Development and content validity of an application to assess 24-hour movement behaviors in 0-4-year-old children involving end-users and key stakeholders: the My Little Moves app.

BACKGROUND: Recently, research focus has shifted to the combination of all 24-h movement behaviors (physical activity, sedentary behavior and sleep) instead of each behavior separately. Yet, no reliable and valid proxy-report tools exist to assess all these behaviors in 0-4-year-old children. By involving end-users (parents) and key stakeholders (researchers, professionals working with young children), this mixed-methods study aimed to 1) develop a mobile application (app)-based proxy-report tool to assess 24-h movement behaviors in 0-4-year-olds, and 2) examine its content validity. METHODS: First, we used concept mapping to identify activities 0-4-year-olds engage in. Parents (n = 58) and professionals working with young children (n = 21) generated a list of activities, sorted related activities, and rated the frequency children perform these activities. Second, using multidimensional scaling and cluster analysis, we created activity categories based on the sorted activities of the participants. Third, we developed the My Little Moves app in collaboration with a software developer. Finally, we examined the content validity of the app with parents (n = 14) and researchers (n = 6) using focus groups and individual interviews. RESULTS: The app has a time-use format in which parents proxy-report the activities of their child, using eight activity categories: personal care, eating/drinking, active transport, passive transport, playing, screen use, sitting/lying calmly, and sleeping. Categories are clarified by providing examples of children's activities. Additionally, 1-4 follow-up questions collect information on intensity (e.g., active or calm), posture, and/or context (e.g., location) of the activity. Parents and researchers considered filling in the app as feasible, taking 10-30 min per day. The activity categories were considered comprehensive, but alternative examples for several activity categories were suggested to increase the comprehensibility and relevance. Some follow-up questions were considered less relevant. These suggestions were adopted in the second version of the My Little Moves app. CONCLUSIONS: Involving end-users and key stakeholders in the development of the My Little Moves app resulted in a tailored tool to assess 24-h movement behaviors in 0-4-year-olds with adequate content validity. Future studies are needed to evaluate other measurement properties of the app.

Developing a digital informed consent app: opportunities and challenges of a new format to inform and obtain consent in public health research.

BACKGROUND: Informed consent procedures for large population-based cohort studies should be comprehensive and easy-to-use. This is particularly challenging when participants from different socio-economic groups and multicultural ethnic backgrounds are involved. Recently, more and more studies have tried to use multimedia in informed consent procedures. We describe the development and testing of a digital informed consent app and elaborate on whether this may contribute to a comprehensive and practical procedure to obtain informed consent for public health research. METHODS: In a sample of parents with young children, we used a mixed method approach to study the user experience of an informed consent app and evaluate whether it can be used to adequately inform people and register their consent. Through semi-structured interviews we investigated participants' experiences with and opinions about the app, with a special focus on comprehensibility of the content and the usability of the app. Information retention questions were asked to evaluate to what extent participants could recall key aspects of the provided study information. RESULTS: The 30 participants in this study used the app between 4 and 15 min to give their consent. Overall, they found the app well-designed, informative and easy to use. To learn more about the study for which informed consent is asked, most of the participants chose to watch the animated film, which was generally found to convey information in a clear manner. The identification process was met with mixed reactions, with some feeling it as a secure way to give consent, while for others it contradicted their view of using data anonymously. Information retention questions showed that while all participants remembered various aspects of the study, fewer than half answered all four questions satisfactorily. CONCLUSION: Our study shows that a well-designed informed consent app can be an effective tool to inform eligible participants and to record consents. Still, some issues remain, including trust barriers towards the identification procedure and lack of information retention in some participants. When implementing consent procedures that incorporate digital formats, it may be beneficial to also invest in a complementary face-to-face recruitment approach.

A systematic review of proxy-report questionnaires assessing physical activity, sedentary behavior and/or sleep in young children (aged 0-5 years).

BACKGROUND: Accurate proxy-report questionnaires, adapted to the child's developmental stage, are required to monitor 24-h movement behaviors in young children, especially for large samples and low-resource settings. OBJECTIVES: This review aimed to summarize available studies evaluating measurement properties of proxy-report questionnaires assessing physical activity, sedentary behavior and/or sleep in children aged 0-5 years. METHODS: Systematic literature searches were carried out in the PubMed, Embase and SPORTDiscus databases, up to January 2021. For physical activity and sedentary behavior questionnaires this is a review update, whereas for sleep questionnaires we included all relevant studies published up to now. Studies had to evaluate at least one of the measurement properties of a proxy-report questionnaire assessing at least duration and/or frequency of physical activity, sedentary behavior and/or sleep in 0- to 5-year-old children. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline was used to evaluate the quality of evidence. RESULTS: Thirty-three studies were included, examining a total of 37 questionnaires. Ten questionnaires were designed for infants, two for toddlers, 11 for preschoolers, and 14 for a broader age range targeting multiple of these age groups. Twenty questionnaires assessed constructs of sleep, four assessed constructs of physical activity, two assessed screen behavior, five assessed constructs of both physical activity and sedentary behavior, and six assessed constructs of all 24-h movement behaviors. Content validity was evaluated for six questionnaires, structural validity for two, internal consistency for three, test-retest reliability for 16, measurement error for one, criterion validity for one, and construct validity for 26 questionnaires. None of the questionnaires were considered sufficiently valid and/or reliable for assessing one or more movement behaviors in 0- to 5-year-old children, and the quality of evidence was mostly low or very low. CONCLUSIONS: Valid and/or reliable questionnaires assessing 24-h movement behaviors in 0- to 5-year-olds are lacking. High-quality studies are therefore required, to develop proxy-report questionnaires and evaluate their measurement properties. PROSPERO REGISTRATION NUMBER: CRD42020169268.

The ENCOMPASS framework: a practical guide for the evaluation of public health programmes in complex adaptive systems.

BACKGROUND: Systems thinking embraces the complexity of public health problems, including childhood overweight and obesity. It aids in understanding how factors are interrelated, and it can be targeted to produce favourable changes in a system. There is a growing call for systems approaches in public health research, yet limited practical guidance is available on how to evaluate public health programmes within complex adaptive systems. The aim of this paper is to present an evaluation framework that supports researchers in designing systems evaluations in a comprehensive and practical way. METHODS: We searched the literature for existing public health systems evaluation studies. Key characteristics on how to conduct a systems evaluation were extracted and compared across studies. Next, we overlaid the identified characteristics to the context of the Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme evaluation and analyzed which characteristics were essential to carry out the LIKE evaluation. This resulted in the Evaluation of Programmes in Complex Adaptive Systems (ENCOMPASS) framework. RESULTS: The ENCOMPASS framework includes five iterative stages: (1) adopting a system dynamics perspective on the overall evaluation design; (2) defining the system boundaries; (3) understanding the pre-existing system to inform system changes; (4) monitoring dynamic programme output at different system levels; and (5) measuring programme outcome and impact in terms of system changes. CONCLUSIONS: The value of ENCOMPASS lies in the integration of key characteristics from existing systems evaluation studies, as well as in its practical, applied focus. It can be employed in evaluating public health programmes in complex adaptive systems. Furthermore, ENCOMPASS provides guidance for the entire evaluation process, all the way from understanding the system to developing actions to change it and to measuring system changes. By the nature of systems thinking, the ENCOMPASS framework will likely evolve further over time, as the field expands with more completed studies.

The Amsterdam Sexual Abuse Case: What Scars did it Leave? Long-Term Course of Psychological Problems for Children Who have been Sexually Abused at a Very Young Age, and their Parents.

Longitudinal research of CSA in infancy and early childhood is scarce. The current study examined the long-term course of psychological outcomes (PTSD, dissociation and internalizing and externalizing behavioral problems) in children who were sexually abused in the early childhood. Additionally, we looked into the outcomes for their parents by assessing PTSD symptoms and negative emotional reactions towards the sexual abuse of their child. We examined the outcomes for five consecutive years in a sample of children (n = 45) who were sexually abused at a very young age (0-3) and their parents (n = 42), included in the Amsterdam Sexual Abuse Case-study. We found that outcomes following CSA in early childhood go beyond PTSD symptoms and can manifest in atypical symptoms such as behavioral problems. Parents experienced persistent PTSD in the years following CSA disclosure. CSA in very young children warrants long-term monitoring, as negative outcomes still present 8 years later.

Weight development between age 5 and 10 years and its associations with dietary patterns at age 5 in the ABCD cohort.

BACKGROUND: Social inequalities in bodyweight start early in life and track into adulthood. Dietary patterns are an important determinant of weight development in children, towards both overweight and underweight. Therefore, we aimed to examine weight development between age 5 and 10 years by ethnicity, SES and thereafter by BMI category at age 5, to explore its association with dietary patterns at age 5. METHODS: Participants were 1765 children from the Amsterdam Born Children and their Development (ABCD) cohort that had valid data on BMI at age 5 and 10 and diet at age 5. Linear mixed model analysis was used to examine weight development between age 5 and 10 years and to assess if four previously identified dietary patterns at age 5 (snacking, full-fat, meat and healthy) were associated with weight development. Analyses were adjusted for relevant confounders, stratified by ethnicity and SES and thereafter stratified per BMI category at age 5. RESULTS: Overall, weight decreased in Dutch and high SES children and increased in non-Dutch and low/middle SES children. Across the range of bodyweight categories at age 5, we observed a conversion to normal weight, which was stronger in Dutch and high SES children but less pronounced in non-Dutch and low/middle SES children. Overall, the observed associations between weight development and dietary patterns were mixed with some unexpected findings: a healthy dietary pattern was positively associated with weight development in most groups, regardless of ethnicity and SES (e.g. Dutch B 0.084, 95% CI 0.038;0.130 and high SES B 0.096, 95% CI 0.047;0.143) whereas the full-fat pattern was negatively associated with weight development (e.g. Dutch B -0.069, 95% CI -0.114;-0.024 and high SES B -0.072, 95% CI -0.119;-0.026). CONCLUSIONS: We observed differential weight development per ethnic and SES group. Our results indicate that each ethnic and SES group follows its own path of weight development. Associations between dietary patterns and weight development showed some unexpected findings; follow-up research is needed to understand the association between dietary patterns and weight development.

The effect of a preconception care outreach strategy: the Healthy Pregnancy 4 All study.

BACKGROUND: Preconception care has been acknowledged as an intervention to reduce perinatal mortality and morbidity. However, utilization of preconception care is low because of low awareness of availability and benefits of the service. An outreach strategy was employed to promote uptake of preconception care consultations. Its effect on the uptake of preconception care consultations was evaluated within the Healthy Pregnancy 4 All study. METHODS: We conducted a community-based intervention study. The outreach strategy for preconception care consultations included four approaches: (1) letters from municipal health services; (2) letters from general practitioners; (3) information leaflets by preventive child healthcare services and (4) encouragement by peer health educators. The target population was set as women aged 18 to 41 years in 14 Dutch municipalities with relatively high perinatal morbidity and mortality rates. We evaluated the effect of the outreach strategy by analyzing uptake of preconception care consultations between February 2013 and December 2014. Registration data of applications for preconception care as well as participant questionnaires were obtained for analysis. RESULTS: The outreach strategy led to 587 applications for preconception care consultations. The majority of applications (n = 424; 72%) were prompted by the invitation letters (132,129) from the municipalities and general practitioners. The effect of the municipal letter seemed to fade out after 3 months. CONCLUSIONS: Outreach strategies amongst the general population promote uptake of preconception care consultations, although on a small scale and with a temporary effect.

Ethnicity and socioeconomic status are related to dietary patterns at age 5 in the Amsterdam born children and their development (ABCD) cohort.

BACKGROUND: Health inequalities are already present at young age and tend to vary with ethnicity and socioeconomic status (SES). Diet is a major determinant of overweight, and studying dietary patterns as a whole in relation to overweight rather than single nutrients or foods has been suggested. We derived dietary patterns at age 5 and determined whether ethnicity and SES were both related to these dietary patterns. METHODS: We analysed 2769 validated Food Frequency Questionnaires filled in by mothers of children (5.7 ± 0.5y) in the Amsterdam Born Children and their Development (ABCD) cohort. Food items were reduced to 41 food groups. Energy adjusted intake per food group (g/d) was used to derive dietary patterns using Principal Component Analysis and children were given a pattern score for each dietary pattern. We defined 5 ethnic groups (Dutch, Surinamese, Turkish, Moroccan, other ethnicities) and 3 SES groups (low, middle, high, based on maternal education). Multivariate ANOVA, with adjustment for age, gender and maternal age, was used to test potential associations between ethnicity or SES and dietary pattern scores. Post-hoc analyses with Bonferroni adjustment were used to examine differences between groups. RESULTS: Principal Component Analysis identified 4 dietary patterns: a snacking, full-fat, meat and healthy dietary pattern, explaining 21% of the variation in dietary intake. Ethnicity was related to the dietary pattern scores (p < 0.01): non-Dutch children scored high on snacking and healthy pattern, whereas Turkish children scored high on full-fat and Surinamese children on the meat pattern. SES was related to the snacking, full-fat and meat patterns (p < 0.01): low SES children scored high on the snacking and meat pattern and low on the full-fat pattern. CONCLUSIONS: This study indicates that both ethnicity and SES are relevant for dietary patterns at age 5 and may enable more specific nutrition education to specific ethnic and low socioeconomic status target groups.

Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study.

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert's interpretations of physical complaints and children's behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0-6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative. CONCLUSION: Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child's behavior during physical examination is needed. What is known • Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases. • So far, there is a lack of studies on symptom patterns of CSA in male, preschool children. What is new • None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA. • The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child's behavior during physical examination is a crucial part of the evaluation of suspected CSA.

Overweight and obesity in young Turkish, Moroccan and Surinamese migrants of the second generation in the Netherlands.

OBJECTIVE: To examine differences in overweight and obesity of second-generation Turkish, Moroccan and Surinamese migrants v. first-generation migrants and the ethnic Dutch. We also studied the influence of sociodemographic factors on this association. DESIGN: Data were collected in 2008 in a cross-sectional postal and online health survey. SETTING: Four major Dutch cities. SUBJECTS: In the survey 42 686 residents aged 16 years and over participated. Data from Dutch (n 3615) and second/first-generation Surinamese (n 230/139), Turkish (n 203/241) and Moroccan (n 172/187) participants aged 16-34 years were analysed using logistic regression with overweight (BMI ≥ 25·0 kg/m²) and obesity (BMI ≥ 30·0 kg/m²) as dependent variables. BMI was calculated from self-reported body height and weight. Sociodemographic variables included sex, age, marital status, educational level, employment status and financial situation. RESULTS: After controlling for age, overweight (including obesity) was more prevalent in most second-generation migrant subgroups compared with the Dutch population, except for Moroccan men. Obesity rates among second-generation migrant men were similar to those among the Dutch. Second-generation migrant women were more often obese than Dutch women. Ethnic differences were partly explained by the lower educational level of second-generation migrants. Differences in overweight between second- and first-generation migrants were only found among Moroccan and Surinamese men. CONCLUSIONS: We did not find a converging trend for the overweight and obesity prevalence from second-generation migrants towards the Dutch host population. Therefore, preventive interventions should also focus on second-generation migrants to stop the obesity epidemic.

Ethnic density is not associated with psychological distress in Turkish-Dutch, Moroccan-Dutch and Surinamese-Dutch ethnic minorities in the Netherlands.

PURPOSE: Ethnic density, the proportion of people of the same ethnic group in the neighbourhood, has been identified as a protective factor with regard to mental health in ethnic minorities. Research on the putative intermediating factors, exposure to discrimination and improved social support, has not yielded conclusive evidence. We investigated the association between ethnic density and psychological well-being in three ethnic minority groups in the Netherlands. We also assessed whether a protective ethnic density effect is related to the degree to which each group experiences discrimination and social support at group level. METHODS: Using multi-level linear regression modelling, we studied the influence of ethnic density at neighbourhood level on psychological distress, measured with the Kessler Psychological Distress scale (K10), in 13,864 native Dutch, 1,206 Surinamese-Dutch, 978 Turkish-Dutch and 784 Moroccan-Dutch citizens of the four major cities in the Netherlands. Based on a nationwide survey among ethnic minorities on social integration, ethnic groups were ordered with respect to the intermediating factors. RESULTS: Ethnic density was not associated with psychological distress in any of the three ethnic minority groups. As a consequence, we found no support for either experiences of discrimination or for own-group social interactions at group level as intermediating factors. In all three ethnic minority groups, as well as in the native Dutch group, individual demographic and socio-economic factors emerged as the main explanations for individuals' mental well-being. CONCLUSIONS: These results suggest that individual demographic and socio-economic risk characteristics outweigh the influence of neighbourhood attributes on mental health.

Similar associations between personality dimensions and anxiety or depressive disorders in a population study of Turkish-Dutch, Moroccan-Dutch, and native Dutch subjects.

It is well established that personality traits are associated with anxiety and depressive disorders in Western populations, but it is not known whether this is true also for people from non-Western cultures. In this study, we examined whether ethnicity moderates the association between personality dimensions and anxiety or depressive disorders or symptoms. In a random urban population sample, stratified by ethnicity, in Amsterdam, the Netherlands, we interviewed 309 native Dutch subjects, 203 Turkish-Dutch subjects, and 170 Moroccan-Dutch subjects. Dimensions of personality were measured using the NEO Five-Factor Inventory. Anxiety and depressive disorders and symptom levels were assessed with the Composite International Diagnostic Interview and the Symptom Checklist-90-Revised. The association between personality factors and disorders or symptoms of anxiety and depression was very similar in the three ethnic groups: all show the typical profile of high neuroticism and low extraversion, agreeableness, and conscientiousness.

A process evaluation: does recruitment for an exercise program through ethnically specific channels and key figures contribute to its reach and receptivity in ethnic minority mothers?

BACKGROUND: Ethnic minority women from low-income countries who live in high-income countries are more physically inactive than ethnic majority women in those countries. At the same time, they can be harder to reach with health promotion programs. Targeting recruitment channels and execution to ethnic groups could increase reach and receptivity to program participation. We explored using ethnically specific channels and key figures to reach Ghanaian, Antillean, and Surinamese mothers with an invitation for an exercise program, and subsequently, to determine the mothers' receptivity and participation. METHODS: We conducted a mixed methods process evaluation in Amsterdam, The Netherlands. To recruit mothers, we employed ethnically specific community organizations and ethnically matched key figures as recruiters over Dutch health educators. Reach and participation were measured using reply cards and the attendance records from the exercise programs. Observations were made of the recruitment process. We interviewed 14 key figures and 32 mothers to respond to the recruitment channel and recruiter used. Content analysis was used to analyze qualitative data. RESULTS: Recruitment through ethnically specific community channels was successful among Ghanaian mothers, but less so among Antillean and Surinamese mothers. The more close-knit an ethnic community was, retaining their own culture and having poorer comprehension of the Dutch language, the more likely we were to reach mothers through ethnically specific organizations. Furthermore, we found that using ethnically matched recruiters resulted in higher receptivity to the program and, among the Ghanaian mothers in particular, in greater participation. This was because the ethnically matched recruiter was a familiar, trusted person, a translator, and a motivator who was enthusiastic, encouraging, and able to adapt her message (targeting/tailoring). Using a health expert was preferred in order to increase the credibility and professionalism of the recruitment. CONCLUSIONS: Recruitment for an exercise program through ethnically specific organizations seems to contribute to its reach, particularly in close-knit, highly organized ethnic communities with limited fluency in the local language. Using ethnically matched recruiters as motivator, translator, and trusted person seems to enhance receptivity of a health promotion program. An expert is likely to be needed for effective information delivery.

A Longitudinal Study in Worrisome Sexual Behavior Following Sexual Abuse in Infancy or Early Childhood: The Amsterdam Sexual Abuse Case.

Worrisome sexual behavior (WSB) is often described as an outcome specific to child sexual abuse (CSA). Therefore, it is highly relevant to study WSB in relation to sexual abuse, especially in very young children, as it is hard to recognize sexual abuse in children who have limited verbal capacities of disclosing. Over time, literature describing WSB following CSA has gradually broadened. However, a gap remains regarding the long-term development of WSB in children who were sexually abused during infancy or very early childhood. To our knowledge, our study is the first to examine developmentally-related sexual behavior versus sexual abuse-specific behavior longitudinally in children who were sexually abused at a very young age. In total, we examined the sexual behavior, as reported by parents of 45 children who experienced early-age sexual abuse for a period of more than five years. Overall, we found that WSB is likely to be a CSA-specific and potentially long-term outcome for children who were sexually abused at a very young age. Despite the decrease in sexual abuse-specific behavior over time, the level of this behavior was still significantly high 8 years after the sexual abuse. This finding supports long-term monitoring and assessment and intervention for WSB over time. Despite these findings, it is important to note that WSB does not serve as proof of sexual abuse in children; likewise, when a child does not present with WSB, it does not indicate the absence of a substantiated history of sexual abuse.

Ethnic differences in the association between cardiovascular risk factors and psychological distress in a population study in the Netherlands.

BACKGROUND: There is growing body of evidence of an association between cardiovascular risk factors and depressive and anxiety symptoms. The purpose of this study was to investigate whether these associations are similar in ethnic minority groups. METHODS: A random urban population sample, aged 18+, stratified by ethnicity (484 native Dutch subjects, 383 Turkish-Dutch subjects, and 316 Moroccan-Dutch subjects), in Amsterdam, the Netherlands, was interviewed with the Kessler Psychological Distress scale (K10) in combination with measurements of several cardiovascular risk factors. The association of psychological distress (defined as a K10 score above cut-off of 20) with cardiovascular risk factors (obesity, abdominal obesity, hypertension, hypercholesterolemia, low HDL cholesterol levels or diabetes), ethnicity and their interaction was analyzed using logistic regression analyses, stratified by gender and adjusted for age. RESULTS: Cardiovascular risk factors were not significantly associated with psychological distress in any of the gender/ethnic groups, with the exception of a positive association of obesity and hypertension with psychological distress in native Dutch women and a negative association of hypertension and psychological distress in Turkish men. Interaction terms of cardiovascular risk factors and ethnicity were approaching significance only in the association of obesity with the K10 in women. CONCLUSION: In this cross-sectional multi-ethnic adult population sample the majority of the investigated cardiovascular risk factors were not associated with psychological distress. The association of obesity with psychological distress varies by gender and ethnicity. Our findings indicate that the prevention of obesity and psychological distress calls for an integrated approach in native Dutch women, but not necessarily in Turkish-Dutch and Moroccan-Dutch women, in whom these problems may be targeted separately.

A sexual abuse case series of infants and toddlers by a professional caregiver: A qualitative analysis of parents' experiences during the initial crisis period post-discovery.

BACKGROUND: The discovery that one's child has been sexually abused may be one of the worst events a parent can experience. The importance of parental support for the recovery of child sexual abuse (CSA) victims emphasizes the need to gain insight in difficulties parents face after disclosure. OBJECTIVE: To improve crisis intervention by exploring how parents of very young, mostly male CSA victims involved in a large unique CSA case, look back on their initial reactions after disclosure, the impact of media coverage, and their experiences with service responses during the immediate aftermath of CSA discovery. PARTICIPANTS AND SETTING: We conducted 18 qualitative interviews with 21 parents enrolled in the longitudinal Amsterdam Sexual Abuse Case (ASAC) study. METHODS: We used thematic analysis, combining a deductive and inductive approach. RESULTS: We identified four themes regarding parents' initial experiences after disclosure: shock, uncertainty, roller coaster and survival mode. Four themes emerged regarding the impact of media coverage: vulnerable to exposure, fear that the child would recognize the suspect, no escape possible, and burden versus acknowledgement. Parents' experiences regarding the actions of professionals also generated four themes: stressful and confronting, need for support, need for information, and need for professional competence. CONCLUSIONS: Disclosure of extrafamilial CSA left parents in shock, affecting their sense of control. Media coverage exacerbated stress for many parents, although some also drew support from it. Actions of professionals defined by parents as helpful included: being supportive, compassionate, accessible, and competent, providing information, and promoting autonomy. Implications for professionals are discussed.

Ethnic variation in validity of the estimated obesity prevalence using self-reported weight and height measurements.

BACKGROUND: We examined ethnic differences between levels of body mass index (BMI) based on self-reported and measured body height and weight and the validity of self-reports used to estimate the prevalence of obesity (BMI≥30 kg/m2) in Turkish, Moroccan, and Dutch people in the Netherlands. Furthermore, we investigated whether BMI levels and the prevalence of obesity in Turkish and Moroccan people with incomplete self-reports (missing height or weight) differ from those with complete self-reports. METHODS: Data on self-reported and measured height and weight were collected in a population-based survey among 441 Dutch, 414 Turks and 344 Moroccans aged 18 to 69 years in Amsterdam, the Netherlands in 2004. BMI and obesity were calculated from self-reported and measured height and weight. RESULTS: The difference between measured and estimated BMI was larger in Turkish and Moroccan women than in Dutch women, which was explained by the higher BMI of the Turkish and Moroccan women. In men we found no ethnic differences between measured and estimated BMI. Sensitivity to detect obesity was low and specificity was high. In participants with available self-reported and measured height and weight, self-reports produced a similar underestimation of the obesity prevalence in all ethnic groups. However, many obese Turkish and Moroccan women had incomplete self-reports, missing height or weight, resulting in an additional underestimation of the prevalence of obesity. Among men (all ethnicities) and Dutch women, the availability of height or weight by self-report did not differ between obese and non obese participants. CONCLUSIONS: BMI based on self-reports is underestimated more by Turkish and Moroccan women than Dutch women, which is explained by the higher BMI of Turkish and Moroccan women. Further, in women, ethnic differences in the estimation of obesity prevalence based on self-reports do exist and are due to incomplete self-reports in obese Turkish and Moroccan women. In men, ethnicity is not associated with discrepancies between levels of BMI and obesity prevalence based on measurements and self-reports. Hence, our results indicate that using measurements to accurately determine levels of BMI and obesity prevalence in public health research seems even more important in Turkish and Moroccan migrant women than in other populations.

DiAlert: a lifestyle education programme aimed at people with a positive family history of type 2 diabetes and overweight, study protocol of a randomised controlled trial.

BACKGROUND: Family history is a known risk factor for type 2 diabetes (T2DM), and more so in the presence of overweight. This study aims to develop and evaluate the effectiveness of a new lifestyle education programme 'DiAlert' targeted at 1st degree relatives of people with T2DM and overweight. In view of the high risk for diabetes and cardiovascular disease in immigrants from Turkish origin living in Western Europe, a culturally appropriate Turkish version of DiAlert will be developed and tested. METHODS/DESIGN: In this RCT, 268 (134 Dutch and 134 Turkish) overweight 1st degree relatives of patients with T2DM will be allocated to either the intervention or control group (leaflet). The intervention DiAlert aims to promote intrinsic motivation to change lifestyle, and sustain achieved behaviour changes during follow-up. Primary outcome is weight loss. Secondary outcomes include biological, behavioural and psychological indices, along with process indicators. Measurements will take place at baseline and after 3 and 9 months. Changes in outcomes are tested between intervention and control group at 3 months; effects over time are tested within and between both ethnic groups at 3 and 9 months. DISCUSSION: The DiAlert intervention is expected to be more effective than the control condition in achieving significant weight loss at 3 months, in both Dutch and Turkish Dutch participants. TRIAL REGISTRATION: Netherlands National Trial Register (NTR): NTR2036.

Developing the logic framework underpinning a whole-systems approach to childhood overweight and obesity prevention: Amsterdam Healthy Weight Approach.

BACKGROUND: Whole-systems approaches (WSAs) are well placed to tackle the complex local environmental influences on overweight and obesity, yet there are few examples of WSAs in practice. Amsterdam Healthy Weight Approach (AHWA) is a long-term, municipality-led program to improve children's physical activity, diet, and sleep through action in the home, neighborhood, school, and city. Adopting a WSA, local political, physical, social, educational, and healthcare drivers of childhood obesity are viewed as a complex adaptive system. Since 2013, AHWA has reached >15,000 children. During this time, the estimated prevalence of 2-18-year-olds with overweight or obesity in Amsterdam has declined from 21% in 2012 to 18.7% in 2017. Declining trends are rarely observed in cities. There is a need to formally articulate AHWA program theory in order to: (i) inform future program evaluation which can interpret this decline within the context of AHWA and (ii) contribute a real-life example of a WSA to the literature. METHODS: This study aimed to formally document the program theory of AHWA to permit future evaluation. A logic framework was developed through extensive document review and discussion, during program implementation. RESULTS: The working principles of the WSA underpinning AHWA were made explicit in an overarching theory of change, articulated in a logic framework. The framework was operationalized using an illustrative example of sugar intake. CONCLUSIONS: The logic framework will inform AHWA development, monitoring, and evaluation and responds to a wider need to outline the working principles of WSAs in public health.

Ethnic differences in total and HDL cholesterol among Turkish, Moroccan and Dutch ethnic groups living in Amsterdam, the Netherlands.

BACKGROUND: High total cholesterol and low HDL (high-density lipoprotein) cholesterol are important determinants of cardiovascular disease. Little is known about dyslipidemia among Turkish and Moroccan migrants, two of the largest ethnic minority groups in several European countries. This study examines ethnic differences in total and HDL cholesterol levels between Dutch, Turkish and Moroccan ethnic groups. METHODS: Data were collected in the setting of a general health survey, in Amsterdam, the Netherlands, in 2004. Total response rate was 45% (Dutch: 46%, Turks: 50%, Moroccans: 39%). From 1,220 adults information on history of hypercholesterolemia, lifestyle and demographic background was obtained via health interviews. In a physical examination measurements of anthropometry and blood pressure were performed and blood was collected. Total and HDL cholesterol were determined in serum. RESULTS: Total cholesterol levels were lower and hypercholesterolemia was less prevalent among the Moroccan and Turkish than the Dutch ethnic population. HDL cholesterol was also relatively low among these migrant groups. The resulting total/HDL cholesterol ratio was particularly unfavourable among the Turkish ethnic group. Controlling for Body Mass Index and alcohol abstinence substantially attenuated ethnic differences in HDL cholesterol levels and total/HDL cholesterol ratio. CONCLUSIONS: Total cholesterol levels are relatively low in Turkish and Moroccan migrants. However part of this advantage is off-set by their relatively low levels of HDL cholesterol, resulting in an unfavourable total/HDL cholesterol ratio, particularly in the Turkish population. Important factors in explaining ethnic differences are the relatively high Body Mass Index and level of alcohol abstinence in these migrant groups.