students completed at least two program modules and 61% made an action plan. About 34% of the student who had prepared an online plan, reported to have implemented the plan successfully in practice, while 65% was partly successful. Program appreciation among students was satisfactory, appreciation among teachers was good. Using pre-structured online action plans seems to work well. The implementation of this postmotivational program element should always be part of a larger program in which elements aimed at changing the premotivational phase of behavior change are included as well.

De implementatie van de NDF Zorgstandaard Diabetes anno 2013

SamenvattingTijdens de looptijd van het Nationaal Actieprogramma Diabetes (NAD) zijn twee monitoronderzoeken (2010 en 2013) uitgezet onder zorgprofessionals en patiënten met (een verhoogd risico op) diabetes. Het hoofddoel van het huidige onderzoek was zicht krijgen op de mate van implementatie van de NDF Zorgstandaard Diabetes (hierna te noemen Zorgstandaard). Dit artikel beschrijft de stand van zaken in 2013 en vergelijkt de resultaten uit het onderzoek met die van het monitorondezoek uit 2010.Het cross-sectioneel vragenlijstonderzoek vond plaats tussen november 2012 en februari 2013 onder 2.423 zorgprofessionals en 5.650 patiënten.Van de zorgprofessionals was 43,7% in het bezit van de Zorgstandaard. De meerderheid van de zorgprofessionals (89,2%) gaf aan (grotendeels) conform de Zorgstandaard te werken en had een positieve houding ten aanzien van de Zorgstandaard en de bijdrage die deze levert aan het waarborgen van de kwaliteit van de diabeteszorg.Patiënten ervaren in hoge mate door de zorgverlener betrokken te worden in hun behandeling en rapporteren dat ze tevreden zijn over het contact met hun zorg verlener( s). Ongeveer 60% van de patiënten was bekend met de Zorgwijzer (de patiëntenversie van de Zorgstandaard) en een kleine minderheid (15,3%) had de Zorgwijzer in bezit.Terugkijkend op het NAD lijkt het erop dat de Zorgstandaard heeft gefungeerd als een vliegwiel om processen ter verbetering van de zorg voor chronisch zieken in Nederland vorm te geven. Een volgende stap zou kunnen zijn om de zorg op lokaal niveau te implementeren en in te bedden in een wijkgerichte aanpak, waarbij ook aandacht is voor de preventie van andere chronische aandoeningen.SummaryDuring the implementation period of the National Diabetes Action Program (NAD) two monitor studies (2010 and 2013) have been conducted among health care professionals and patients with (a high risk of) diabetes. The main aim of this study was to obtain insight in the implementation of the Dutch Diabetes Federation Health Care Standard for diabetes. This article describes the current situation in 2013 and makes a comparison with the results in 2010.A cross-sectional questionnaire study was conducted among 2423 health care professionals and 5650 patients between November 2012 and February 2013.The results showed that 43.7% of the health care professionals was in possession of the Care Standard. The majority of the professionals (89.2%) worked (largely) in accordance with the Care Standard and had a positive attitude towards the Care Standard and its contribution to ensuring the quality of diabetes care.Patients perceived a high degree of involvement in their treatment and were satisfied about the contact with their caregiver(s). Approximately 60% was familiar with the ‘Diabetes Zorgwijzer’ (patient version of the Standard) and a minority (15.3%) was in possession of the Zorgwijzer.Looking back on the NAD it seems that the Care Standard has functioned as flywheel in implementing processes to improve the care for chronic diseases in the Netherlands. A next step could be to implement the care on a local level, embedding it into a community approach, with possibilities for prevention of other chronic diseases as well.