[Financing, organization, costs and services performance of the Argentinean health sub-systems.]

Objective:

To analyze the relationship between health system financing and services organization models with costs and health services performance in each of Rosario's health sub-systems.

Materials and methods:

The financing and organization models were characterized using secondary data. Costs were calculated using the WHO/SHA methodology. Healthcare quality was measured by a household survey (n=822).

Results:

Public subsystem:Vertically integrated funding and primary healthcare as a leading strategy to provide services produced low costs and individual-oriented healthcare but with weak accessibility conditions and comprehensiveness. Private subsystem: Contractual integration and weak regulatory and coordination mechanisms produced effects opposed to those of the public sub-system. Social security: Contractual integration and strong regulatory and coordination mechanisms contributed to intermediate costs and overall high performance.

Conclusion:

Each subsystem financing and services organization model had a strong and heterogeneous influence on costs and health services performance.

Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians?

OBJECTIVE

Primary care services form the foundation of modern healthcare systems, yet the breadth and complexity of services and diversity of patient populations may present challenges for creating comprehensive primary care information systems. Our objective is to develop regional-level information on the performance of primary care in Canada.

METHODS

A scoping review was conducted to identify existing initiatives in primary care performance measurement and reporting across 11 countries. The results of this review were used by our international team of primary care researchers and clinicians to propose an approach for regional-level primary care reporting.

RESULTS

We found a gap between conceptual primary care performance measurement frameworks in the peer-reviewed literature and real-world primary care performance measurement and reporting activities. We did not find a conceptual framework or analytic approach that could readily form the foundation of a regional-level primary care information system. Therefore, we propose an approach to reporting comprehensive and actionable performance information according to widely accepted core domains of primary care as well as different patient population groups.

CONCLUSIONS

An approach that bridges the gap between conceptual frameworks and real-world performance measurement and reporting initiatives could address some of the potential pitfalls of existing ways of presenting performance information (i.e., by single diseases or by age). This approach could produce meaningful and actionable information on the quality of primary care services.

The challenges of measuring quality-of-care indicators in rural emergency departments: a cross-sectional descriptive study

BACKGROUND

Evidence-based indicators of quality of care have been developed to improve care and performance in Canadian emergency departments. The feasibility of measuring these indicators has been assessed mainly in urban and academic emergency departments. We sought to assess the feasibility of measuring quality-of-care indicators in rural emergency departments in Quebec.

METHODS

We previously identified rural emergency departments in Quebec that offered medical coverage with hospital beds 24 hours a day, 7 days a week and were located in rural areas or small towns as defined by Statistics Canada. A standardized protocol was sent to each emergency department to collect data on 27 validated quality-of-care indicators in 8 categories: duration of stay, patient safety, pain management, pediatrics, cardiology, respiratory care, stroke and sepsis/infection. Data were collected by local professional medical archivists between June and December 2013.

RESULTS

Fifteen (58%) of the 26 emergency departments invited to participate completed data collection. The ability to measure the 27 quality-of-care indicators with the use of databases varied across departments. Centres 2, 5, 6 and 13 used databases for at least 21 of the indicators (78%-92%), whereas centres 3, 8, 9, 11, 12 and 15 used databases for 5 (18%) or fewer of the indicators. On average, the centres were able to measure only 41% of the indicators using heterogeneous databases and manual extraction. The 15 centres collected data from 15 different databases or combinations of databases. The average data collection time for each quality-of-care indicator varied from 5 to 88.5 minutes. The median data collection time was 15 minutes or less for most indicators.

INTERPRETATION

Quality-of-care indicators were not easily captured with the use of existing databases in rural emergency departments in Quebec. Further work is warranted to improve standardized measurement of these indicators in rural emergency departments in the province and to generalize the information gathered in this study to other health care environments.

Prevalence of self-reported multimorbidity in the general population and in primary care practices: a cross-sectional study

Background

Settings affect estimation of multimorbidity prevalence. Multimorbidity prevalence was reported to be substantially higher among family practice-based patients than in the general population, but prevalence estimates were obtained with different methods and at different time periods. The aim of the present study was to compare estimates of the prevalence of multimorbidity in the general population and in primary care clinical practices, both measured simultaneously and with the same methods.

Methods

Cross-sectional analysis of results from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Subjects aged between 25 and 75 years. A randomly-selected cohort in the general population recruited by telephone, and patients recruited in the waiting room of 12 primary care clinics. Prevalence of multimorbidity was estimated using three operational definitions of multimorbidity: (a) two or more chronic conditions (MM 2+); (b) three or more chronic conditions (MM 3+); and (c) disease burden morbidity assessment score of 10 or higher (DBMA 10+).

Results

Prevalence in the general population ranged from 59.4 % (with MM2+) to 16.9 %, (with DBMA10+). In primary care practices, prevalence estimates ranged from 69.5 to 29.5 %. Prevalence estimates of multimorbidity were about 10 % higher in primary care clinical practices than in the sample from the general population. The difference was not importantly affected by the use of different operational definitions of multimorbidity. Also, there was a higher burden of disease among patients attending primary care clinics.

Conclusions

The study suggests that the problem of multimorbidity in the two settings is different both quantitatively (a higher proportion of patients with multimorbidity in primary care clinical practices), and qualitatively (a higher disease burden of patients attending primary care clinics). For decision-makers interested in resource allocation, prevalence estimates in samples from primary care practices are more informative than estimates in the general population, but burden of disease should also be considered as it results in more complexity in primary care clinical practices.

Comparing the performance of the public, social security and private health subsystems in Argentina by core dimensions of primary health care

BACKGROUND

Most Latin American health systems are comprised of public (PubS), social security (SSS) and private (PrS) subsystems. These subsystems coexist, causing health care fragmentation and population segmentation.

OBJECTIVE

To estimate the extent of subsystem cross-coverage in a geographically bounded population (Rosario city) and to compare the subsystems' performance on primary health care (PHC) dimensions.

METHODS

Through a cross-sectional, interviewer-administered survey to a representative sample (n = 822) of the Rosario population, we measured the percentage of cross-coverage (people with usual source of care in one subsystem but also covered by another subsystem) and the health services' performance by core PHC dimensions, as reported by each subsystem's usual users. We compared the subsystems' performance using chi-square analysis and one-way analysis of variance testing. We analyzed whether the observed differences were coherent with the predominant institutional and organizational features of each subsystem.

RESULTS

Overall, 39.3% of the population was affiliated with the PubS, 44.8% with the SSS and 15.9% with the PrS. Cross-coverage was reported by 40.6% of respondents. The performance of the PubS was weak on accessibility but strong on person-and-community-oriented care, the opposite of the PrS. The SSS combined the strengths of the other two subsystems.

CONCLUSION

Rosario's health system has a high percentage of cross-coverage, contributing to issues of fragmentation, segmentation, financial inequity and inefficiency. The overall performance of the SSS was better than that of the PrS and PubS, though each subsystem had a particular performance pattern with areas of strength and weakness that were consistent with their institutional and organizational profiles.

Equity of access to primary healthcare for vulnerable populations: the IMPACT international online survey of innovations

BACKGROUND

Improving access to primary healthcare (PHC) for vulnerable populations is important for achieving health equity, yet this remains challenging. Evidence of effective interventions is rather limited and fragmented. We need to identify innovative ways to improve access to PHC for vulnerable populations, and to clarify which elements of health systems, organisations or services (supply-side dimensions of access) and abilities of patients or populations (demand-side dimensions of access) need to be strengthened to achieve transformative change. The work reported here was conducted as part of IMPACT (Innovative Models Promoting Access-to-Care Transformation), a 5-year Canadian-Australian research program aiming to identify, implement and trial best practice interventions to improve access to PHC for vulnerable populations. We undertook an environmental scan as a broad screening approach to identify the breadth of current innovations from the field.

METHODS

We distributed a brief online survey to an international audience of PHC researchers, practitioners, policy makers and stakeholders using a combined email and social media approach. Respondents were invited to describe a program, service, approach or model of care that they considered innovative in helping vulnerable populations to get access to PHC. We used descriptive statistics to characterise the innovations and conducted a qualitative framework analysis to further examine the text describing each innovation.

RESULTS

Seven hundred forty-four responses were recorded over a 6-week period. 240 unique examples of innovations originating from 14 countries were described, the majority from Canada and Australia. Most interventions targeted a diversity of population groups, were government funded and delivered in a community health, General Practice or outreach clinic setting. Interventions were mainly focused on the health sector and directed at organisational and/or system level determinants of access (supply-side). Few innovations were developed to enhance patients' or populations' abilities to access services (demand-side), and rarely did initiatives target both supply- and demand-side determinants of access.

CONCLUSIONS

A wide range of innovations improving access to PHC were identified. The access framework was useful in uncovering the disparity between supply- and demand-side dimensions and pinpointing areas which could benefit from further attention to close the equity gap for vulnerable populations in accessing PHC services that correspond to their needs.

Portrait of rural emergency departments in Québec and utilization of the provincial emergency department management Guide: cross sectional survey

Background

Rural emergency departments (EDs) constitute crucial safety nets for the 20 % of Canadians who live in rural areas. Pilot data suggests that the province of Québec appears to provide more comprehensive access to services than do other provinces. A difference that may be attributable to provincial policy/guidelines “the provincial ED management Guide”. The aim of this study was to provide a detailed description of rural EDs in Québec and utilization of the provincial ED management Guide.

Methods

We selected EDs offering 24/7 medical coverage, with hospitalization beds, located in rural or small towns. We collected data via telephone, paper, and online surveys with rural ED/hospital staff. Data were also collected from Québec’s Ministry of Health databases and from Statistics Canada. We computed descriptive statistics, ANOVA and t-tests were used to examine the relationship between ED census, services and inter-facility transfer requirements.

Results

A total of 23 of Québec’s 26 rural EDs (88 %) consented to participate in the study. The mean annual ED visits was 18 813 (Standard Deviation = 6 151). Thirty one percent of ED physicians were recent graduates with fewer than 5 years of experience. Only 6 % had residency training or certification in emergency medicine. Teams have good local access (24/7) to diagnostic equipment such as CT scanner (74 %), intensive unit care (78 %) and general surgical services (78 %), but limited access to other consultants. Sixty one percent of participants have reported good knowledge of the provincial ED management Guide, but only 23 % of them have used the guidelines. Furthermore, more than 40 % of EDs were more than 300 km from levels 1 to 2 trauma centers, and only 30 % had air transport access.

Conclusions

Rural EDs in Québec are staffed by relatively new graduates working as solo physicians in well-resourced and moderately busy (by rural standards) EDs. The provincial ED management Guide may have contributed to this model of service attribution. However, the majority of rural ED staff report limited knowledge or use of the provincial ED management Guide and increased efforts at disseminating this Guide are warranted.

Mandated Local Health Networks across the province of Québec: a better collaboration with primary care working in the communities?

Background In 2004, the Québec government implemented an important reform of the healthcare system. The reform was based on the creation of new organisations called Health Services and Social Centres (HSSC), which were formed by merging several healthcare organisations. Upon their creation, each HSSC received the legal mandate to establish and lead a Local Health Network (LHN) with different partners within their territory. This mandate promotes a 'population-based approach' based to the responsibility for the population of a local territory. Objective The aim of this paper is to illustrate and discuss how primary healthcare organisations (PHC) are involved in mandated LHNs in Québec. For illustration, we describe four examples that facilitate a better understanding of these integrated relationships. Results The development of the LHNs and the different collaboration relationships are described through four examples: (1) improving PHC services within the LHN - an example of new PHC models; (2) improving access to specialists and diagnostic tests for family physicians working in the community - an example of centralised access to specialists services; (3) improving chronic-disease-related services for the population of the LHN - an example of a Diabetes Centre; and (4) improving access to family physicians for the population of the LHN - an example of the centralised waiting list for unattached patients. Conclusion From these examples, we can see that the implementation of large-scale reform involves incorporating actors at all levels in the system, and facilitates collaboration between healthcare organisations, family physicians and the community. These examples suggest that the reform provided room for multiple innovations. The planning and organisation of health services became more focused on the population of a local territory. The LHN allows a territorial vision of these planning and organisational processes to develop. LHN also seems a valuable lever when all the stakeholders are involved and when the different organisations serve the community by providing acute care and chronic care, while taking into account the social, medical and nursing fields.

Room for improvement: noise on a maternity ward

BACKGROUND

For mothers who have just given birth, the postpartum hospital stay is meant to promote an environment where resting, healing and bonding can take place. New mothers, however, face many interruptions throughout the day including multiple visitors and noise caused by medical equipment, corridor conversations and intercom announcements. This paper argues that disruptions and noise on a maternity ward are detrimental to the healing process for new mothers and their newborns and healthcare decision-makers need to act to improve the environment for these patients. This paper also provides recommendations on how to reduce the noise levels, or at least control the noise on a maternity ward, through the implementation of a daily quiet time.

DISCUSSION

Hospital disruptions and its negative health effects in particular for new mothers and their children are illustrated in this paper. Hospital noise and interruptions act as a stressor for both new mothers and staff, and can lead to sleep deprivation and detrimental cardiovascular health effects. Sleep deprivation is associated with a number of negative mental and physical health consequences such as decreased immune function, vascular dysfunction and increased sympathetic cardiovascular modulation. Sleep deprivation can also increase the risk of postpartum mental health disorders in new mothers. Some efforts have been made to reduce the disruptions experienced by these patients within a hospital setting. For example, the introduction of a daily quiet time is one way of controlling noise levels and interruptions, however, these have mostly been implemented in intensive care units. Noise and disruptions are a significant problem during postpartum hospital stay. Healthcare institutions are responsible for patient-centered care; a quiet time intervention promises to contribute to a safe, healing environment in hospitals.

Validation of 2 new measures of continuity of care based on year-to-year follow-up with known providers of health care

PURPOSE

In a primary care context favoring group practices, we assessed the validity of 2 new continuity measures (both versions of known provider continuity, KPC) that capture the concentration of care over time from multiple physicians (multiple provider continuity, KPC-MP) or from the physician seen most often (personal provider continuity, KPC-PP).

METHODS

Patients with diabetes or cardiovascular disease (N = 765) were approached in the waiting rooms of 28 primary care clinics in 3 regions of the province of Quebec, Canada; answered a survey questionnaire measuring relational continuity, interpersonal communication, coordination within the clinic, coordination with specialists, and overall coordination; and gave permission for their medical records to be reviewed and their medical services utilization data for the previous 2 years to be accessed to measure KPC. Using generalized linear mixed models, we assessed the association between KPC and the patients' responses.

RESULTS

Among the 5 different patient-reported measures or their combination, KPC-MP was significantly related with overall coordination of care: for high continuity, the odds ratio (OR) = 2.02 (95% CI, 1.33-3.07), and for moderate continuity, OR = 1.61 (95% CI, 1.06-2.46). KPC-MP was also related with the combined continuity score: for high continuity, OR = 1.52 (95% CI, 1.11-2.09), and for moderate continuity, OR = 1.48 (95% CI, 1.10-2.00). KPC-PP was not significantly associated with any of the survey measures.

CONCLUSIONS

The KPC-MP measure, based on readily available administrative data, is associated with patient-perceived overall coordination of care among multiple physicians. KPC measures are potentially a valuable and low-cost way to follow the effects of changes favoring group practice on continuity of care for entire populations. They are easy to replicate over time and across jurisdictions.

Lifestyle factors and multimorbidity: a cross sectional study

BACKGROUND

Lifestyle factors have been associated mostly with individual chronic diseases. We investigated the relationship between lifestyle factors (individual and combined) and the co-occurrence of multiple chronic diseases.

METHODS

Cross-sectional analysis of results from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Subjects aged 45 years and older. A randomly-selected cohort in the general population recruited by telephone. Multimorbidity (3 or more chronic diseases) was measured by a simple count of self-reported chronic diseases from a list of 14. Five lifestyle factors (LFs) were evaluated: 1) smoking habit, 2) alcohol consumption, 3) fruit and vegetable consumption, 4) physical activity, and 5) body mass index (BMI). Each LF was given a score of 1 (unhealthy) if recommended behavioural targets were not achieved and 0 otherwise. The combined effect of unhealthy LFs (ULFs) was evaluated using the total sum of scores.

RESULTS

A total of 1,196 subjects were analyzed. Mean number of ULFs was 2.6 ± 1.1 SD. When ULFs were considered separately, there was an increased likelihood of multimorbidity with low or high BMI [Odd ratio (95% Confidence Interval): men, 1.96 (1.11-3.46); women, 2.57 (1.65-4.00)], and present or past smoker [men, 3.16 (1.74-5.73)]. When combined, in men, 4-5 ULFs increased the likelihood of multimorbidity [5.23 (1.70-16.1)]; in women, starting from a threshold of 2 ULFs [1.95 (1.05-3.62)], accumulating more ULFs progressively increased the likelihood of multimorbidity.

CONCLUSIONS

The present study provides support to the association of lifestyle factors and multimorbidity.

[Comparison of three weight classification systems for preschool children in a region of Quebec]

INTRODUCTION

Overweight in children is a serious public health problem. The use of different weight classification systems in research and clinical practice results in variable the estimate of prevalences of overweight, which complicates follow-up of this health problem in the population. The study compared three child body weight classification systems by estimating the prevalence of overweight established by each system.

METHOD

In 2010, a study was conducted in 259 five-year-old children at the time of routine childhood vaccination. The children's height and weight were measured. The prevalence of overweight was determined and compared to the International Obesity Task Force (IOTF), the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) criteria.

RESULTS

According to the IOTF, 16.6% of children of the study were overweight (obesity 3.1%). According to the CDC, 24.3% of children were overweight (obesity 9.1%) and according to WHO, the prevalence was 26.3% (obesity 6.2%). According to the IOTF criteria, obesity affected more girls than boys (2.7% vs. 0.4%), whereas similar proportions were observed with the other two systems.

CONCLUSION

This study demonstrates that the prevalence of overweight in children varies considerably depending on the classification system used. These results support the need to consider the system used in clinical practice and in research when monitoring the course of the prevalence of this health problem.

[Parent's social representations of preschool childrens' weight and lifestyle]

BACKGROUND

For preschool children aged four-five years, parents play a key role in the adoption of a healthy lifestyle. Social representations is central to understanding the choice of health behaviours promoted by the parent in their child's life.

OBJECTIVE

To describe the social representations of parents with respect to the weight and lifestyle of children aged four to five.

METHODS

In their descriptive qualitative study, two semi-structured interviews were conducted with a purposive sample of 14 parents who had either normal weight or (overweight or obese) children aged four to five until data saturation was achieved. The collected data was analyzed using inductive analysis.

RESULTS

Some parents view weight as a health issue while others consider a chubby appearance as normal for child aged four to five. All participating parents view lifestyle as a demanding challenge.

CONCLUSION

The results provide guidance for developing healthy lifestyle strategies that are consistent with parental obligations.

Characteristics of primary care practices associated with high quality of care

BACKGROUND

No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care.

METHODS

We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling.

RESULTS

The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care.

INTERPRETATION

We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.

Portrait of rural emergency departments in Quebec and utilisation of the Quebec Emergency Department Management Guide: a study protocol

INTRODUCTION

Emergency departments are important safety nets for people who live in rural areas. Moreover, a serious problem in access to healthcare services has emerged in these regions. The challenges of providing access to quality rural emergency care include recruitment and retention issues, lack of advanced imagery technology, lack of specialist support and the heavy reliance on ambulance transport over great distances. The Quebec Ministry of Health and Social Services published a new version of the Emergency Department Management Guide, a document designed to improve the emergency department management and to humanise emergency department care and services. In particular, the Guide recommends solutions to problems that plague rural emergency departments. Unfortunately, no studies have evaluated the implementation of the proposed recommendations.

METHODS AND ANALYSIS

To develop a comprehensive portrait of all rural emergency departments in Quebec, data will be gathered from databases at the Quebec Ministry of Health and Social Services, the Quebec Trauma Registry and from emergency departments and ambulance services managers. Statistics Canada data will be used to describe populations and rural regions. To evaluate the use of the 2006 Emergency Department Management Guide and the implementation of its various recommendations, an online survey and a phone interview will be administered to emergency department managers. Two online surveys will evaluate quality of work life among physicians and nurses working at rural emergency departments. Quality-of-care indicators will be collected from databases and patient medical files. Data will be analysed using statistical (descriptive and inferential) procedures.

ETHICS AND DISSEMINATION

This protocol has been approved by the CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-1213-011). The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.

Second hematopoietic SCT for leukemia relapsing after myeloablative T cell-depleted transplants does not prolong survival

Patients with leukemia relapsing after allogeneic hematopoietic stem cell transplantation (SCT) have a dismal prognosis. A second SCT offers a further opportunity for cure, but has a high rate of treatment failure. To determine the utility of this option, we analyzed 59 consecutive patients relapsing after a myeloablative HLA-matched sibling T cell depleted SCT. Twenty five patients (13 relapsing within 6 months and 12 relapsing between 6 – 170 months after the first SCT) received a T-replete second SCT. Thirty-eight patients relapsing early had a shorter survival than the 21 patients relapsing later (median 96 vs 298 days, p = 0.0002). In patients relapsing early, the second SCT did not improve overall survival compared to patients receiving non-SCT treatments (median survival 109 vs 80 days, p = 0.41). In patients relapsing late, despite an early trend in favor of second SCT, overall survival was comparable for patients receiving a second SCT compared with patients not retransplanted (median survival 363.5 vs 162 days, p = 0.49). Disappointingly our results do not demonstrate an important survival benefit for a second T-replete allogeneic SCT to treat relapse following a T cell depleted SCT.

Developing an evaluation framework for consumer-centred collaborative care of depression using input from stakeholders

OBJECTIVE

To develop a framework for research and evaluation of collaborative mental health care for depression, which includes attributes or domains of care that are important to consumers.

METHODS

A literature review on collaborative mental health care for depression was completed and used to guide discussion at an interactive workshop with pan-Canadian participants comprising people treated for depression with collaborative mental health care, as well as their family members; primary care and mental health practitioners; decision makers; and researchers. Thematic analysis of qualitative data from the workshop identified key attributes of collaborative care that are important to consumers and family members, as well as factors that may contribute to improved consumer experiences.

RESULTS

The workshop identified an overarching theme of partnership between consumers and practitioners involved in collaborative care. Eight attributes of collaborative care were considered to be essential or very important to consumers and family members: respectfulness; involvement of consumers in treatment decisions; accessibility; provision of information; coordination; whole-person care; responsiveness to changing needs; and comprehensiveness. Three inter-related groups of factors may affect the consumer experience of collaborative care, namely, organizational aspects of care; consumer characteristics and personal resources; and community resources.

CONCLUSION

A preliminary evaluation framework was developed and is presented here to guide further evaluation and research on consumer-centred collaborative mental health care for depression.

Supporting parents of preschool children in adopting a healthy lifestyle

BACKGROUND

Childhood obesity is a public health epidemic. In Canada 21.5% of children aged 2-5 are overweight, with psychological and physical consequences for the child and economic consequences for society. Parents often do not view their children as overweight. One way to prevent overweight is to adopt a healthy lifestyle (HL). Nurses with direct access to young families could assess overweight and support parents in adopting HL. But what is the best way to support them if they do not view their child as overweight? A better understanding of parents' representation of children's overweight might guide the development of solutions tailored to their needs.

METHODS/DESIGN

This study uses an action research design, a participatory approach mobilizing all stakeholders around a problem to be solved. The general objective is to identify, with nurses working with families, ways to promote HL among parents of preschoolers. Specific objectives are to: 1) describe the prevalence of overweight in preschoolers at vaccination time; 2) describe the representation of overweight and HL, as reported by preschoolers' parents; 3) explore the views of nurses working with young families regarding possible solutions that could become a clinical tool to promote HL; and 4) try to identify a direction concerning the proposed strategies that could be used by nurses working with this population. First, an epidemiological study will be conducted in vaccination clinics: 288 4-5-year-olds will be weighed and measured. Next, semi-structured interviews will be conducted with 20 parents to describe their representation of HL and their child's weight. Based on the results from these two steps, by means of a focus group nurses will identify possible strategies to the problem. Finally, focus groups of parents, then nurses and finally experts will give their opinions of these strategies in order to find a direction for these strategies. Descriptive and correlational statistical analyses will be done on the quantitative survey data using SPSS. Qualitative data will be analyzed using Huberman and Miles' (2003) approach. NVivo will be used for the analysis and data management.

DISCUSSION

The anticipated benefits of this rigorous approach will be to identify and develop potential intervention strategies in partnership with preschoolers' parents and produce a clinical tool reflecting the views of parents and nurses working with preschoolers' parents.