Socioeconomic inequalities in paediatric metabolic syndrome: mediation by parental health literacy.

BACKGROUND: Parental health literacy may explain the relationship between parental socioeconomic status (SES) and paediatric metabolic syndrome (MetS). For this reason, we assessed to what extent parental health literacy mediates the relationships between parental SES and paediatric MetS. METHODS: We used data from the prospective multigenerational Dutch Lifelines Cohort Study. Our sample consisted of 6683 children with an average follow-up of 36.2 months (SD 9.3) and a mean baseline age of 12.8 years (SD 2.6). We used natural effects models to assess the natural direct, natural indirect and total effects of parental SES on MetS. RESULTS: On average, an additional 4 years of parental education, e.g. university instead of secondary school, would lead to continuous MetS (cMetS) scores that were 0.499 (95% confidence interval (CI): 0.364-0.635) units lower, which is a small effect (d: 0.18). If parental income and occupational level were 1 SD higher, on average cMetS scores were 0.136 (95% CI: 0.052-0.219) and 0.196 (95% CI: 0.108-0.284) units lower, respectively; these are both small effects (d: 0.05 and 0.07, respectively). Parental health literacy partially mediated these pathways; it accounted for 6.7% (education), 11.8% (income) and 8.3% (occupation) of the total effect of parental SES on paediatric MetS. CONCLUSIONS: Socioeconomic differences in paediatric MetS are relatively small, the largest being by parental education. Improving parental health literacy may reduce these inequalities. Further research is needed into the mediating role of parental health literacy on other socioeconomic health inequalities in children.

Promoting Mental Health Help-Seeking Behaviors by Mental Health Literacy Interventions in Secondary Education? Needs and Perspectives of Adolescents and Educational Professionals.

Mental health literacy (MHL) interventions in secondary schools may help to improve competencies that adolescents require to stay mentally healthy and seek help if mental health problems arise. These MHL interventions should be tailored to the needs of adolescents and educational professionals (EPs) to reach sustainable implementation and long-term effectiveness. However, evidence is lacking on these needs. Thus, our aim was to explore their experiences with, and perspectives on, mental health help seeking and needs regarding MHL interventions. We performed online focus group discussions and interviews with adolescents (n = 21; 13-19 years) and EPs (n = 12) and analyzed the data using directed content analysis. We identified three themes related to mental health help seeking: (1) Limited MHL competencies of adolescents, (2) Limited competencies of EP to provide mental health support, and (3) Limited mental health promotion in the school environment. We further identified three themes regarding MHL interventions: (1) Addressing basic mental health knowledge and skills, (2) Interactive and easily accessible, and (3) Sustainable implementation. Improving the MHL competencies of adolescents and EPs, and creating a mental health-literate school environment can promote adolescents' mental health help seeking. Our findings highlight the importance of developing MHL interventions that are tailored to both adolescents' and EPs needs.

Outcomes and Critical Factors for Successful Implementation of Organizational Health Literacy Interventions: A Scoping Review.

Organizational health literacy (OHL)-interventions can reduce inequality and demands in health care encountered by patients. However, an overview of their impact and critical factors for organization-wide implementation is lacking. The aim of this scoping review is to summarize the evidence on: (1) the outcomes of OHL-interventions at patient, professional and organizational levels; and (2) the factors and strategies that affect implementation and outcomes of OHL-interventions. We reviewed empirical studies following the five-stage framework of Arksey and O'Malley. The databases Scopus, PubMed, PsychInfo and CINAHL were searched from 1 January 2010 to 31 December 2019, focusing on OHL-interventions using terms related to "health literacy", "health care organization" and "intervention characteristics". After a full-text review, we selected 24 descriptive stu-dies. Of these, 23 studies reported health literacy problems in relation to OHL-assessment tools. Nine out of thirteen studies reported that the use of interventions resulted in positive changes on OHL-domains regarding comprehensible communication, professionals' competencies and practices, and strategic organizational changes. Organization-wide OHL-interventions resulted in some improvement of patient outcomes but evidence was scarce. Critical factors for organization-wide implementation of OHL-interventions were leadership support, top-down and bottom-up approaches, a change champion, and staff commitment. Organization-wide interventions lead to more positive change on OHL-domains, but evidence regarding OHL-outcomes needs strengthening.

Socioeconomic Health Inequalities in Adolescent Metabolic Syndrome and Depression: No Mediation by Parental Depression and Parenting Style.

We assessed to what extent parental depression and parenting style mediate the relationships between different measures of parental socioeconomic status (SES) and both depression and metabolic syndrome (MetS) in adolescents, and whether sex moderates these mechanisms. Data were from the prospective multigenerational Dutch Lifelines Cohort Study. Our sample consisted of 1217 adolescents with an average follow-up of 33.3 (SD = 7.33) months and a median baseline age of 13 (IQR:13-14) years. We used structural equation models to assess the direct and indirect effects of SES on baseline and changes at follow-up in both depression and MetS, and to assess moderation by sex. For each additional year of education, continuous MetS scores were 0.098 (95%CI: 0.020; 0.184) units lower at baseline and decreased 0.079 (95%CI: 0.004; 0.158) units at follow-up. No other direct or indirect effects of SES were found, and there was no moderation by sex. Additionally, warmer parenting style was generally associated with more favorable outcome scores. Therefore, improving parenting style may improve health for all adolescents. However, in this study parental depression and parenting style did not account for adolescent socioeconomic health inequalities. This may be partly due to good access to social services within the Netherlands.

Alternative pediatric metabolic syndrome definitions impact prevalence estimates and socioeconomic gradients.

BACKGROUND: There is no consensus regarding the definition of pediatric metabolic syndrome (MetS). This study assessed the impact of alternative definitions on the prevalence, children identified, and association with socioeconomic status (SES). METHODS: Data were from the prospective multigenerational Dutch Lifelines Cohort Study. At baseline, 9754 children participated, and 5085 (52.1%) with average follow-up of 3.0 (SD = 0.75) years were included in the longitudinal analyses; median ages were 12 (IQR = 10-14) and 14 years (IQR = 12-15), respectively. We computed MetS prevalence according to five published definitions and measured the observed proportion of positive agreement. We used logistic regression to assess the SES-MetS association, adjusted for age and sex. Longitudinal models were also adjusted for baseline MetS. RESULTS: MetS prevalence and positive agreement varied between definitions, from 0.7 to 3.0% and from 0.34 (95% CI: 0.28; 0.41) to 0.66 (95% CI: 0.58; 0.75) at baseline, respectively. We consistently found a socioeconomic gradient; in the longitudinal analyses, each additional year of parental education reduced the odds of having MetS by 8% (95% CI: 1%; 14%) to 19% (95% CI: 7%; 30%). CONCLUSIONS: Alternative MetS definitions had differing prevalence estimates and agreed on 50% of the average number of cases. Additionally, regardless of the definition, low SES was a risk factor for MetS. IMPACT: Little is known about the impact of using different definitions of pediatric metabolic syndrome on study results. Our study showed that the choice of pediatric metabolic syndrome definition produces very different prevalence estimates. We also showed that the choice of definition influences the socioeconomic gradient. However, low socioeconomic status was consistently a risk factor for having pediatric metabolic syndrome. In conclusion, studies using different definitions of metabolic syndrome could be reasonably compared when investigating the association with socioeconomic status but not always validly when comparing prevalence studies.

Implementation and Long-Term Outcomes of Organisational Health Literacy Interventions in Ireland and The Netherlands: A Longitudinal Mixed-Methods Study.

Organisational Health Literacy (OHL)-interventions are needed to overcome health inequality. OHL-interventions have successfully identified communication barriers at the organisational level, but evidence is limited on the extent to which this leads to sustainable organisational change. This study aims to assess the implementation fidelity, moderators (barriers and facilitators), and long-term impact of OHL-interventions in hospitals in Ireland and The Netherlands. We used a longitudinal mixed-methods approach to assess two similar OHL-interventions in one Irish and three Dutch hospitals. The OHL-interventions concerned the improvement of navigation and implementation of health literacy-friendly communication throughout organisations. Participants were 24 hospital employees and 40 older adults who use hospital services. At six, eight, and eighteen months, we assessed the level of implementation, barriers and facilitators, and impact through questionnaires and in-depth semi-structured interviews. After older adults and professionals had identified a number of communication problems, we found that professionals had successfully implemented OHL-interventions to promote navigation and comprehensible communication. Limited resources and variation in organisational structures and procedures were perceived as barriers to implementation. The participation of service users, leadership support, and a stepwise implementation of interventions were perceived to facilitate implementation. In the long term, the OHL-interventions led to system-wide improvements, as shown by better embedding of health literacy policies, enhanced patient engagement, provision of plain language training and comprehensible information. Findings were similar for the two countries. Embedded OHL-interventions resulted in sustainable and system-wide health literacy changes in all four hospitals. Following implementation, OHL-interventions have the potential to promote health equity and empowerment among health service users.

Developing a community-based intervention for Dutch older adults in a socioeconomically disadvantaged community.

Unhealthy eating and low levels of physical activity are major health risks, especially for older adults and people with a low socioeconomic status. The aim of this article is to describe the development of a community-based intervention aimed at promoting physical activity and healthy eating among people aged 55 years and over, in a socioeconomically disadvantaged community. The Intervention Mapping protocol was used to develop the intervention. We conducted a literature search, consultation with community partners and inhabitants, and a quantitative study, in order to obtain insight into the determinants of the target population and to identify appropriate theory-based methods and practical strategies for behavioural change. An assessment was performed of the problem with respect to health behaviour and the underlying determinants. Findings were translated into program, performance and change objectives which specify determinants related to behavioural change. Theory-based methods and practical applications were selected, resulting in a plan for adoption and implementation. The intervention included a local media campaign, social environmental approaches and physical environmental activities in the community, with an intermediating role for inhabitants and health professionals in the promotion of the campaign. An evaluation plan was produced to evaluate the effectiveness of the intervention. The Intervention Mapping protocol was a helpful instrument in developing a feasible, theory and evidence-based intervention tailored to a specific target population in the area of health promotion. The systematic and structured approach provided insight into the relationship between the objectives, methods and strategies used to develop the comprehensive intervention.

Moving towards a Comprehensive Approach for Health Literacy Interventions: The Development of a Health Literacy Intervention Model.

Low health literacy (HL) is associated with many negative health outcomes, and is a major challenge in public health and healthcare. Interventions to improve outcomes associated with HL are needed. In this paper, we aim to develop a comprehensive HL intervention model. We used a multimethod approach, consisting of (1) a literature review of articles listed in MEDLINE, presenting HL intervention models, (2) online consultation of international HL experts, and (3) two consensus meetings with members (n = 36 and 27) of a consortium studying HL among older adults (50+) in Europe. In our literature review, we identified twenty-two HL models, only a few of which focused explicitly on interventions. Sixty-eight health literacy experts took part in the online survey. The results from all three methods came together in a comprehensive HL intervention model. This model conceptualized interventions as potentially targeting five factors affecting HL outcomes: (1) individuals’ personal characteristics, (2) individuals’ social context, (3) communication between individuals and health professionals, (4) health professionals’ HL capacities, and (5) health systems. Our model is the first comprehensive HL model focused specifically on interventions. The model can support the further development of HL interventions to improve the health outcomes of people with low HL.

Less reduction of psychosocial problems among adolescents with unmet communication needs.

Patient-professional communication has been suggested to be a major determinant of treatment outcomes in psychosocial care for children and adolescents. However, the mechanisms involved are largely unknown and no longitudinal studies have been performed. Our aim was, therefore, to assess over the course of 1 year, the impact of patient-centered communication on psychosocial problems of adolescents in psychosocial care, including the routes mediating this impact. We obtained data on 315 adolescents, aged 12-18 years, enrolled in child and adolescent social or mental health care. We assessed patient-centered communication by comparing the needs and experiences of adolescents with regard to three aspects of communication: affective quality, information provision, and shared decision-making. Changes in psychosocial problems comprised those reported by adolescents and their parents between baseline and 1 year thereafter. Potential mediators were treatment adherence, improvement of understanding, and improvement in self-confidence. We found a relationship between unmet needs for affective quality, information provision, and shared decision-making and less reduction of psychosocial problems. The association between the unmet need to share in decision-making and less reduction of psychosocial problems were partially mediated by less improvement in self-confidence (30 %). We found no mediators regarding affective quality and information provision. Our findings confirm that patient-centered communication is a major determinant of treatment outcomes in psychosocial care for adolescents. Professionals should be aware that tailoring their communication to individual patients' needs is vital to the effectiveness of psychosocial care.

Development of a Communication Intervention for Older Adults With Limited Health Literacy: Photo Stories to Support Doctor-Patient Communication.

Successful doctor-patient communication relies on appropriate levels of communicative health literacy, the ability to deal with and communicate about health information. This article aims to describe the development of a narrative- and picture-based health literacy intervention intended to support older patients with limited health literacy when communicating during their primary care consultations. We performed a formative evaluation that included a review of the literature and interviews with stakeholders on relevant health literacy issues, qualitative studies with the target group, intervention planning, and a small-scale evaluation. Cocreation with the target group was a major component. Seven photo stories were developed incorporating principles from narrative and social learning theory and covering communication themes and strategies identified during focus group discussions and role-play exercises. The intervention was developed in 3 different formats: 1-page photo stories, narrated video clips using the original photo story pictures, and interactive video clips covering participation and communication during primary care consultations. In our small-scale evaluation, older adults considered the cocreated intervention appealing and comprehensible. The intervention shows promise for improving the health of older adults but needs further evaluation. This study provides a rigorous template for the participatory development of health literacy interventions.

Health Literacy Is Associated With Health Behaviors and Social Factors Among Older Adults: Results from the LifeLines Cohort Study.

This study assesses the associations between health literacy and various health behaviors and social factors among older adults, and whether social factors moderate the other associations. Data from 3,241 participants in the LifeLines Cohort Study were analyzed (mean baseline age = 68.9 years). Data on health literacy, health behaviors (physical activity, fruit and vegetable consumption, smoking, breakfast consumption, alcohol consumption, and body mass index (BMI), and social factors (loneliness, social support, social activities, social contacts, and living situation) were collected in three waves. Logistic regression analyses were used, adjusted for age and gender. Low health literacy was associated with insufficient physical activity, insufficient fruit and vegetable consumption, lack of regular breakfast consumption, obesity (odds ratios (ORs) > 1.31, p-values < .005) and low alcohol use (OR = 0.81, p = .013), but not with smoking. Low health literacy was also associated with greater loneliness, engaging in fewer social activities, and having fewer social contacts (ORs > 1.48, p-values < .005), but not with social support or living situation. Only the association between health literacy and smoking was moderated by social contacts, but this finding needs confirmation in future studies. In conclusion, low health literacy is negatively associated with health behaviors and social factors in older adults, but social factors seldom moderate the associations between health literacy and health behaviors.

The association between health literacy and self-management abilities in adults aged 75 and older, and its moderators.

PURPOSE: Low health literacy is an important predictor of poor health outcomes and well-being among older adults. A reason may be that low health literacy decreases older adults' self-management abilities. We therefore assessed the association between health literacy and self-management abilities among adults aged 75 and older, and the impact of demographic factors, socioeconomic factors, and health status on this association. METHODS: We used data of 1052 older adults, gathered for a previously conducted randomized controlled trial on Embrace, an integrated elderly care model. These data pertained to health literacy, self-management abilities, demographic background, socioeconomic situation, and health status. Health literacy was measured by the validated three-item Brief Health Literacy Screening instrument. Self-management abilities were measured by the validated Self-Management Ability Scale (SMAS-30). RESULTS: After adjustment for confounders, self-management abilities were poorer in older adults with low health literacy (ß = .34, p < .001). This was more pronounced in medium- to high-educated older adults than in low-educated older adults. Sex, age, living situation, income, presence of chronic illness, and mental health status did not moderate the association between health literacy and self-management abilities. CONCLUSIONS: Low health literacy is associated with poor self-management abilities in a wide range of older adults. Early recognition of low health literacy among adults of 75 years and older and interventions to improve health literacy might be very beneficial for older adults.

Moderators of physical activity and healthy eating in an integrated community-based intervention for older adults.

BACKGROUND: An integrated community-based intervention was developed to stimulate physical activity (PA) and healthy eating in older adults in a socioeconomically disadvantaged area. This study aims to assess whether its short-term effects among older adults vary by sociodemographic, psychosocial and health-related variables. METHODS: The study was a controlled pre-post quasi-experimental design (intervention condition n = 430; control condition n = 213), with a baseline measurement and a 9-month follow-up measurement. The intervention consisted of a local media campaign and environmental approaches. Changes in PA and fruit and vegetable consumption (FVC) were dependent variables assessed at 9-month follow-up. Sociodemographic, psychosocial and health-related variables at baseline were tested as potential moderators of the effects of the conditions. RESULTS: We found different types of moderators in particular for transport-related PA and FVC. Regarding sociodemographic characteristics, gender was a moderator for household-related PA, and educational level for transport-related PA and FVC. Self-efficacy, as a psychosocial variable, was a moderator of transport-related PA and vegetable consumption. Concerning health-related outcomes, baseline levels of transport-related PA and fruit consumption were moderators for transport-related PA and fruit consumption. If adjusted for multiple testing, only three moderators persisted: educational level regarding vegetable consumption, and baseline levels regarding transport-related PA and fruit consumption. CONCLUSION: The effects of the community intervention vary somewhat by sociodemographic, psychosocial and health-related variables. The intervention seems to be especially beneficial to those who are most in need of more PA and healthy eating.

Longitudinal patterns and predictors of multiple health risk behaviors among adolescents: The TRAILS study.

BACKGROUND: Most studies on multiple health risk behaviors among adolescents have cross-sectionally studied a limited number of health behaviors or determinants. PURPOSE: To examine the prevalence, longitudinal patterns and predictors of individual and multiple health risk behaviors among adolescents. METHODS: Eight health risk behaviors (no regular consumption of fruit, vegetables or breakfast, overweight or obesity, physical inactivity, smoking, alcohol use and cannabis use) were assessed in a prospective population study (second and third wave). Participants were assessed in three waves between ages 10 and 17 (2001-2008; n=2230). Multiple linear regression was used to assess the influence of gender, self-control, parental health risk behaviors, parental monitoring and socioeconomic factors on the number of health risk behaviors adjusted for preceding multiple health risk behaviors (analysis: 2013-2014). RESULTS: Rates of >5 health risk behaviors were high: 3.6% at age 13.5 and 10.2% at age 16. Smoking at age 13.5 was frequently associated with health risk behaviors at age 16. No regular consumption of fruit, vegetables and breakfast, overweight or obesity, physical inactivity and smoking predicted the co-occurrence of health risk behaviors at follow-up. Significant predictors of the development of multiple health risk behaviors were adolescents' levels of self-control, socioeconomic status and maternal smoking. CONCLUSIONS: Multiple health risk behaviors are common among adolescents. Individual and social factors predict changes in multiple health risk behaviors, showing that prevention targeting multiple risk behaviors is needed. Special attention should be paid to adolescents with low self-control and families with low socioeconomic status or a mother who smokes.

Reach and effectiveness of an integrated community-based intervention on physical activity and healthy eating of older adults in a socioeconomically disadvantaged community.

The aim of this study is to assess the reach and effectiveness of an integrated community-based intervention designed to promote physical activity and healthy eating among older adults in a socioeconomically disadvantaged community in the Netherlands. The intervention was evaluated with a controlled pre-post quasi-experimental design, with 430 randomly selected older adults participating in the intervention group and 213 in a control group at baseline. The intervention included a local media campaign and environmental approaches (e.g., community involvement) and was implemented during a 3-month high-intensity period, followed by a 6-month low-intensity one. Levels of physical activity and fruit and vegetable consumption were assessed at baseline and at 3 and 9 months after baseline. At the follow-up measurements, the intervention had reached respectively 68 and 69% of the participants in the intervention group. No significant differences were found between the intervention group and the control group in changes to any outcome except for transport-related PA at 3 and 9 months follow-up. The systematically developed community-based intervention reached a relatively large proportion of the participants, but had only small effects on the levels of physical activity and healthy eating in older adults in the short and medium term.

Development of a training programme for home health care workers to promote preventive activities focused on a healthy lifestyle: an intervention mapping approach.

BACKGROUND: Lifestyle is an important aspect in maintaining good health in older adults, and home health care (HHC) workers can play an important role in promoting a healthy lifestyle. However, there is limited evidence in the literature regarding how to develop an effective training programme to improve the physical activity level and fruit and vegetable consumption of older adults within a HHC setting. The aim of this paper is to describe how Intervention Mapping (IM) was used to develop a training programme to promote preventive activities of HHC workers relating to the physical activity and fruit and vegetable intake of older adults living at home. METHODS: IM, a systematic theory and evidence-based approach was used to develop, implement and evaluate the training programme. This entailed a literature search, a survey, semi-structured interviews and consultation with HHC workers and various field experts, and a pilot training session. RESULTS: The determinants associated with the provision of preventive activities were identified, and an overview was created of those objectives, matching methods and practical applications that could influence these determinants. The performance objectives for the HHC workers were early detection and monitoring, promoting a healthy lifestyle, informing colleagues, continuing allocated preventive activities and referring to other experts and facilities. Findings were translated into a comprehensive training programme for HHC workers focused on motivating older adults to adopt and maintain a healthier lifestyle. CONCLUSIONS: IM was a useful tool in the development of a theory-based training programme to promote preventive activities by HHC workers relating to fruit and vegetable intake and physical activity of older adults.

Priorities in the communication needs of adolescents with psychosocial problems and their parents.

BACKGROUND: In patient-centred care, professionals should recognize their patient's needs and adapt their communication accordingly. Studies into patients' communication needs suggest priorities vary depending on sociodemographic characteristics, and type and severity of the complaints. However, evidence lacks on priorities in the communication needs of adolescents in psychosocial care and their parents. OBJECTIVE: To assess adolescents' and parents' importance ratings concerning affective communication, information provision, shared decision-making, interprofessional communication and the degree to which client and care characteristics determine these. METHODS: Adolescents aged 12-18 (n = 403) and one of their parents (n = 403) rated the importance of communication before the psychosocial care process started. Multivariable logistic regression analysis was applied to determine which characteristics were associated with the 25% lowest importance ratings for communication aspects. RESULTS: Adolescents and parents considered affective communication to be the most important, with shared decision-making the least important. For adolescents, lower importance ratings were associated with dissatisfaction with prior care (OR 1.8), negative expectations (ORs 1.9-2.4), emotional problems (ORs 0.2-0.5) and low prosocial behaviour skills (ORs 2.0). For parents, low education (ORs 1.7-1.8), negative expectations (OR 0.4), adolescent's hyperactivity/inattention (ORs 0.4-0.5) and low prosocial behaviour skills (ORs 1.8-2.6) determined lower importance ratings. CONCLUSIONS: Affective communication has highest priority for adolescents and their parents. Client and care characteristics are associated with client priorities in communication. Being attentive to clients' educational level, previous care experiences, current expectations and specific problem types might help professionals to adapt better to their clients' communication needs.

Do child's psychosocial functioning, and parent and family characteristics predict early alcohol use? The TRAILS Study.

BACKGROUND: Given the negative consequences of early alcohol use for health and social functioning, it is essential to detect children at risk of early drinking. The aim of this study is to determine predictors of early alcohol use that can easily be detected in Preventive Child Healthcare (PCH). METHODS: We obtained data from the first two waves on 1261 Dutch adolescents who participated in TRAILS (TRacking Adolescents' Individual Lives Survey) at ages 10-14 years and from the PCH records regarding ages 4-10 years. Early adolescence alcohol use (age 10-14 years) was defined as alcohol use at least once at ages 10-12 years (wave 1) and at least once in the previous 4 weeks at ages 12-14 years (wave 2). Predictors of early alcohol use concerned parent and teacher reports at wave 1 and PCH registrations, regarding the child's psychosocial functioning, and parental and socio-demographic characteristics. RESULTS: A total of 17.2% of the adolescents reported early alcohol use. Predictors of early alcohol use were teacher-reported aggressive behaviour [odds ratios (OR); 95% confidence interval (CI): 1.86; 1.11-3.11], being a boy (OR 1.80, 95%-CI 1.31-2.56), being a non-immigrant (OR 2.31, 95%CI 1.05-5.09), and low and middle educational level of the father (OR 1.71, 95%CI 1.12-2.62 and OR 1.77, 95%CI 1.16-2.70, respectively), mutually adjusted. CONCLUSION: A limited set of factors was predictive for early alcohol use. Use of this set may improve the detection of early adolescence alcohol use in PCH.

Behavioural and emotional problems in moderately preterm children with low socioeconomic status: a population-based study.

Moderately preterm (MP) birth is associated with higher rates of behavioural and emotional problems. To determine the extent to which low socioeconomic status (SES) contributes to these higher rates, we assessed independent and joint effects of MP birth and low SES, overall and by gender. Dutch preventive child health care centres provided a population-based sample of 915 MP children (32-36 weeks gestation) and 543 term-born children, born in 2002/2003. In multivariable logistic regression analyses, we determined the risk of behavioural and emotional problems per standard deviation (SD) decrease in gestational age and SES, using standardized measures for both. We also assessed three SES categories, being low (1SD or more below mean of standardized SES), intermediate (mean ± 1SD), and high (greater than mean + 1SD). The Child Behavior Checklist for 1.5-5 years was used to assess behavioural (externalizing), emotional (internalizing), and total problems at age 4 years. MP children with low SES had significantly higher total problem scores than those with high SES (11.3 vs. 5.1%, respectively). Each SD decrease in SES was associated with a 42% higher odds of elevated total problem scores (OR 1.42, 95% CI 1.14-1.77). No joint effects were found, meaning that lower gestational age independently added to the risk of behaviour problems (OR 1.24, 95% CI 1.00-1.56). Effects of MP birth and low SES were more pronounced in girls. In conclusion, MP birth and low SES multiply the risk of behavioural and emotional problems. The combination of risk factors identifies children who could benefit greatly from early intervention.

The association of health literacy with physical activity and nutritional behavior in older adults, and its social cognitive mediators.

Inadequate health literacy is a common problem among older adults and is associated with poor health outcomes. Insight into the association between health literacy and health behaviors may support interventions to mitigate the effects of inadequate health literacy. The authors assessed the association of health literacy with physical activity and nutritional behavior in community-dwelling older adults. The authors also assessed whether the associations between health literacy and health behaviors are mediated by social cognitive factors. Data from a study among community-dwelling older adults (55 years and older) in a relatively deprived area in The Netherlands were used (baseline n=643, response: 43%). The authors obtained data on health literacy, physical activity, fruit and vegetable consumption, and potential social cognitive mediators (attitude, self-efficacy, and risk perception). After adjustment for confounders, inadequate health literacy was marginally significantly associated with poor compliance with guidelines for physical activity (OR=1.52, p=.053) but not with poor compliance with guidelines for fruit and vegetable consumption (OR=1.20, p=.46). Self-efficacy explained 32% of the association between health literacy and compliance with physical activity guidelines. Further research may focus on self-efficacy as a target for interventions to mitigate the negative effects of inadequate health literacy.