[Long-Term Implementation of Structures and Activities Needed for Health Promotion]. / Was fördert die Verstetigung von Strukturen und Angeboten der Gesundheitsförderung?

To achieve sustainable effects of health promotion interventions, first of all, long-term implementation is needed. However, there are just a few studies that explore how to maintain health-promoting structures and activities after external funding comes to an end. Using a mixed-methods approach, the evaluation study of the Bielefeld University analysed long-term implementation of government-funded projects. Our results show that maintenance of project structures and activities is a multiplex and contextual process. Apart from conceptual factors that can be influenced by project activities, interviewees reported on contextual factors (e. g., political support) that particularly affect successful long-term implementation. Thus, strategies need to be planned and initiated in the early stages of a project.

[There is no Need to Reinvent the Wheel - Requirements for a Successful Project Transfer]. / "Man muss das Rad nicht neu erfinden, sondern damit fahren." ­ Voraussetzungen für einen erfolgreichen Projekttransfer.

Although the transfer of an existing project can be a resource-efficient form of implementation of successful interventions, project transfers are rarely carried out in practice. The aim of this article is to pool the experience of 3 projects about the transfer of their prevention approaches to other municipalities and regions, as well as to make recommendations for future trans-regional transfer processes in the field of disease prevention and health promotion. To achieve this, documentation sheets were used and interviews were conducted with team members of the transfer projects. The results show that the ability to adapt intervention to context is an essential condition of successful implementation. In addition, there has to be a need for the intervention in the transfer region and a benefit to the participant organizations as well as to the team members. Furthermore, constructive and personal communication and cooperation between the participants of the original and the transferred project are required for successful transfer.

[Acceptance of Recommendations of "Healthy Start - Young Family Network" on Infant Nutrition and Nutrition for Breastfeeding Mothers. A Survey of Different Professional Groups]. / Akzeptanz von Handlungsempfehlungen des Netzwerks "Gesund ins Leben ­ Netzwerk Junge Familie" zur Säuglingsernährung und Ernährung der stillenden Mutter. Befragung unterschiedlicher Berufsgruppen.

STUDY AIM: This study aims to measure the level of acceptance of the recommendations of the "Healthy Start - Young Family Network" on infant nutrition and nutrition for breastfeeding mothers among different professional groups. METHODS: A standardised online questionnaire was used to investigate the level of acceptance (dichotomised response mode: accept vs. not accept). The first survey was of midwives, gynaecologists and paediatricians among others, the second survey was of paediatricians. The level of acceptance was categorised as low (<75%), moderate (75-89%), strong (90-94%), very strong (95-99%) and absolute (100%). RESULTS: 1 311 health professionals participated in the first survey (n=908 midwives) and 77.6% reported having knowledge of the recommendations. The average level of acceptance was lowest among midwives (67.5%). 119 paediatricians participated in the second survey and 86.5% of this group said they had knowledge of the recommendations. A low acceptance level was mainly found with regard to recommendations on supplementation (fluoride and iodine). A focus on the individual situation of young families, an orientation towards other recommendations and subjective assessment were the main reasons for non-acceptance. CONCLUSION: Recommendations have not been successfully implemented in midwives' practices. Due to overrepresentation of midwives, the observed results do not necessarily apply to other occupational groups. However, the implementation of the recommendations into training and education of health professionals, revision of ambiguous statements as well as the communication of the scientific background of the recommendations are meaningful measures to raise acceptance levels.

[Assessment of subjective physical well-being in heart failure : Validation of the FEW16 questionnaire]. / Erfassung des subjektiven körperlichen Wohlbefindens bei Herzinsuffizienz : Validierung des FEW16-Fragebogens.

INTRODUCTION: Improvement in the quality of life (QoL) is a major goal of therapy for heart failure (HF) patients. Physical well-being as an important component of QoL has not yet been sufficiently covered by disease-specific assessment instruments. The aim of the study was to validate the questionnaire for assessing subjective physical well-being (FEW16) in HF patients with preserved ejection fraction (HFpEF) from the exercise training in diastolic heart failure (Ex-DHF­P) trial. METHOD: A total of 64 HFpEF patients (65 years, 56 % female) were randomized to usual routine treatment with (n = 44) or without training (n = 20). At baseline and 3 months, patients were clinically evaluated and assessed using appropriate questionnaires on the QoL (SF36), physical well-being (FEW16) and depression (PHQ-D). RESULTS: The FEW16 showed good values for Cronbachs' alpha coefficients (0.85-0.93). The cross-validity with SF36 and PHQ-D was highly significant but more so for psychological aspects. At baseline, the FEW16 score correlated with age, the subscale resilience with age and the 6 min walking distance test. At follow-up, the total and resilience scores had improved in the training group. In contrast to the SF36, the FEW16 did not detect differences between the groups in Ex-DHF­P. DISCUSSION: The FEW16 questionnaire showed good internal consistency and correlation with SF36, its total score and resilience had improved after training; however, it did not reflect different changes between the study groups. The FEW16 is therefore more suited to assess general/mental well-being than the subjective physical well-being.

[Postal Survey Among Women With Turkish Migration Background in Germany - Identification, Sample Revision and Response in the InEMa Study]. / Postalische Befragung von Frauen mit türkischem Migrationshintergrund ­ Identifizierung, Stichprobenbereinigung und Response im Rahmen der InEMa-Studie.

AIM OF THE STUDY: Migrants are an important target group for mailed surveys but also difficult to reach. For planning these surveys and invitational health measures, we assessed response figures for women with and without Turkish migration background. METHODS: Women aged 50 years living in Westphalia-Lippe were invited to a postal survey at 2 time points about mammography screening. Turkish migrant women were identified in the contact database by a name-based algorithm. Possible differences in sample revision and response among women with and without Turkish migration background were assessed. RESULTS: Women with Turkish migration background had unknown addresses significantly more often (4.6 vs. 1.7%) and responded to the questionnaires less often (first questionnaire: 14.3 vs. 35.9%; second questionnaire: 70.7 vs. 85.6%). CONCLUSIONS: For postal invitation to participate in healthcare measures, or recruitment of Turkish migrants for studies, differences in current address and readiness to respond must be taken into consideration.

[HBSC Study as an Instrument for Health Reporting among Children and Adolescents - Potential and Limitations]. / HBSC-Studie als Instrument der Gesundheitsberichterstattung im Kindes- und Jugendalter - Potenziale und Grenzen.

Prevention and health promotion have to target children and adolescents. Health reporting significantly contributes to assess the needs in terms of intervention planning in children and adolescents and to plan interventions of the highest priority. In Germany, reporting on children and adolescent's health takes place at federal, federal state and regional levels. Health reporting is based on surveys or monitoring, official statistics or on other data provided by institutions and stakeholders in the health system. The nationally representative Health Behaviour in School-Aged Children (HBSC) survey under the auspices of the WHO - which has been conducted every 4 years since 1982, is a further database in Germany that is representative for the 11-15-year olds girls and boys from general educational schools. In this paper, the HBSC survey will be located within the canon of the German health reporting system. A special emphasis is to describe the potential and limitations of HBSC study for health reporting and to highlight the additional value for health reporting in Germany.

[An overview of the infrastructure for school health promotion in Germany]. / Eine Bestandsaufnahme struktureller Rahmen-bedingungen der schulischen Gesundheitsförderung in Deutschland.

This paper provides an overview of the frameworks and infrastructure of health promotion in German general schools. In the context of the German "Health Behaviour in School-aged Children" (HBSC) survey an additional survey among headmasters has been conducted between autumn 2009 and spring 2010. 276 out of 289 schools, chosen to represent Germany, participated. 273 questionnaires were analysed. In German general schools, health-promoting infrastructure and conditions have been established in general terms. Often, school health promotion takes place across different areas but tends to be limited to short-term implementation. Further research needs to be carried out in order to better document developments in health-promoting school structures and school environments. Moreover, further studies, assessing the association between school structures, school environments and intrapersonal factors of health and health behaviours, are required.

[Evaluation of the "Obeldicks Light Training" Programme for Overweight Children and Adolescents]. / Evaluation des Programms Obeldicks light für übergewichtige Kinder und Jugendliche.

In a randomised controlled study (n=34 intervention group, n = 32 control group) the effects of a 6-month outpatient training for overweight but not obese children and adolescents (BMI > 90(th) ≤ 97(th) percentile) were assessed up to 12 months after the end of intervention. BMI-SDS reduction was the main outcome. The results show that the lifestyle intervention "Obeldicks light" is effective to reduce overweight, as well as blood pressure and several other risk parameters in overweight children. Effects are stable over a 12 months period.

[Gesundheitsziele.de. Selection of a new health target for Germany]. / Gesundheitsziele.de. Die Auswahl eines neuen Gesundheitsziels für Deutschland.

In 2013, the forum gesundheitsziele.de selected "reduction of alcohol consumption" and "patient safety" as new health targets. Besides the two selected targets, three other topics were considered: health at work, health during pregnancy and childbirth, and health and migration. This paper describes the selection process, which followed several criteria: mortality, morbidity, prevalence, burden of disease, economic impact, potential for improvement, equity in health, empowerment of and priorities of health problems in the population. The analysis particularly focused on the assessment of the feasibility and the readiness of stakeholders to participate in the development and implementation of health targets.

[Decision for or against HPV vaccination--a qualitative study with adolescent girls]. / Entscheidungsfindung zur HPV-Impfung--Eine qualitative Studie mit jugendlichen Mädchen.

This study aims at analysing motives of adolescent girls to undergo HPV vaccination. 13 girls aged 13-17 years were interviewed, 6 of them had been vaccinated and 7 of them had not. The interviews were analysed using qualitative content analysis. The main reason to decide for vaccination is the protection against (cervical) cancer in later years. The recommendation of experts (namely gynaecologists) is important as well. Girls who did not undergo vaccination do not feel at risk for cervical cancer. They evaluate the vaccination as having too many unknown effects and risks. Mothers and peers were named as the most important sources for information. Both groups expressed a desire for neutral information. The risks and benefits of HPV vaccination should be communicated clearly to help adolescent girls to make informed decisions.

[Time trends in sex differences in adolescents' health behaviour from 2001 to 2010]. / Die Entwicklung von Geschlechterunterschieden im gesundheitsrelevanten Verhalten Jugendlicher von 2001 bis 2010.

Health behaviours are influenced by gender-specific conceptions and norms of the society. These conceptions and norms are changing over time. The aim of this analysis is to describe gender differences in health behaviour of adolescents and to interpret these gender differences in terms of theories of social construction.We used the national German data of the Health-Behaviour in School-aged Children (HBSC) studies conducted in the years 2001/02, 2005/06 und 2009/10 with respect to the following health behaviours: tobacco use, binge drinking, diet, fruit and vegetable consumption, daily breakfast and physical activity. We describe the difference in frequencies between girls and boys and used a series of logistic regressions to test the significance of the gender difference in health behaviours with survey year as the predictor.There is only a small difference -between girls and boys with respect to tobacco use and binge drinking. For binge drinking girls nearly converge with the figures of boys. Relatively stable gender differences over time are existing for diet, nutrition and physical activity.From a theoretical gender perspective it might be possible that with respect to risky behaviours like tobacco use and alcohol consumption a clear gender specific connotation has changed over time. In other words risk behaviours become less important in presenting oneself as masculine. A gender sensible development of preventive interventions should consider the changes over time of gender-related -social constructions.

[Evaluation of the sponsoring initiative of the "action plan healthy life-style and life worlds" - instruments and first results on planning quality]. / Evaluation der Förderinitiative "Aktionsbündnisse Gesunde Lebensstile und Lebenswelten" - Instrumentarium und erste Ergebnisse zur Planungsqualität.

In line with the National Action Plan "IN FORM" the German Federal Ministry of Health funds the establishment of 11 regional community health promotion networks (alliances). To meet quality development standards, an external evaluation project has been established in addition to the alliances' internal evaluation. Scientific monitoring focuses on alliance-spanning investigation of quality of planning, structures and processes and uses different methods and instruments (e.g., guided interviews, analytical framework, Goal Attainment Scaling). Regional networks also receive support for their efforts to quality development. Up to now concluding analysis can be done on aspects of planning quality based on findings of the analytical framework developed within the project. 5 selected results presented in the article reveal a heterogeneous picture: on one hand the standard on which the alliances' rationales on demands justifying the project's strategy are written at is very encouraging. The situation is similar with the descriptions of the work planning and statements concerning the sustainability at which the implemented activities are aimed. On the other hand, in explaination criteria like consideration of target group's needs or definition of goals the possibilities are not exhausted yet considering the state of the debate. Hence in similar future projects there is a clear necessity of assistance in approaching these aspects, provided preferably in an early stage of the planning phase.

[The HBSC Study in Germany--study design and methodology]. / Die HBSC-Studie in Deutschland--Studiendesign und Methodik.

The aim of the HBSC-Study is to collect data on the physical and mental health and health behaviour of children and adolescents and to gain a deeper insight into their situation and the specific environment they grow up in. The HBSC-study is an international school-based cross-sectional survey conducted in collaboration with the World Health Organization (WHO). The survey takes place every 4 years since 1982 and is based on a standardised protocol. In Germany the survey was first conducted in 1994 as a pilot study in North Rhine-Westphalia. The German sample is based on a random sample of classes in all public schools in Germany. 11-, 13-, and 15-year-old pupils are surveyed by means of a paper and pencil questionnaire. The questionnaire comprises a broad selection of -topics, including sociodemographics, health and risk behaviours, family, school and peers. The reported trends in the supplement are based on the data from surveys in 2002 (N=5.650), 2006 (N=7.274) and 2010 (N=5.005). The representative samples for each of the survey years are defined as follows: in 2002 the data is based on information collected in 4 Federal States (Berlin, Hesse, North Rhine-Westphalia, Saxony); in 2006 5 states define the German data file (Berlin, Hamburg, Hesse, North Rhine-Westphalia, Saxony). The data from the 2010 survey comprises data from 15 Federal States. The HBSC-data contributes towards a better understanding of the relationship between health and living conditions of young people. The papers in this supplement deliver important insights into the living context of young people and in doing this they provide important information about their health and the long-term effectiveness of public-health-measures.

Attitudes to cesarean delivery: the view of cesarean section mothers.

OBJECTIVE: This study analyses the attitudes to cesarean section of women who have undergone a section. The subjects of the study are differentiated into primiparous and multiparous women and women with planned and intrapartum sections. DESIGN: A total of 2 685 women from a statutory health insurance fund who had given birth by cesarean section in the year 2004 were questioned (response rate: 48%; n=1,339). A written questionnaire was used to assess the reasons for cesarean section as well as to explore the three following attitude areas: the right to choose the mode of delivery, safety and childbirth risks, lifestyle factors. RESULTS: 771 women (57.6%) were primiparous, 560 women (41.8%) were multiparous, 8 women (0.6%) did not answer the question about previous births. 346 had a repeat section, 53 had been delivered once (3 twice) with a vacuum extractor or forceps. In 733 women (54.7%) a planned cesarean section was performed, 606 women (45.3%) had an intrapartum cesarean section. Two-thirds (61.1%) agreed with statements that emphasised the woman's right to choose the mode of delivery. Another two thirds (68.9%) stated that cesarean sections should be reserved for emergency situations and that women should always try to deliver vaginally. In relation to operation risks and the safety of cesarean sections, the women had varying opinions. The answers to the lifestyle questions were also quite varied. Women with planned sections emphasised a woman's right to choose more strongly than women with intrapartum cesarean delivery and assessed the risks to be lower. There was almost no difference between primiparous and multiparous women in all three attitude areas. CONCLUSIONS: The results clearly show the ambivalent situation in which women find themselves. Although they are aware of the social changes in obstetrics, they still do not consider a cesarean section as an option for themselves unless indicated.

[Frequency of caesarean sections amongst single-foetus births following infertility treatment: an investigation by the Hessian Perinatal Registry (HEPE)]. / Sectio-Häufigkeit nach Sterilitätsbehandlung bei Einlingen: Eine Auswertung der Hessischen Perinatalerhebung (HEPE).

PURPOSE: This study investigates which factors increase the probability of the need to perform a Caesarean section in an uncomplicated single-foetus pregnancy following infertility treatment. MATERIAL AND METHODS: The Hessian Perinatal Registry (HEPE) was used as a basis to determine the development of the rate of Caesarean sections and the delivery method for births in 2007. It is linked to anamnestic and perinatal risks and the foetal and maternal outcome. RESULTS: The total rate of Caesarean sections in the state of Hesse has doubled in a period of over 15 years and stood at 33.0 % in 2007. The same period also saw a rise in the percentage of births that followed infertility treatment, for which an increased risk for multiple-foetus pregnancies can be verified. A comparison of mature single-foetuses in cephalic presentation (at 37-41 weeks gestation) with and without preceding infertility treatment shows the risk involved for Caesarean section to have increased (caesarean section rate 24.7 vs. 31.2 %). The higher rate of Caesarean sections following infertility treatment is associated with higher pregnancy risks (family history, allergies, obesity, premature contractions) and can lead to a higher rate of labour induction, but remains an independent risk even after these factors have been controlled (OR = 1.74, 95 % CI = 1.68-1.79). CONCLUSION: The risks for Caesarean section are increased even for uncomplicated pregnancies when they follow infertility treatment. It can be assumed that, amongst other things, increased safety needs for couples and doctors together with more high-tech intensive care of pregnancies following infertility treatment will be required. In the event of a planned Caesarean section, comprehensive explanation of the risks involved will be necessary.

7-Year follow-up of a lifestyle intervention in overweight children: Comparison to an untreated control group.

BACKGROUND & AIMS: We present the 7-year follow-up analysis in overweight children and adolescents, who had participated originally in a randomized control trial of a lifestyle intervention. We compared them to an untreated population-based control group to demonstrate the effectiveness of the intervention. METHODS: Degree of overweight (BMI-SDS) was determined in 32 overweight children (mean age 11.5 ± 1.5yrs, 65.6% females, mean BMI 23.7 ± 1.5 kg/m2) at onset of intervention (T0), end of 6-month intervention (T1), 12 months (T2) and 7 years after end of intervention (T3). A total of 76 overweight children derived from a representative national population survey served as control group. RESULTS: The participants in the intervention group reduced significantly their BMI-SDS between T0-T1 (mean ± standard deviation -0.28 ± 0.28, p < 0.001) and demonstrated no significant changes between T1-T2 (mean ± standard deviation -0.10 ± 0.34) and between T2-T3 (median +0.07; interquartile range: -0.54-0.62). BMI-SDS at T3 was significantly (p = 0.015) lower compared to T0. At T3, 46.8% of the participants in the intervention were normal-weight. The reduction in BMI-SDS between T0-T3 was significantly (p = 0.043) greater in the intervention group (median -0.26; interquartile range -0.87-0.23 BMI-SDS) compared to the control group (mean ± standard deviation -0.05 ± 0.77). CONCLUSIONS: The lifestyle intervention led to a significant reduction of overweight in the 7-year follow-up period. This decrease in BMI-SDS was significantly greater than the changes in BMI-SDS in a control group. This study is registered at clinicaltrials.gov (NCT00422916).

Validation of the FEW16 questionnaire for the assessment of physical well-being in patients with heart failure with reduced ejection fraction: results from the CIBIS-ELD study.

AIMS: Patients with heart failure (HF) commonly suffer from severe impairment of quality of life (QoL). One main goal of HF treatment is improvement of QoL. Physical well-being is an essential component of QoL. To enable assessment of physical well-being in HF patients, we validated the FEW16 questionnaire in a prospective study with patients from the Cardiac Insufficiency Bisoprolol Study in ELDerly. METHODS AND RESULTS: In 127 HF patients (age 73 ± 5.5 years, 72% male, 60% New York Heart Association class II, left ventricular ejection fraction 37 ± 8.5%), we measured physical well-being (FEW16), QoL [36-Item Short-Form Health Survey (SF36)], and depressive symptoms [PRIME MD Patient Health Questionnaire German short version for depression (PHQ-D)] at baseline and two follow-up visits, and correlated FEW16 scores with QoL data and clinical parameters. FEW16 mean scores are 3.04 ± 1.04 at baseline, 3.19 ± 0.94 after 3 months, and 2.77 ± 0.94 after 2-4 years. We assessed data quality, scale assumptions, and construct validity and reliability. Cronbach's alpha for subscales resilience: 0.84; ability to enjoy: 0.80; vitality: 0.88; inner peace: 0.87; total score: 0.95. Intraclass correlation coefficient (ICC) is 0.87 (95% CI 0.84-0.89, ICC (1.4). Pearson's correlations of FEW16 with SF36 and PHQ-D were significant. Six minutes walking distance and heart rate correlated significantly with the FEW16 total score. CONCLUSIONS: The FEW16 showed good reliability, internal consistency, and intraclass correlation. FEW16 scores correlated well with psychological and physical well-being (SF36) and clinical markers of exercise tolerance (6 min walk test and heart rate). Our results indicate a strong correlation of self-reported physical well-being with psychological factors. FEW16 values at baseline predicted the development of several aspects of QoL during beta-blocker up-titration.

An effective lifestyle intervention in overweight children: one-year follow-up after the randomized controlled trial on "Obeldicks light".

BACKGROUND & AIMS: Lifestyle interventions address primarily obese children, while interventions tailored to overweight but not obese children are scarce. The effectiveness of the lifestyle intervention "Obeldicks light" based on physical activity training, nutrition education, and behavior counseling for overweight children and their parents has been demonstrated by a randomized controlled trial. Here, we present the 12 months follow-up analysis of these children after end of intervention. METHODS: Degree of overweight (BMI and SDS-BMI), waist circumference, skinfold thickness, bioimpedance analyses (BIA), and blood pressure were determined in 76 overweight (BMI>90(th)≤97(th) percentile) children (mean age 11.8 ± 1.8years, 67% females, mean BMI 24.3 ± 1.9 kg/m(2)) participating in the evaluation study of "Obeldicks light" at onset of intervention (T0), end of 6 months intervention (T1), 6 months after end of intervention (T2) and 12 months after end of intervention (T3). Comparisons were performed on an intention-to-treat approach. RESULTS: The drop-out rate was 4% in the intervention period and additional 3% during follow-up. The children reduced significantly (p < 0.001) their SDS-BMI in the intervention period between T0 and T1 (-0.27 ± 0.23; p < 0.001). This SDS-BMI reduction remained stable at T2 (T0-T2:-0.26 ± 0.31; p < 0.001) and T3 (T0-T3:-0.26 ± 0.39; p < 0.001). SDS-BMI reductions were independent from age and gender. Body fat measured by skinfold thickness and BIA, waist circumference, and blood pressure decreased significantly in the intervention period and remained stable in the follow-up period as well. CONCLUSIONS: The lifestyle intervention "Obeldicks light" was effective in reducing degree of overweight, fat mass, waist circumference, and blood pressure both at end of intervention and in a 12 months follow-up period.

An effective lifestyle intervention in overweight children: findings from a randomized controlled trial on "Obeldicks light".

BACKGROUND & AIMS: Randomized controlled trials (RCT) have demonstrated the effectiveness of lifestyle interventions in obese children. However, the effectiveness of interventions for overweight, but no obese children has not been demonstrated yet by RCTs. METHODS: A total of 66 overweight (BMI>90th< or =97th percentile) children (mean age 11.5+/-1.6 years, 58% females, mean BMI 23.4+/-1.5kg/m(2)) were randomized into a control group (CG) (n=32; no intervention for a duration of 6 months) or intervention group (IG) (n=34; 6 months intervention "Obeldicks light" based on physical activity, nutrition education, and behaviour counselling). BMI, waist circumference, skinfold thickness, bioimpedance analyses, blood pressure, physical activity based on questionnaires, and three-day-weighed dietary records were determined at baseline (T0) and 6 months (T1) later. Degree of overweight was calculated as BMI-SDS. Comparisons were performed on an intention-to-treat approach. RESULTS: The drop-out rate was 3% in IG and 16% in CG. At T1, 94% of the children in IG decreased their BMI-SDS and 24% of them were normal weight. The changes between T0 and T1 in BMI-SDS differed significantly (p<0.001) between IG and CG (CG: +0.05+/-0.19 BMI-SDS; IG: -0.26+/-0.22 BMI-SDS). Similar findings were observed for blood pressure, waist circumference, skinfold thickness, and fat mass based on bioimpedance analyses. In the IG, energy, fat and sugar intake decreased significantly between T0 and T1, while no significant changes were observed in the CG. CONCLUSIONS: The lifestyle intervention was associated with an improvement of dietary patterns and was effective in reducing degree of overweight, fat mass, waist circumference, and blood pressure.