A qualitative study on the views of experts regarding the incorporation of non-health outcomes into the economic evaluations of public health interventions.

BACKGROUND: Public health interventions can impact a broad number of outcomes, including both health and non-health outcomes (NHOs). However, although it is often acknowledged that it's important to take NHOs into account in economic evaluation studies, in practice these are often neglected. To address this issue, our study investigated expert views regarding the incorporation of NHOs into the economic evaluations of public health interventions, by means of a qualitative study. METHODS: A purposive sampling method was used to recruit the experts in the field of health economics and/or public health for this study. Twenty-two semi-structured interviews were held. After recording, the interviews were transcribed verbatim and entered in Nvivo. The data was analyzed using a thematic analysis to identify all important themes mentioned by the experts. Data collection and analysis was continued until saturation was reached. Multiple coding and validity checks were performed to further strengthen the rigour of our methodology. RESULTS: Based on the expert interviews, the following overarching themes were identified; Theme 1: NHOs on the individual level, direct social level and societal level. Theme 2: Pros and Cons regarding the development of a new instrument to measure NHOs. Theme 3: The most important requirements for a new questionnaire to be developed for measuring broader outcomes. Theme 4: Alternative methods which could be used for measuring and valuating NHOs in economic evaluations for public health. DISCUSSION: Our research findings indicate that the importance of NHOs and the need to measure them are universally accepted. Most of the experts acknowledge the importance of measuring broader outcomes and support the development of a new instrument to measure these. The experts, who do not support the development of a new instrument, question its usefulness and feasibility; i.e., they are not sure whether it is possible to valuate NHOs. Furthermore, experts have strong and sometimes conflicting views on the specific requirements of a new instrument to be developed for measuring NHOs. They did not identify a single preferred alternative method for measurement and valuation. CONCLUSIONS: Most experts find a wide range of NHOs important and are in favor of developing a new instrument for identifying and measuring NHOs. Hence, an open discussion needs to be initiated with experts and other stakeholders about which steps need to be taken to move forward.

Exploring Outcomes to Consider in Economic Evaluations of Health Promotion Programs: What Broader Non-Health Outcomes Matter Most?

BACKGROUND: Attention is increasing on the consideration of broader non-health outcomes in economic evaluations. It is unknown which non-health outcomes are valued as most relevant in the context of health promotion. The present study fills this gap by investigating the relative importance of non-health outcomes in a health promotion context. METHOD: We investigated the relative importance of ten non-health outcomes of health promotion programs not commonly captured in QALYs. Preferences were elicited from a sample of the Dutch general public (N = 549) by means of a ranking task. These preferences were analyzed using Borda scores and rank-ordered logit models. RESULTS: The relative order of preference (from most to least important) was: self-confidence, insights into own (un)healthy behavior, perceived life control, knowledge about a certain health problem, social support, relaxation, better educational achievements, increased labor participation and work productivity, social participation, and a reduction in criminal behavior. The weight given to a particular non-health outcome was affected by the demographic variables age, gender, income, and education. Furthermore, in an open question, respondents mentioned a number of other relevant non-health outcomes, which we classified into outcomes relevant for the individual, the direct social environment, and for society as a whole. CONCLUSION: The study provides valuable insights in the non-health outcomes that are considered as most important by the Dutch general population. Ideally, researchers should include the most important non-health outcomes in economic evaluations of health promotion.

Associations between environmental characteristics and active commuting to school among children: a cross-sectional study.

BACKGROUND: Active commuting to school can contribute to active living among children, and environmental characteristics might be related to transportation mode to school. PURPOSE: The purpose of this study is to explore the association between physical and social environmental characteristics in the home, neighborhood, and school environment and walking and bicycling to school. METHOD: Data were collected among parents (n = 5,963) of children of primary schools in four Dutch cities. Parents reported mode of transportation to school, and individual, home environmental, neighborhood, and school environmental characteristics. Social as well as physical characteristics were included for the home and neighborhood environment. Multilevel multinomial logistic regression analyses were conducted to quantify the association between environmental characteristics and walking and bicycling to school. RESULTS: Three quarter of all children usually commute to school by active transportation, but age and distance from home to school were important prerequisites. Besides home environmental characteristics, lower neighborhood socioeconomic status was negatively associated with walking [odds ratio (OR) = 0.51] and bicycling (OR = 0.86). Perceived social safety was positively related to walking and bicycling (OR = 1.04 for both), as was perceived social cohesion (OR = 1.04 and 1.02 for walking and bicycling). Living in the city center was positively associated with walking (OR = 1.91), whereas living in a city green neighborhood was negatively associated with walking and bicycling (OR = 0.48 and 0.76, respectively). Traffic safety as perceived by school boards was positively associated with bicycling (OR = 1.25). CONCLUSION: This study shows that there is a relation between several characteristics in the home, neighborhood, and school environment and walking and bicycling to school among Dutch primary school children. Especially the social neighborhood characteristics were related to active commuting. Therefore, apart from providing a physical infrastructure that facilitates safe and convenient active commuting to school, policy makers should be aware of opportunities to facilitate active commuting by social initiatives in local communities.

Outdoor play among children in relation to neighborhood characteristics: a cross-sectional neighborhood observation study.

BACKGROUND: Although environmental characteristics as perceived by parents are known to be related to children's outdoor play behavior, less is known about the relation between independently measured neighborhood characteristics and outdoor play among children. The purpose of this study was to identify quantitative as well as qualitative neighborhood characteristics related to outdoor play by means of neighborhood observations. METHODS: Questionnaires including questions on outdoor play behavior of the child were distributed among 3,651 parents of primary school children (aged 4-12 years). Furthermore, neighborhood observations were conducted in 33 Dutch neighborhoods to map neighborhood characteristics such as buildings, formal outdoor play facilities, public space, street pattern, traffic safety, social neighborhood characteristics, and general impression. Data of the questionnaires and the neighborhood observations were coupled via postal code of the respondents. Multilevel GEE analyses were performed to quantify the correlation between outdoor play and independently measured neighborhood characteristics. RESULTS: Parental education was negatively associated with outdoor play among children. Neither the presence nor the overall quality of formal outdoor play facilities were (positively) related to outdoor play among children in this study. Rather, informal play areas such as the presence of sidewalks were related to children's outdoor play. Also, traffic safety was an important characteristic associated with outdoor play. CONCLUSIONS: This study showed that, apart from individual factors such as parental education level, certain modifiable characteristics in the neighborhood environment (as measured by neighborhood observations) were associated with outdoor play among boys and girls of different age groups in The Netherlands. Local policy makers from different sectors can use these research findings in creating more activity-friendly neighborhoods for children.

Towards translation of environmental determinants of physical activity in children into multi-sector policy measures: study design of a Dutch project.

BACKGROUND: Physical inactivity in children is a major health problem in The Netherlands as well as in many other Western countries. In addition to health promotion among parents and children, creating "active" neighbourhoods can contribute to the solution of this health problem. However, changing environmental characteristics is often the responsibility of policy sectors outside the Public Health domain. Therefore this project identifies and evaluates the possibilities of multi-sector policy measures to stimulate physical activity in children. METHODS AND DESIGN: The project consists of quantitative as well as qualitative research methods and is conducted in four medium sized Dutch cities. To identify perceived environmental determinants of physical activity in children, a large scale health survey was conducted at 42 primary schools. Written questionnaires including topics on the children's physical activity behaviour (i.e. sports participation, outdoor play, active commuting, television watching and computer usage) and physical and social environmental characteristics were completed by 6,601 parents of children aged 3-13 years old and 3449 children aged 9-13 years old. In addition, 33 neighbourhood audits (systematic observations) were conducted to assess objective neighbourhood characteristics. Furthermore, a policy analysis was conducted in the four participating municipalities to provide an overview of the current local policy measures directed at stimulation of physical activity in children. Policy plans of six different policy sectors (Public Health, Sports, Education & Youth, Spatial Planning, Traffic & Transport, and Safety) were screened for their content on physical activity in children. In addition, semi-structured interviews were conducted with policy makers of each of these sectors to identify critical success factors in the development and realization of multi-sector policy plans aimed at stimulating physical activity in children. The results of all these research activities will be discussed with local policy makers during interactive workshop sessions in order to identify clear cut multi-sector policy measures that stimulate physical activity in children. DISCUSSION: This paper describes the study design of a project that focuses on multi-sector policy measures that stimulate physical activity in children. Next to extensive research into the environmental determinants of physical activity in children, much emphasis is placed on the translation of the research outcomes into concrete and feasible policy plans.

Opportunities to reduce health inequalities by 'Health in All Policies' in the Netherlands: an explorative study on the national level.

OBJECTIVES: In the last few years the Dutch ministry of Health has been searching for a renewed Health in All Policies (HiAP) strategy. This study analyses the Dutch practices and explores opportunities to reduce health inequalities by HiAP. METHODS: A qualitative screening on the Dutch national budget was performed to explore ongoing policy resolutions of ministries inside and outside the public health domain. Additionally, semi-structured (group) interviews were conducted with 19 policy officers of seven ministries to identify critical factors for intersectoral collaboration. RESULTS: Using the Dutch model on health inequalities 38 policy resolutions were selected: 15 on improving the socioeconomic position of people; four on improving participation of people with health problems; 19 on improving living and working conditions and lifestyle; and four on accessibility and quality of care. To improve intersectoral collaboration, policy officers suggested to strengthen existing links between the ministries, create common interest of objectives as well as visible results, approach this theme in a coordinated way, and to achieve broad political agreement. CONCLUSIONS: The main challenges for a formal HiAP strategy are to (a) cover the determinants of health inequalities in a balanced way linked to concrete objectives and visible results, (b) enhance high level agreement and coordinated mechanisms from the government in general and the ministry of Health in particular.

Multi-sector policy action to create activity-friendly environments for children: a multiple-case study.

OBJECTIVES: The aim of this study is (1) to gain insight into current multi-sector policy initiatives that contribute to activity-friendly environments for children in four Dutch municipalities, (2) to investigate the role of multi-sector collaboration in multi-sector policy action and (3) to gain insight into critical facilitators and possible challenges for multi-sector policy action aimed at creating activity-friendly environments for children. METHODS: A policy analysis was conducted in four Dutch municipalities by means of semi-structured interviews with 25 policy officers from different policy sectors. Interviews were transcribed ad verbatim and analyzed using qualitative data coding software. RESULTS: Each policy sector carried out policy measures related to (the environmental determinants of) physical activity among children, but most respondents were not aware of the potential effectiveness of their policy measures regarding this topic. In two municipalities structural collaboration between policy sectors was present, but the number of sectors involved was limited. Awareness and support among all policy sectors, a stimulating political environment, and knowing each other and being informed about other sectors' policies were mentioned as facilitators for multi-sector policy action. The main challenge for multi-sector policy action was lack of time and resources. CONCLUSIONS: This study shows that multi-sector policy action aimed at activity-friendly environments could be stimulated by raising awareness and defining problem ownership, enhancing multi-sector collaboration and paying attention to facilitators and challenges.

Feasibility of multi-sector policy measures that create activity-friendly environments for children: results of a Delphi study.

BACKGROUND: Although multi-sector policy is a promising strategy to create environments that stimulate physical activity among children, little is known about the feasibility of such a multi-sector policy approach. The aims of this study were: to identify a set of tangible (multi-sector) policy measures at the local level that address environmental characteristics related to physical activity among children; and to assess the feasibility of these measures, as perceived by local policy makers. METHODS: In four Dutch municipalities, a Delphi study was conducted among local policy makers of different policy sectors (public health, sports, youth and education, spatial planning/public space, traffic and transportation, and safety). In the first Delphi round, respondents generated a list of possible policy measures addressing three environmental correlates of physical activity among children (social cohesion, accessibility of facilities, and traffic safety). In the second Delphi round, policy makers weighted different feasibility aspects (political feasibility, cultural/community acceptability, technical feasibility, cost feasibility, and legal feasibility) and assessed the feasibility of the policy measures derived from the first round. The third Delphi round was aimed at reaching consensus by feedback of group results. Finally, one overall feasibility score was calculated for each policy measure. RESULTS: Cultural/community acceptability, political feasibility, and cost feasibility were considered most important feasibility aspects. The Delphi studies yielded 16 feasible policy measures aimed at physical and social environmental correlates of physical activity among children. Less drastic policy measures were considered more feasible, whereas environmental policy measures were considered less feasible. CONCLUSIONS: This study showed that the Delphi technique can be a useful tool in reaching consensus about feasible multi-sector policy measures. The study yielded several feasible policy measures aimed at physical and social environmental correlates of physical activity among children and can assist local policy makers in designing multi-sector policies aimed at an activity-friendly environment for children.

Environmental determinants of outdoor play in children: a large-scale cross-sectional study.

BACKGROUND: Outdoor play is a cheap and natural way for children to be physically active. PURPOSE: This study aims to identify physical as well as social correlates of outdoor play in the home and neighborhood environment among children of different age groups. METHODS: Cross-sectional data were derived from 6470 parents of children from 42 primary schools in four Dutch cities by means of questionnaires (2007-2008). Multivariate sequential Poisson GEE analyses were conducted (2010) to quantify the correlation between physical and social home and neighborhood characteristics and outdoor play among boys and girls aged 4-6 years, 7-9 years, and 10-12 years. RESULTS: This study showed that next to proximal (home) environmental characteristics such as parental education (RR=0.93-0.97); the importance parents pay to outdoor play (RR=1.32-1.75); and the presence of electronic devices in the child's own room (RR=1.04-1.15), several neighborhood characteristics were significantly associated with children's outdoor play. Neighborhood social cohesion was related to outdoor play in five of six subgroups (RR=1.01-1.02), whereas physical neighborhood characteristics (e.g., green neighborhood type, presence of water, diversity of routes) were associated with outdoor play in specific subgroups only. CONCLUSIONS: Neighborhood social cohesion was related to outdoor play among children of different age and gender, which makes it a promising point of action for policy development. Policies aimed at improving physical neighborhood characteristics in relation to outdoor play should take into account age and gender of the target population.